Abstract ID: A14
Abstract Title: Resolution of an atypical post-dural puncture headache after epidural blood patch in a patient with a cerebral cavernous angioma
Poster Type: Either
ABSTRACT BODY
Introduction: Intracranial hypotension (IH) or localized intracranial vascular abnormalities (LIVA) are risk factors for intracranial hemorrhage. Cerebrospinal fluid (CSF) leakage after dural puncture is a cause of post-dural puncture headache as well as IH. We report a successful outcome after epidural blood patch in a patient with an unusual initial presentation of PDPH in the presence of and possibly linked to an intracerebral cavernous angioma (CA). Case: An otherwise healthy 34 yo. woman with a history of episodic ophthalmic migraines for 7 years underwent an uneventful spinal anesthetic for lower extremity varicose vein stripping. She presented on postoperative day 2 with a postural headache (HA), and normal neurological exam. The patient had awakened the prior night with “the worst headache in my life”, distinctly different from her migraine HA and poorly responding to oral acetaminophen/oxycodone. Cranial CT, performed because this complaint suggested an acute intracranial hemorrhage, showed no bleed but small left parietal lobe calcifications, warranting a non-emergent MRI. The patient received an epidural blood patch in the left lateral decubitus position. The injection was stopped after 15 cc of autologous blood, when she complained of a sudden throbbing HA that resolved after approximately 2 minutes. A cranial MRI 6 hours later to exclude intracerebral pathology requiring future intervention, revealed a left parietal CA with a chronic hemosiderin rim. The patient’s symptoms completely resolved after the blood patch, and the neurosurgeon recommended monitoring of her lesion by follow-up MRI in one year. Discussion: Spontaneous as well as post dural puncture intracranial hypotension from CSF leakage has been implicated in cerebral hemorrhage likely due to intracranial pressure modulation (IPM), specifically IH, and subsequent vascular distension, shear or tear. The initial symptom of this patient’s PDPH suggested acute subarachnoid hemorrhage. Cranial CT and MRI excluded this catastrophe but revealed a seemingly incidental cavernous angioma. The expansion of a CA due to a post dural puncture CSF leak its compression by transient intracranial hypertension by blood patching are consistent with our patient’s atypical initial PDPH and the throbbing HA during epidural blood injection. Although intracranial hemorrhage has been reported after lumbar puncture, the risk of an intracerebral hemorrhage from coexistent IH and CA is likely greater than for each condition alone. Our patient’s course suggests that urgent normalization of low intracranial pressure by epidural blood patching may avert intracranial hemorrhage. Implication: Atypical PDPH suggestive of localized intracranial vascular abnormalities should trigger cranial CT and/or MRI. Otherwise silent LIVA, such as a cavernous angioma, may become symptomatic from intracranial hypotension and increase the risk for intracranial hemorrhage after dural puncture. By restoring intracranial normotension epidural blood patching may possibly reduce this risk. However, an epidural blood patch has its own risks and may cause transient intracranial hypertension. This dilemma mandates careful individual risk/benefit analysis.
ATTACHED FILES
Reg Anesth Pain Med 2004; 29(2):A14