CSF Pressure, Volume, and Post-Dural Puncture Headache: A Case-Control Study and Systematic Review.

OBJECTIVES: (1) To perform a systematic literature review to evaluate associations between post-dural puncture headache (PDPH) and opening pressure (OP), closing pressure (CP), and volume of cerebrospinal fluid (V) removed. (2) To perform a case-control study to evaluate pressure-volume index (PVI) as a novel risk factor for PDPH. BACKGROUND: According to the International Classification of Headache Diagnoses, 3rd Edition (ICHD-3), the diagnosis of PDPH requires documentation of intracranial hypotension. However, this remains an unproven concept. METHODS: A systematic literature review was conducted, searching Cochrane Database of Systematic Reviews, Ovid EMBASE, OVID MEDLINE, Scopus, and Web of Science. Study inclusion required a comparison of headache incidence following a LP as a function of OP, CP, and/or V. A retrospective, case-control study with 1:1 matching was conducted utilizing ICHD-3 criteria. Patients with factors that could influence CSF pressure were excluded. RESULTS: In our case-control study, we did not identify a paired difference in either median (95% CI) elastance (0.05 [-0.09, 0.11], P = .503) or PVI (4.53 [-7.98, 19.97], P = .678). We identified 22 references, evaluating V (n = 14), OP (n = 11), and/or CP (n = 4). There was no convincing evidence for an association of PDPH with either OP or CP. A minority of studies documenting an association with V included patients with high-volume CSF removal, and/or stratified patients by the timing of the headache onset. CONCLUSIONS: The overall risk of PDPH does not appear to be influenced by OP, CP, V or PVI. PDPH may be related to V in instances of high-volume removal, and depend on the timing of outcome assessment. Future revision of criteria should consider the existence of immediate and delayed PDPH subtypes, and not presume intracranial hypotension as a mandatory feature.

Normal intrathecal leukocyte cell number and composition do not decrease the incidence of post-lumbar puncture headache.

The pathogenesis of post-lumbar puncture headache (PLPH) has remained unclear. A beneficial role of CSF cells in the repair of a post-traumatic dural CSF leak has been suggested. The primary purpose of this study was to investigate the effects of 8weeks of induction therapy with high-dose PF-00547659 on the cellular elements of CNS immune surveillance in patients with active Crohn's Disease and a history of immunosuppressive therapy (Clinicaltrials.govNCT01387594). PF-00547659 is a human monoclonal antibody that binds to mucosal addressin-cell adhesion molecule 1 (MAdCAM-1) on endothelial cells and blocks its interaction with beta7-integrin expressing lymphocytes. The study was executed in three parts or cohorts under two protocols. The incidence of a PLPH was 35% after the initial lumbar puncture, and 26% following the second lumbar puncture. After initiation of PF-00547659 anti-MAdCAM-1 therapy, there was a small and non-significant increase in the numbers of overall CSF leukocytes, and in lymphocyte subsets (CD3+, CD4+, and CD8+ T cells). The lymphocyte composition was unaltered by PF-00547659 anti-MAdCAM-1 therapy. Our observations suggest that normal numbers and composition of intrathecal leukocytes do not decrease the incidence of PLPH.

The effect of serial in vitro haemodilution with maternal cerebrospinal fluid and crystalloid on thromboelastographic (TEG(®) ) blood coagulation parameters, and the implications for epidural blood patching.

Epidural blood patches may be used to treat post-dural puncture headache following accidental dural puncture in parturients. Their mode of action and the optimum volume of blood for injection remain controversial, with the interaction between injected blood and cerebrospinal fluid unknown. We aimed to establish the effects of serial haemodilution of whole blood with cerebrospinal fluid from 34 pregnant patients compared with serial haemodilution with Hartmann's solution, using the thromboelastogram. Haemodilution with either cerebrospinal fluid or Hartmann's solution had significant procoagulant and clot destabilising effects, enhanced with progressive haemodilution up to 30%. The effect of cerebrospinal fluid was greater compared with Hartmann's solution (p < 0.001). Cerebrospinal fluid led to a mean (95% CI) decrease in r-time by 2.4 (1.6-3.2) min, a decrease in k-time by 0.6 (0.4-0.8) min, an increase in alpha angle by 7.3 (5.5-9.0)°, and a decrease in maximum amplitude by 2.0 (0.6-3.4) mm. This may have implications for epidural blood patch, as success may be reduced near the time of dural puncture when cerebrospinal fluid leak is at its greatest, and large volumes of blood may be required to reduce haemodilution and clot destabilisation by cerebrospinal fluid. In addition, blood patching should be performed at the level of the dural puncture in order to ensure that the maximum volume of blood comes into contact with the cerebrospinal fluid.

[Post-dural puncture headache and blood-patch: theoretical and practical approach]. / Céphalées post-brèches méningées et blood-patch: aspects théoriques et pratiques.

OBJECTIVE: To review the current research and formulate a rational approach to the physiopathology, cause and treatment of post-dural puncture headache (PDPH). DATA SOURCES: Articles published to December 2011 were obtained through a search of Medline for the MeSh terms "epidural blood-patch" and "post-dural puncture headache". STUDY SELECTION: Six hundred and eighty-two pertinent studies were included and 200 were analysed. DATA SYNTHESIS: Resulting of a dural tap after spinal anaesthesia or diagnostic lumbar puncture or as a complication of epidural anaesthesia, PDPH occurs when an excessive leak of cerebrospinal fluid leads to intracranial hypotension associated to a resultant cerebral vasodilatation. Reduction in cerebrospinal fluid volume in upright position may cause traction of the intracranial structure and stretching of vessels. Typically postural, headache may be associated to nausea, photophobia, tinnitus or arm pain and changes in hearing acuity. In severe cases, there may be cranial nerve dysfunction and nerve palsies secondary to traction on those nerves. The Epidural Blood-Patch (EBP) is considered as the "gold standard" in the treatment of PDHP because it induces a prolonged elevation of subarachnoid and epidural pressures, whereas such elevation is transient with saline or dextran. EBP should be performed within 24-48hours of onset of headache; the optimum volume of epidural blood appears to be 15-20mL. Severe complications following EBP are exceptional. The use of echography may be safety puncture. The optimum timing of epidural blood-patch, the resort of repeating procedure if the symptomatology does not disappear, the alternative to the conventional medical treatment need to be determined by future clinical trial.

[Obstetrical epidural analgesia during labour: one dural puncture, repeated postural headaches, three blood patches ]. / Analgésie péridurale obstétricale pour le travail: une brèche dure-mérienne, des céphalées posturales, trois blood patchs

We report the case of a patient in whom three blood patches had to be performed to treat a post-dural puncture headache following the insertion of an epidural catheter for labour analgesia. There are few data about repeated blood patches used to treat recurring symptoms after failure of a previous blood patch. The technical guidelines used to perform a first blood patch should be followed for the next procedure as well. The role of the cerebrospinal fluid leaking in the symptoms has to be verified, to avoid performing a useless blood patch and to miss another cause, which needs an urgent treatment.