It’s not always postdural puncture headache: a case report and note to the astute anesthesiologist
Nem sempre é cefaleia pós-punção dural: relato de caso e nota para o anestesiologista astuto
Ejaz Khan; Rovnat Babazade; Mohamed Ibrahim; Michelle Simon; Lindsay Juarez; Mandonca Roni; Vadhera Rakesh
Abstract
Dural puncture is either diagnosed by unexpectedly profound response to medication test dose or development of a postpartum postural headache. Epidural blood patch is the gold standard for treatment of PDPH when conservative management fails. However, postpartum headaches can be resistant to multiple epidural blood patches. In such cases, preexisting intracranial processes should be considered and ruled out. We report here the unique case of a pregnant patient who developed a resistant headache in the postpartum period related to an incidental intracranial aneurysm. Subsequent treatment with endovascular embolization adequately relieved her symptoms. Early surgical consultation and a multidisciplinary team approach involving neurology and neuroimaging is required for successful management of patients such as the one described here.
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Resumo
A punção dural é diagnosticada por uma resposta inesperadamente profunda à dose de teste de medicamento ou pelo desenvolvimento de uma cefaleia postural pós-parto. O tampão sanguíneo epidural é o padrão-ouro para o tratamento da CPPD quando o tratamento conservador falha. No entanto, dores de cabeça pós-parto podem ser resistentes a múltiplos tampões de sangue epidural. Nesses casos, processos intracranianos preexistentes devem ser considerados e descartados. Relatamos aqui o caso único de uma paciente grávida que desenvolveu cefaleia resistente no pós-parto relacionada a um aneurisma intracraniano incidental. O tratamento subsequente com embolização endovascular aliviou adequadamente seus sintomas. A consulta cirúrgica precoce e uma abordagem de equipe multidisciplinar envolvendo neurologia e neuroimagem são necessárias para o tratamento bem-sucedido de pacientes como o descrito aqui.
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References
1 C.L. Gurudatt Unintentional dural puncture and postdural puncture headache – can this headache of the patient as well as the anaesthesiologist be prevented? Indian J Anaesth., 58 (2014), pp. 385-387
2 R.G. Davies, C.J. Laxton, F.A. Donald Unrecognised dural punctures Int J Obstet Anesth., 12 (2003), pp. 142-143
3 J.S. Sprigge, S.J. Harper Accidental dural puncture and post dural puncture headache in obstetric anaesthesia: presentation and management: a 23-year survey in a district general hospital Anaesth Rep., 63 (2008), pp. 36-43
4 V. Safa-Tisseront, F. Thormann, P. Malassiné, M. Henry, B. Riou, P. Coriat, et al. Effectiveness of epidural blood patch in the management of post-dural puncture headache Anesthesiology., 95 (2001), pp. 334-339
5 Y.W. Kim, D. Neal, B.L. Hoh Cerebral aneurysms in pregnancy and delivery: pregnancy and delivery do not increase the risk of aneurysm rupture Neurosurgery., 72 (2013), pp. 143-149 discussion 150
6 G.J. Rinkel Natural history, epidemiology and screening of unruptured intracranial aneurysms J Neuroradiol., 35 (2008), pp. 99-103
7 H.J. Priebe Aneurysmal subarachnoid haemorrhage and the anaesthetist Br J Anaesth., 99 (2007), pp. 102-118
8 L.A. Nelson Ruptured cerebral aneurysm in the pregnant patient Int Anesthesiol Clin., 43 (2005), pp. 81-97
9 R.R. Al-Metwali Epidural morphine injections for prevention of post dural puncture headache Anaesth Rep., 63 (2008), pp. 847-850
10 E.N. Grant, J. Wang, B. Gelpi, A. Wortman, W. Tao Diagnosing and managing peripartum headache Proc (Bayl Univ Med Cent)., 28 (2015), pp. 463-465
11 S. Reddi, V. Honchar, M.S. Robbins Pneumocephalus associated with epidural and spinal anesthesia for labor Neurol Clin Pract., 5 (2015), pp. 376-382
12 E. Stanhope, L. Foulds, G. Sayed, U. Goldmann Diagnosing causes of headache within the postpartum period J Obstet Gynaecol., 38 (2018), p. 728
13 D.K. Turnbull, D.B. Shepherd Post-dural puncture headache: pathogenesis, prevention and treatment Br J Anaesth., 91 (2003), pp. 718-729
14 Yao, F. Yao and Artusio’s Anesthesiology. 6th edition. 2008-625-629.