Postdural Puncture Headache

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1 2015 Annual Meeting and Workshops Postdural Puncture Headache Christopher L. Wu, M.D. Professor of Anesthesiology The Johns Hopkins University Baltimore, Maryland

2 Disclosures No financial conflicts of interest Off-label discussions (Rx for PDPH): Caffeine Gabapentin Pregabalin Hydrocortisone, dexamethasone Theophylline Sumatriptan Adrenocorticotropic hormone (ATCH) Cosyntropin

3 Overview Pathophysiology Clinical presentation Risk factors Patient-related Needle-related Treatment options Conservative therapy Epidural blood patch

4 Pathophysiology Loss of Cerebrospinal Fluid (CSF) Rate of loss (12 ml/min) > rate of replacement (0.35 ml/min) 150 ml of CSF in brain and spinal cord CSF leakage ICP/traction on cranial structures Blood vessels, meninges, cranial nerves Evidence of CSF loss as main culprit: Direct removal of CSF HA Arch Neurol Psych 1943;49: MRI studies in PDPH patients AA 1997;84:585-90; Brain 2015;138:1492-8

5 Pathophysiology Evidence of CSF loss as main culprit: Removal of 20 ml of CSF HA Arch Neurol Psych 1943;49: HA resolved after intrathecal injection of NaCl HA traction by the sagging brain on pain-sensitive anchoring structures MRI studies in PDPH patients Extradural local static fluid collection in PDPH patients Anesth Analg 1997;84: PDPH rostral distributions of periradicular leaks and epidural collections Brain 2015;138:1492-8

6 Anesth Analg 1997;84:585-90

7 Brain 2015;138:1492-8

8 Brain 2015;138:1492-8

9 Pathophysiology: Other Compensatory cerebral vasodilatation Monro-Kellie hypothesis: cranial homeostasis by maintaining the sum of the volumes of brain, blood and CSF constant Inverse relationship between blood ( 4% of total intracranial volume) and CSF volume ( 10%) CSF will lead to cerebral blood (vasodilatation) to maintain equilibrium and constant intracranial volume Experimental data suggests that an cerebral blood represents cerebral vasodilatation RAPM 2001;26:401-6

10 Pathophysiology: Other Pneumocephalus Anesthesiology 1998;88:76-81 RCT: air vs. saline-lor syringe, 20-G Tuohy No difference: incidence of accidental dural puncture Air = 48/1812 cases (2.6%); Saline = 51/1918 cases (2.7%) However, incidence of PDPH: air > saline PDPH: Air (32/48 = 66.7%) > saline (5/51 = 9.8%) Intrathecal air bubbles detected on CT:» Air = 30/32 patients, Saline = 0/51 patients Exacerbation or co-existence of HA from other etiologies (migraine, tension)

12 Clinical Presentation Cardinal feature: postural component of HA Severity varies but PDPH may render the patient bedridden May also have: Neck stiffness (57%), backache (35%), nausea (22%), photophobia, cranial nerve signs, muscle spasms Auditory symptoms (4-12%) Acta Anaesthesiol Scand 1995;39: Ocular symptoms (3-13%) Acta Anaesthesiol Scand 1995;39: Cranial nerves III, IV and VI may result in diplopia and difficulty with accommodation Rarely: visual field defects and nystagmus

13 Clinical Presentation Typical course (without intervention) Onset: onset varies from 1-7 days (median = 2 days) 40-65% within first 24 h; 70-90% within 48 h Severity: varies with needle characteristics Duration: median duration is 5-7 days (no active treatment) PDPH is a diagnosis of exclusion Other etiologies may mimic or co-exist with PDPH May miss some other potentially critical diagnoses Acta Anaesthesiol Scand 1995;39: JAMA 1956;161:586-91

14 Clinical Presentation EBPs for a presumed diagnosis of PDPH; however, patients subsequently were diagnosed with: Meningitis (persistent HA and fever) Obstet Gynecol 1989;74:437-9 Late-onset pre-eclampsia (seizures) BJA 2002;90: Subdural hematoma (seizures) RAPM 2002;27:433-6 Cortical vein thrombosis (confusion, sedation, seizures) Incidence of 1 in 11,000 with onset of HA within 2-3 days postpartum Obstet Gynecol 1997;89:413-8

15 Clinical Presentation Peripartum isolated cortical vein thrombosis 32 y/o with HA 3 days after delivery of her baby Initial dx = PDPH; RX analgesia, caffeine, and fluids Readmitted 2 days after d/c with generalized seizures 1 st MRI intracranial hypotension, received EBP Symptoms worsened; 3 days later visual field defect 2 nd MRI R parietal hematoma with evidence of isolated cortical vein thrombosis Case Rep Med 2013;2013:701264

16 Case Rep Med 2013;2013:701264

17 MRI Findings Cerebellar tonsillar descent and posterior fossa crowding Subdural fluid collections, engorged cerebral venous sinuses, or decreased size of the ventricles Pachymeningeal gadolinium enhancement Nonspecific finding: lower ICP, infectious-inflammatory, neoplastic, or iatrogenic etiologies Neurosurg Rev 2015;38: Headache 2013;53:673-5

18 Headache 2013;53:673-5

20 Patient-related Risk Factors Age: PDPH with age Gender: PDPH with female gender? BMI: PDPH with BMI Needle-related factors Needle characteristics Size and shape Needle insertion Bevel orientation: parallel vs. perpendicular Midline vs. paramedian? Continuous intrathecal catheters

21 Age as a Risk Factor Age: PDPH with age Etiology unclear: Elasticity of dura; reactivity of cerebral vessels Narrowed exit routes from the epidural space Differences in pain perception in the elderly (vs. younger) Incidence of PDPH: 22g = 10.8% elderly vs. 27.6% young Anaesthesia 1989;44:571-3 Incidence of PDPH: 25g = 7.8% elderly vs. 12.6% young

22 Gender as a Risk Factor Initial studies: incidence in females JAMA 1956;161: Did not adjust for gender: relatively spinals in paturients Other studies suggest that gender is not a risk factor Multivariate analysis of 1021 spinal anesthetics no association between gender and PDPH AA 1990;70: Cohort study: 2378 spinals with 29-G Quincke: no difference between (1.1%) and (1.5%) Acta Anaesthesiol Scand 1994;38:691-3 Menstrual cycle, hormonal levels do not influence the incidence of PDPH RAPM 1998;23:485-90

23 Gender is a Risk Factor OR= 0.55 (0.44,0.67); p< Anesthesiology 2006;105:613-8

24 BMI as a Risk Factor? PDPH with BMI: epidural pressure in obese IT/EP pressure gradient CSF Intraabd pressure non-csf volume in epidural space Retrospective review of 518 ADP Anesth Analg 2015;121:451-6 PDPH (parturients) = 51% PDPH BMI 31.5 (39%) vs. BMI < 31.5 (56%, p=0.0004) No difference in HA severity or rate of EBP Retrospective review of 125 ADP Int J Obstet Anesth 2014;23:371-5 BMI < 30 (n=65) vs. BMI 30 (n=60) ND in PDPH rate (82% vs. 80%, p=0.83), severity of PDPH (severe 36% vs. 23%, p=0.34), need for EBP (57% vs. 54%, p=0.81)

25 Needle Size as a Risk Factor Needle size = PDPH due to CSF loss/dural hole size CSF loss with 22- vs. 25-G Quincke vs ml/min AA 1989;69: Meta-analysis of 16 RCTs Anesthesiology 1994;81: Incidence of PDPH: less with smaller needles Also, significant reduction in the incidence of severe PDPH with smaller needles No effect of needle size on back pain or failure rate

26 Needle Size as a Risk Factor Needle size in parturients Systematic review of 51 articles CJA 2003;50:460-9 Meta-analysis of PDPH for epidural needles = 52.1% For parturients: 1.5% risk of accidental dural puncture Pooled incidence of PDPH: Husted 18-G = 41.3% Quincke 25-G = 6.3% Sprotte 24-G = 3.5% Whitacre 25-G = 2.2%

27 Needle Shape as a Risk Factor Non-cutting (Whitacre) vs. cutting (Quincke) Meta-analysis of 16 RCTs Anesthesiology 1994;81: Incidence of PDPH significantly less with non-cutting vs. cutting needles Also, significant reduction in the incidence of severe PDPH with non-cutting needles Pencil point needles may cause more trauma and the resulting inflammatory response may close the dural hole faster RAPM 2000;25:

Reg Anesth Pain Med 2000;25:393-402 Figure 2: Dural lesions produced by 25-G

28 Figure 1: Dural lesions produced by 25-G Quincke needles (perpendicular [A] and parallel [B]). Dural surface observed from the epidural space. Reg Anesth Pain Med 2000;25: Figure 2: Dural lesions produced by 25-G Quincke needle observed from subarachnoid space. Note the clean-cut produced in the edges of the lesion

Reg Anesth Pain Med 2000;25:393-402 Figure 3: Dural lesion produced with a 25-G Whitacre needle

Note the flaps of collagen fibers at the borders of the lesions Figure 4: Dural lesions produced

29 Reg Anesth Pain Med 2000;25: Figure 3: Dural lesion produced with a 25-G Whitacre needle seen from the external (epidural) surface. Note the flaps of collagen fibers at the borders of the lesions Figure 4: Dural lesions produced by 25-G Whitacre needles observed from the subarachnoid space. Note the flaps of fibers at the edge of the lesions and the ripple effect around the hole.

30 Bevel Orientation:? Risk Factor Bevel orientation: parallel vs. perpendicular Theory: longitudinal (parallel) insertion will PDPH as dural fibers more likely be spread than cut thus CSF leakage This assume dural fibers runs longitudinally (controversial) Human dura models: fluid leakage greater when bevel inserted perpendicular vs. parallel 30% lower rate of leakage with parallel vs. perpendicular Anesth Analg 1989;69:457-60

31 Bevel Orientation is a Risk Factor Anesth Analg 1989;69:457-60

32 Bevel Orientation is a Risk Factor OR= 0.29 (0.17,0.50); p< Neurologist 2006;12:224-8

33 Midline vs Paramedian Human dura models: transdural fluid leak when needle inserted at 30 vs. 90 Anesth Analg 1989;69: Little leakage after tangential entry (20- to 25-G Quincke) even at spinal pressures as high as 55 cm H2O Headache 1977;17:64-6 Paramedian: tangential entry will create dural flaps which overlap both entry and exit puncture sites Perpendicular: creation of a tin lid flap which will allow unimpeded transdural outflow of CSF Reg Anesth 1997;22: RCT (n=150) 25-gauge Crawford needle Anesth Pain Med 2011;1:66-9 NS between midline (9.3%) vs. paramedian (10.7%)

34 Reg Anesth 1997;22: Anesth Analg 1989;69:457-60

35 Decreased Risk with IT Catheters? Use of a continuous IT catheters? PDPH Inflammatory response from catheter closure of dural hole 45 C/S pts with dural puncture Acta Anaesthesiol Scand 1994;38: /15 (33%) with EA; 8/17 (47%) with SA; 0/13 (0%) with IT Dural puncture with 16-G Husted needle CJA 1998;45:42-5 IT catheters for hours; no PDPH (n = 3) Spinal drains: 19-G needle used Only a 2.5% [95% CI: %] of patients (15/530) developed PDPH AA 1999;88:388-92

36 Decreased Risk with IT Catheters? 128 witnessed accidental dural punctures 39 EP; 89 IT catheters Acta Anesthesiol Scand 2014;58: PDPH EP = 62% vs. 42% for IT catheters PDPH with EP (vs. IT) OR = 2.2 (95%CI: ) Meta-analysis of 8 studies Internat J Obstet Anesth 2013;22;26-30 EBP with IT catheter (RR = 0.64, 95%CI: , p = 0.001) ND for PDPH with IT (RR = 0.82, 95%CI: , p = 0.06) Meta-analysis of 6 studies (no benefit with IT cath) Br J Anaesth 2010;105: Short-term IT cath (RR = 0.88, 95%CI: , p = 0.32) Long-term IT cath (RR = 0.21, 95%CI: , p = 0.23)

37 Internat J Obstet Anesth 2013;22;26-30

38 Internat J Obstet Anesth 2013;22;26-30

39 Br J Anaesth 2010;105:255-63

41 Conservative vs. Invasive Treatment Options Conservative: symptomatic Rx until dural puncture self-seals Invasive: physical attempt to stop leakage of CSF Surveys of management of PDPH Nordic survey (n=153 OB anesth) Acta Anaesth Scand 2011;55: % parturients received EP, EBP = 86% Most common time from Dx to EBP = h N. Am. survey (n = 843 SOAP members) J Clin Anesth 2011;23: After accidental dural puncture (ADP) 75% EP, 25% IT EBP = 81% w/in 24 h after ADP

42 Treatment Options: Conservative Attenuate symptoms until puncture naturally closes Analgesic agents: oral or systemic (NSAIDs, opioids) Hydration: patients may be underhydrated due to nausea Oral fluid intake has not been shown to decrease incidence of PDPH Eur Arch Psychiatr Neurol Sci 1988;237:194-6 Bedrest: will not prevent development of PDPH Lancet 1981;ii: Cochrane Database Syst Rev. 2002;(2):CD001790

43 Treatment Options: Conservative Conservative therapy (%) used by North American OB anesthesiologists after onset of PDPH J Clin Anesth 2011;23:349-60

44 Treatment Options: Conservative Review of RCTs - pharmacologic drugs treating PDPH 13 RCTs (n = 479); unable to perform meta-analysis Caffeine = effective for treating PDPH Pain scores = Gabapentin, hydrocortisone, theophylline Lack of conclusive evidence = sumatriptan, adrenocorticotropic hormone (ATCH), pregabalin, cosyntropin Cochrane Database Syst Rev 2015;CD007887

45 Treatment Options: Caffeine Mechanism of action: cerebral vasoconstriction Caffeine withdrawal cerebral blood flow Psychopharm 2000;147:371-7 May also act through adenosine receptors Neurolog 2001;7: Treatment: IV (500mg caffeine sodium benzoate) or PO 70% efficacy but relief only temporary Ann Pharmacother 1996;30:831-9 May be effective when given prophylactically RAPM 1999;24:51-4 RCT in 60 patients for SA (22-G Quincke) Moderate-severe PDPH less with caffeine Caffeine = 3/30 (10%) vs. Saline = 11/30 (37%), p = 0.03

46 Treatment Options: Steroids Hydrocortisone J Anaesthesiol Clin Pharmacol 2012;28:190-3 RCT (n = 60): hydrocortisone 100mg IV vs placebo At 6 h, VAS with hydrocortisone (6.0 vs. 2.1, p<0.0001) At 24 h, VAS with hydrocortisone (3.8 vs. 1.9, p<0.0001) At 48 h, VAS with hydrocortisone (2.0 vs. 1.1, p<0.0001) Dexamethasone RCT (n = 178); 8 mg IV vs. placebo Acta Anaesthesiol Belg 2011;62:143-6 Intensity of PDPH with dexamethasone RCT (n = 372); 8 mg IV vs. placebo Acta Neurol Belg 2012;112: Severity and incidence of PDPH with dexamethasone

47 Treatment Options: Gabapentanoids Pregabalin J Clin Neurosci 2011;18: RCT; pregabalin (150mg x 3d, then 300mg x 2d) vs. placebo Pregabalin = VAS pain scores and diclofenac requirements Gabapentin Pak J Pharm Sci 2014;27: RCT (n=120); gabapentin 300mg x 2 vs. placebo Gabapentin = VAS pain scores at 24 h Gabapentin vs. ergotamine/caffeine Adv Med Sci 2011;56:25-9 RCT (n=42); Gabapentin = VAS pain vs. ergotamine/caffeine Gabap. vs. pregab. vs. acetaminophen Saudi J Anaesth 2014;8:374-7 RCT (n=90); treatment x 3 days Pain scores = pregabalin < gabapentin < acetaminophen

48 Treatment Options: Others Cosyntropin (ACTH analogue) Anesthesiology 2010;113; RCT (n=90); cosyntropin 1 mg IV vs. saline Cosyntropin = PDPH (33% VS. 69%, P = 0.001), ebp (11% VS. 29%, P = 0.035), time to PDPH development (17.5 h) Mechanism? = aldosterone (salt retention), CSF, morphine Ondansetron J Anesth 2015 (in press) RCT (n = 210): 0.15 mg/kg ondansetron vs. placebo Ondansetron = PDPH (5% vs. 21%, p = 0.001) Mechanism? = venodilation in brain

49 Anesthesiology 2010;113;413-20

51 Treatment Options: Invasive Epidural blood patch (EBP): considered definitive Rx Immediate relief: mass effect intracranial pressure MRI: mass effect immediately after EBP BJA 1993;71:182-8 Injection of blood into epidural space may result in cerebral vasoconstriction; HA relief RAPM 2001;26:401-6 Long-term relief due to sealant effect of blood over the dural puncture allowing replenishment of lost CSF 6-7 hours after EBP, MRI evaluation demonstrated a thin layer of clot over the dural puncture BJA 1993;71:182-8 Fibroblastic activity over dural puncture seen at 48 hours; collagen deposition seen at 2 weeks AA 1972;51:226-32

52 Epidural Blood Patch Ideal volume, timing of EBL uncertain (15 20 ml) Initial report used only 2 3 ml Anesthesiology 1960;21:565-6 Timing (prophylactic vs. delayed) still controversial Typical reported efficacy of 90-95% may be misleading Anesthesiology 2001;95:334-9 Prospective observational study of 504 EBP for PDPH Complete relief = 75%, incomplete relief = 18%, failure = 7% Failure of EBP was associated with: Needle diameter < 20-G (p < 0.001) Administration of EBP < 4 days (p = 0.037) EBP may be more likely performed in severe PDPH leakage of CSF from large needles

53 incidence of headache is not as high as anticipated when a bloody tap is produced.. (in a patient with PDPH)..Two milliliters of the patient s own blood was injected into the epidural space immediate relief from pain (Dr. Gormley s personal experience who had a postural HA after myelogram) a colleague injected 3 cc. of blood into (Dr. Gormley s) epidural space. headache disappeared with minutes. Anesthesiology 1960;21:565-6

54 Epidural Blood Patch: Prophylactic vs. Therapeutic? Several reviews do not recommend prophylactic EBP over other treatments due to insufficient evidence Cochrane Database Syst Rev 2010;20:CD001791; Anesth Analg 2012;115:133-6 EBP is not a risk-free procedure Some meta-analyses prophylactic EBP may be of benefit 5 non-rct, prophylactic EBP = PDPH (RR = 0.48, 95%CI: 0.23/0.99, p = 0.05) Br J Anaesth 2010;105: RCT, prophylactic EBP = ND in PDPH (RR = 0.25, p = 0.06) 4 RCT (n=173); median quality score = 2 (out of 5) Acta Anaesthesiol Scand 2013;57: Prophylactic EBP = PDPH (RD = -0.48, p = 0.017)

55 Br J Anaesth 2010;105:255-63

EBP: How Much Blood to Use? RCT (n=121) 15, 20, 30 ml of blood Anesth Analg 2011 ;113:126-33 Partial HA relief = 61%, 73%, 67%, respectively Complete HA relief = 10%, 32%, 26%.

56 EBP: How Much Blood to Use? RCT (n=121) 15, 20, 30 ml of blood Anesth Analg 2011 ;113: Partial HA relief = 61%, 73%, 67%, respectively Complete HA relief = 10%, 32%, 26%. Respectively Optimal dose = 20 ml Study of epidural pressure during EBP Internat J Obstet Anesth 2014;23: Injection of blood until mild back pressure or discomfort Mean final volume = 18.9 ± 7.8 ml N. Am. survey (n=843 SOAP members) J Clin Anesth 2011;23:349-60

57 Epidural Blood Patch EBP does not impair subsequent epidural anesthesia 96.6% success in patients with prior EBP AA 1999;89:390-4 Complications (mostly transient): Discomfort (78%) and pain (54%) Anesthesiology 2001;95:334-9 Lower extremity sensory disturbances and weakness (18%), neck discomfort, radicular pain, bradycardia Rare (case reports) but potentially severe Facial nerve paralysis Reg Anesth 1993;18:196-8 Pneumocephalus Ann Emerg Med 1994;23: Meningeal irritation Anesth Analg 1998;87: Permanent paraparesis and cauda equina syndrome (30 ml of blood injected) Anesthesiology 2002;96:1515-7

58 EBP and Infections Concern for the introduction of spreading infection or cancer into the EP/IT space EBP in HIV patients Anesthesiology 1992;76: sero(+), 2 sero(-) received EBP, no adverse neurologic or infectious sequelae in f/u up to 24 months EBP in acute varicella Anesth Analg 2004;99: Asymptomatic 30 d and 1 year after EBP EBP in ALL patient Pain Med 2014;15: Flow cytometry no circulating blasts in peripheral blood No evidence of CNS ALL at 3 months Use of allogenic blood for EBP Int J Obstet Anesth 2005;14:261-2 Postpartum fever concern that blood infected

59 Other Invasive Treatments Epidural Saline (ES): Like EBP, ES is thought to immediately alleviate PDPH by increasing both epidural and lumbar CSF pressures This in turn will increase intracerebral CSF pressures and decrease traction on pain sensitive cranial structures Less effective than EBP, relief is transient Dextran: mechanisms of action presumably similar to ES Fibrin glue: case report of successful treatment after epidural injection of fibrin glue Anesthesiology 1999;91:576-7 Surgical closure: only for the most severe and refractory cases Cephalalgia 2013;33:

61 Summary Pathophysiology CSF leakage Clinical presentation PDPH is a diagnosis of exclusion Risk factors Patient-related: age, gender Needle-related: size and shape Treatment options Conservative therapy Epidural blood patch

Post-Dural Puncture Headache. Dr. Jacobs Aurélie Krans Anesthesie 18/03/2016 Kliniek St.-Jan, Brussel

Post-Dural Puncture Headache. Dr. Jacobs Aurélie Krans Anesthesie 18/03/2016 Kliniek St.-Jan, Brussel Post-Dural Puncture Headache Dr. Jacobs Aurélie Krans Anesthesie 18/03/2016 Kliniek St.-Jan, Brussel I - PATHOPHYSIOLOGY August Bier (intrathecal cocaïn1898)! first 2 cases PDPH CSF leak trough dura mater