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Wu X, Cao X, Zhang M, Wang Q, Han J, Sun X, Huo K, Shang S, Luo G. Post-dural puncture headache combined with pneumocephalus secondary to vaginal delivery following epidural anesthesia: a case report. BMC Pregnancy Childbirth 2023; 23:548. [PMID: 37525146 PMCID: PMC10388502 DOI: 10.1186/s12884-023-05861-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 07/20/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Pneumocephalus is rare in vaginal deliveries. Pneumocephalus may be asymptomatic or present with signs of increased intracranial pressure. However, parturients who received epidural anesthesia with air in their brains may experience low intracranial pressure headaches after giving birth, causing the diagnosis of pneumocephalus to be delayed. We report a case of a parturient who developed post-dural puncture headache combined with pneumocephalus secondary to vaginal delivery following epidural anesthesia. CASE PRESENTATION A 24-year-old G1P0 Chinese woman at 38 weeks gestation was in labor and received epidural anesthesia using the loss of resistance to air technique and had a negative prior medical history. She presented with postural headache, neck stiffness and auditory changes 2 h after vaginal delivery. The head non-contrast computed tomography revealed distributed gas density shadows in the brain, indicating pneumocephalus. Her headache was relieved by bed rest, rehydration, analgesia, and oxygen therapy and completely disappeared after 2 weeks of postpartum bed rest. CONCLUSIONS This is the first report that positional headaches after epidural anesthesia may not indicate low intracranial pressure alone; it may combine with pneumocephalus, particularly when using the loss of resistance to air technique. At this moment, head computed tomography is essential to discover other conditions like pneumocephalus.
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Affiliation(s)
- Xiaoyu Wu
- First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, P.R. China
| | - Xiangqi Cao
- Tang Du Hospital, The Fourth Military Medical University, No.1 Xinsi Road, Xi'an, 710038, P.R. China
| | - Mengyuan Zhang
- Second Affiliated Hospital of Xi'an Jiaotong University, No. 157 Xiwu Road, Xi'an, 710004, P.R. China
| | - Qingfan Wang
- First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, P.R. China
| | - Jiaxin Han
- First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, P.R. China
| | - Xinyue Sun
- First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, P.R. China
| | - Kang Huo
- First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, P.R. China
| | - Suhang Shang
- First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, P.R. China
| | - Guogang Luo
- First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, P.R. China.
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Salih HR, Jaafer H, Ismail M, Khallaf AK, Mohammed AJ, Al-Mosawy MSMJ, Naser HS, Maulood ZT, Hafedh AN, Hoz SS. Extensive tension pneumocephalus presented in the setting of a challenging etiology. Surg Neurol Int 2022; 13:570. [PMID: 36600732 PMCID: PMC9805630 DOI: 10.25259/sni_948_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 11/21/2022] [Indexed: 12/14/2022] Open
Abstract
Background Pneumocephalus (PNC) is a well-described consequence in postoperative settings and skull fractures that is usually self-limiting. It can get complicated into tension PNC on some rare occasions, leading to an intracranial mass effect. PNC was also reported after unintentional dural puncture throughout the epidural anesthesia process. However, tension PNC resulting from epidural anesthesia procedures is an extremely rare outcome that implies urgent intervention to relieve the tension within the brain. Here, we report a case of an extensive tension intraventricular PNC 2 days following an epidural anesthesia procedure for a femur fixation surgery. Case Description A 23-year-old male presented to the emergency department with basal skull fractures and a femur fracture due to a motorcycle accident. His skull base fracture was managed conservatively then he underwent a femur fixation procedure under epidural anesthesia. Two days after, he developed a severe headache with a disturbed level of consciousness. Computed tomography of the brain revealed an extensive PNC that involved all the subarachnoid spaces down to the cervical region and compressing the cerebellum, which was not found in the initial imaging. The patient's status improved after the twist-drill burr-hole evacuation of air under the water seal. Conclusion Extensive tension PNC can occur after traumatic brain injury, especially after epidural anesthesia. Such cases should gain high focus because they may differ from simple PNC regarding diagnosis, treatment, and follow-up.
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Affiliation(s)
- Hayder R. Salih
- Department of Neurosurgery, Neurosurgery Teaching Hospital, Baghdad, Iraq
| | - Huda Jaafer
- Department of Neurosurgery, University of Baghdad, College of Medicine, Baghdad, Iraq
| | - Mustafa Ismail
- Department of Neurosurgery, University of Baghdad, College of Medicine, Baghdad, Iraq
| | - Ali Kareem Khallaf
- Department of Neurosurgery, Neurosurgery Teaching Hospital, Baghdad, Iraq
| | | | | | - Hawraa Sadiq Naser
- Department of Neurosurgery, University of Alameed, College of Medicine, Karbala, Iraq
| | | | - Anwar N. Hafedh
- Department of Neurosurgery, Neurosurgery Teaching Hospital, Baghdad, Iraq
| | - Samer S. Hoz
- Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio, United States.,Corresponding author: Samer S. Hoz, Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio, United States.
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Zetlaoui PJ, Buchheit T, Benhamou D. Epidural blood patch: A narrative review. Anaesth Crit Care Pain Med 2022; 41:101138. [DOI: 10.1016/j.accpm.2022.101138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 04/01/2022] [Accepted: 04/01/2022] [Indexed: 11/24/2022]
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Kovalevska K, Hochstätter R, Augustin M, Schittek GA, Bornemann-Cimenti H. [Subdural hematoma and pneumocephalus after neuraxial anesthesia : Clarification of postdural puncture headache after obstetric peridural anesthesia]. Anaesthesist 2022; 71:373-376. [PMID: 34923591 PMCID: PMC9068636 DOI: 10.1007/s00101-021-01077-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 10/21/2021] [Accepted: 11/20/2021] [Indexed: 10/27/2022]
Affiliation(s)
- Kateryna Kovalevska
- Klin. Abt. für allgemeine Anästhesiologie, Notfall- und Intensivmedizin, Medizinische Universität Graz, Auenbruggerplatz 5/5, 8036, Graz, Österreich
| | - Rüdiger Hochstätter
- Klin. Abt. für Geburtshilfe, Universitätsklinik für Frauenheilkunde und Geburtshilfe, Medizinische Universität Graz, Graz, Österreich
| | - Michael Augustin
- Universitätsklinik für Radiologie, Medizinische Universität Graz, Graz, Österreich
| | - Gregor Alexander Schittek
- Klin. Abt. für allgemeine Anästhesiologie, Notfall- und Intensivmedizin, Medizinische Universität Graz, Auenbruggerplatz 5/5, 8036, Graz, Österreich
| | - Helmar Bornemann-Cimenti
- Klin. Abt. für allgemeine Anästhesiologie, Notfall- und Intensivmedizin, Medizinische Universität Graz, Auenbruggerplatz 5/5, 8036, Graz, Österreich.
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5
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Don't Forget Rare Causes of Postpartum Headache! Cases Report and Literature Review. ACTA ACUST UNITED AC 2021; 57:medicina57040376. [PMID: 33924718 PMCID: PMC8069772 DOI: 10.3390/medicina57040376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/07/2021] [Accepted: 04/12/2021] [Indexed: 11/22/2022]
Abstract
Headache is a common finding in the postpartum period, caused by a spectrum of different conditions. Most headaches in the postpartum period are self-limiting and benign in etiology, but there are some potentially serious causes to be considered. We disclose two cases of postpartum headache, initially considered as post-dural puncture headache (PDPH), that evolved into a harmful condition and showed that an expanded differential diagnosis for headache in the postpartum is mandatory, requiring a high level of attention from health professionals. In fact, a careful examination of the medical history, physical examination, and the recognition for the need for early neuroradiological imaging should increase diagnostic accuracy.
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6
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Park SK, Park SH, Lee BW, Cho WJ, Choi YS. Pneumocephalus following fluoroscopy-guided lumbar epidural injection in elderly patients: two cases report and a review of Korean literatures - Two cases report. Anesth Pain Med (Seoul) 2020; 15:492-497. [PMID: 33329854 PMCID: PMC7724120 DOI: 10.17085/apm.19087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/14/2019] [Accepted: 11/25/2019] [Indexed: 11/17/2022] Open
Abstract
Background Pneumocephalus can originate from accidental dural puncture while performing epidural block using the loss-of-resistance (LOR) technique with an air-filled syringe. Case We present two cases of pneumocephalus after lumbar epidural block under fluoroscopy for pain control in elderly patients. Conclusions Lumbar epidural block should be performed under fluoroscopic guidance in elderly patients with severe lesions. The physician should be aware of the increased possibility of a dural puncture occurring due to anatomical changes in older patients. The use of saline is recommended for the LOR technique. A contrast injection should be used together with the LOR technique to locate the epidural space. If a dural puncture occur, the patient should be carefully monitored to determine whether pneumocephalus has developed.
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Affiliation(s)
- Sun Kyung Park
- Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, Jeju, Korea
| | - Sang Hyun Park
- Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, Jeju, Korea
| | - Bang Won Lee
- Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, Jeju, Korea
| | - Woo Jin Cho
- Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, Jeju, Korea
| | - Yun Suk Choi
- Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, Jeju, Korea
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7
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Gupta A, von Heymann C, Magnuson A, Alahuhta S, Fernando R, Van de Velde M, Mercier FJ, Schyns-van den Berg AMJV, Bryon B, Soetens F, Dewandre PY, Lambert G, Christiaen J, Schepers R, Van Houwe P, Kalmar A, Vanoverschelde H, Bauters M, Roofthooft E, Devroe S, Van de Velde M, Jadrijevic A, Jokic A, Marin D, Sklebar I, Mihaljević S, Kosinova M, Stourac P, Adamus M, Kufa C, Volfová I, Zaoralová B, Froeslev-Friis C, Mygil B, Krebs Albrechtsen C, Kavasmaa T, Alahuhta S, Mäyrä A, Mennander S, Rautaneva K, Hiekkanen T, Kontinen V, Linden K, Toivakka S, Boselli E, Greil PÉ, Mascle O, Courbon A, Lutz J, Simonet T, Barbier M, Hlioua T, Meniolle d’Hauthville F, Quintin C, Bouattour K, Lecinq A, Soued M, Bonnet MP, Carbonniere M, Fischer C, Picard PC, Bonnin M, Storme B, Bouthors AS, Detente T, Nguyen Troung M, Keita H, Nebout S, Osse L, Delmas A, Vial F, Kaufner L, Hoefing C, Mueller S, Becke K, Blobner M, Lewald H, Schaller SJ, Muggleton E, Bette B, Neumann C, Weber S, Grünewald M, Ohnesorge H, Helf A, Jelting Y, Kranke P, von Heymann C, Welfle S, Staikou C, Stavrianopoulou A, Tsaroucha A, Kalopita K, Loukeri A, Valsamidis D, Matsota P, Thorsteinsson A, Tome R, Eidelman LA, Davis A, Orbach-Zinger S, Ioscovich A, Ramona I, De Simone L, Pesetti B, Brazzi L, Zito A, Camorcia M, Della Rocca G, Aversano M, Frigo MG, Todde C, Morina Q, Macas A, Keraitiene G, Rimaitis K, Borg F, Tua C, Kuijpers-Visser AG, Schyns-van den Berg A, Hollmann MW, Van den Berg T, Koolen E, Dons I, van der Knijff A, van der Marel C, Ruysschaert N, Pelka M, Pluymakers C, Koopman S, Teunissen AJ, Cornelisse D, van Dasselaar N, Verdouw B, Beenakkers I, Dahl V, Hagen R, Vivaldi F, Eriksen JR, Wiszt R, Aslam Tayyaba N, Ringvold EM, Chutkowski R, Skirecki T, Wódarski B, Faria MA, Ferreira A, Sampaio AC, Ferreira I, Matias B, Teixeira J, Araujo R, Cabido H, Fortuna R, Lemos P, Cardoso C, Moura F, Pereira C, Pereira S, Tavares F, Vasconcelos P, Abecasis M, Lança F, Muchacho P, Ormonde L, Guedes-Araujo I, Pinho-Oliveira V, Paredes P, Bentes C, Gouveia F, Milheiro A, Castanheira C, Neves M, Pacheco V, Cortez M, Tranquada R, Tareco G, Furtado I, Pereira E, Marinho L, Seabra M, Bulasevic A, Kendrisic M, Jovanovic L, Pujić B, Kutlesic M, Grochova M, Simonova J, Pavlovic G, Rozman A, Blajic I, Graovac D, Stopar Pintraic T, Chiquito T, Monedero P, Carlos-Errea DJ, Guillén-Casbas R, Veiga-Gil L, Basso M, Garcia Bartolo C, Hernandez C, Ricol L, De Santos MP, Gràcia Solsona JA, López-Baamonde M, Magaldi Mendaña M, Plaza Moral AM, Vendrell M, Trillo L, Perez Garcia AR, Alamillo Salas C, Moret E, Ramió L, Aguilar Sanchez JL, Soler Pedrola M, Valldeperas Hernandez MI, Aldalur G, Bárcena E, Herrera J, Iturri F, Martínez A, Martínez L, Serna R, Gilsanz F, Guasch Arevalo E, Iannuccelli F, Latorre J, Rodriguez Roca C, Pérez Pardo OC, Sierra Biddle N, Suárez Cendaña C, Hernández González L, Remacha González C, Sánchez Nuez R, Anta D, Beleña JM, García-Cuadrado C, Garcia I, Manrique S, Suarez E, Hein A, Arbman E, Hansson H, Tillenius M, Al-Taie R, Ledin-Eriksson S, Lindén-Söndersö A, Rosén O, Austruma E, Gillberg L, Darvish B, Gupta A, Nordstöm JL, Persson J, Rosenberg J, Brühne L, Forshammar J, Ugarph Edfeldt M, Rolfsson H, Hellblom A, Levin K, Rabow S, Thorlacius K, Bansch P, Robertson (Baeriswyl) M, Stamer U, Mathivon S, Savoldelli G, Auf der Maur P, Filipovic M, Dullenkopf A, Brunner M, Girard T, Vonlanthen C, Ozbilgin S, Gunaydin D B, Corman Dincer P, Tas Tuna A. Management practices for postdural puncture headache in obstetrics: a prospective, international, cohort study. Br J Anaesth 2020; 125:1045-1055. [PMID: 33039123 DOI: 10.1016/j.bja.2020.07.061] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 07/05/2020] [Accepted: 07/30/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Accidental dural puncture is an uncommon complication of epidural analgesia and can cause postdural puncture headache (PDPH). We aimed to describe management practices and outcomes after PDPH treated by epidural blood patch (EBP) or no EBP. METHODS Following ethics committee approval, patients who developed PDPH after accidental dural puncture were recruited from participating countries and divided into two groups, those receiving EBP or no EBP. Data registered included patient and procedure characteristics, headache symptoms and intensity, management practices, and complications. Follow-up was at 3 months. RESULTS A total of 1001 patients from 24 countries were included, of which 647 (64.6%) received an EBP and 354 (35.4%) did not receive an EBP (no-EBP). Higher initial headache intensity was associated with greater use of EBP, odds ratio 1.29 (95% confidence interval 1.19-1.41) per pain intensity unit increase. Headache intensity declined sharply at 4 h after EBP and 127 (19.3%) patients received a second EBP. On average, no or mild headache (numeric rating score≤3) was observed 7 days after diagnosis. Intracranial bleeding was diagnosed in three patients (0.46%), and backache, headache, and analgesic use were more common at 3 months in the EBP group. CONCLUSIONS Management practices vary between countries, but EBP was more often used in patients with greater initial headache intensity. EBP reduced headache intensity quickly, but about 20% of patients needed a second EBP. After 7 days, most patients had no or mild headache. Backache, headache, and analgesic use were more common at 3 months in patients receiving an EBP.
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Affiliation(s)
- Anil Gupta
- Department of Perioperative Medicine and Intensive Care and Institution of Physiology and Pharmacology, Karolinska Hospital and Karolinska Institutet, Stockholm, Sweden.
| | - Christian von Heymann
- Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Anders Magnuson
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Seppo Alahuhta
- Department of Anaesthesiology, Medical Research Center Oulu, University of Oulu, Oulu University Hospital, Oulu, Finland
| | - Roshan Fernando
- Department of Anesthesiology and Intensive Care Medicine, The Womens Wellness and Research Centre, Doha, Qatar
| | | | - Frédéric J Mercier
- Département d'Anesthésie, Hôpital Antoine Béclère, AP-HP, Université Paris-Saclay, France
| | - Alexandra M J V Schyns-van den Berg
- Department of Anesthesiology, Albert Schweitzer Ziekenhuis, Dordrecht and Department of Anesthesiology, Leiden University Medical Centre, Leiden, The Netherlands
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Koo J, Cho KT. Pneumocephalus and Chemical Meningitis after Inadvertent Dural Puncture during Lumbar Epidural Injection. Korean J Neurotrauma 2020; 16:67-72. [PMID: 32395453 PMCID: PMC7192798 DOI: 10.13004/kjnt.2020.16.e8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 03/25/2020] [Accepted: 03/27/2020] [Indexed: 01/10/2023] Open
Abstract
Inadvertent dural puncture (IDP) is one of the complications of lumbar epidural steroid injections (ESIs). We report a case in which pneumocephalus and chemical meningitis developed at the same time after an IDP during a lumbar interlaminar ESI. A 60-year-old woman presented to the emergency room with thunderclap headache and febrile sensation 3 hours after receiving a lumbar interlaminar ESI. Brain computed tomography (CT) scan showed multiple small foci of air within the subarachnoid space and ventricle. After the admission, the patient was afebrile and reported mild improvement of headache with analgesics. However, 2 days after the admission, headache worsened and fever recurred. Follow-up brain CT scan revealed resolution of the pneumocephalus. A diagnostic lumbar puncture for cerebrospinal fluid (CSF) examination revealed the findings suggestive of aseptic (chemical) meningitis rather than bacterial meningitis. With symptomatic treatment, headache improved and there was no fever after 48 hours. No bacteria, Mycobacterium, or fungi grew in the CSF for 7 days. This case shows an IDP during a lumbar ESI can cause pneumocephalus and chemical meningitis at the same time and efforts should be made to reduce the risk of IDP during lumbar ESIs.
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Affiliation(s)
- Jinhwan Koo
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Keun-Tae Cho
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
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Pires AF, Mendes TM, Reis AA, Pacheco AF, Fagundes V, Mesquita M. Symptomatic Pneumocephalus as a Complication of Lumbar Epidural Anaesthesia. Eur J Case Rep Intern Med 2020; 7:001425. [PMID: 32133317 PMCID: PMC7050972 DOI: 10.12890/2020_001425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 12/18/2019] [Indexed: 11/05/2022] Open
Abstract
Introduction Lumbar epidural anaesthesia is a commonly used technique for analgesia during labour. One of the rare complications of this technique is pneumocephalus. Case description We report the case of a 35-year-old female admitted to the Emergency Department with severe headache associated with fast head movements. Five days previously she had a eutocic delivery and lumbar epidural anaesthesia was performed. A brain computed tomography (CT) scan showed pneumocephalus and she was admitted to the hospital ward. A brain CT scan on the fourth day of hospitalization showed resolution of ventricular pneumocephalus. Discussion The most frequently occurring symptom with pneumocephalus is headache associated with fast brain motion resulting from air injection and meningeal irritation. When there is clinical suspicion of pneumocephalus, a brain CT scan should be performed for the diagnosis. LEARNING POINTS Pneumocephalus is the presence of air in the intracranial cavity and its development after spinal or epidural anaesthesia is extremely infrequent.Headache that occurs in the setting of lumbar epidural anaesthesia should not be labelled as post-dural puncture headache.The suspicion of pneumocephalus, based on the characteristics of the headache, should be maintained to obtain an emergent brain CT scan.
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Affiliation(s)
- Ana Filipa Pires
- Serviço de Medicina Interna, Hospital Padre Américo, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | - Teresa Martins Mendes
- Serviço de Medicina Interna, Hospital Padre Américo, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | - Ana Areia Reis
- Serviço de Medicina Interna, Hospital Padre Américo, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | - Ana Ferreira Pacheco
- Serviço de Medicina Interna, Hospital Padre Américo, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | - Vítor Fagundes
- Serviço de Medicina Interna, Hospital Padre Américo, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | - Mari Mesquita
- Serviço de Medicina Interna, Hospital Padre Américo, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
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Algahtani HA, Sait BW, Shirah BH, Almuraee MA. Post-partum headache caused by dual pathology: A message to the anesthetist. ACTA ACUST UNITED AC 2019; 23:262-264. [PMID: 30008004 PMCID: PMC8015576 DOI: 10.17712/nsj.2018.3.20180489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Hussein A Algahtani
- Neurology Section, Department of Medicine, King Saud University for Health Sciences, Jeddah, Kingdom of Saudi Arabia. E-mail:
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Guryildirim M, Kontzialis M, Ozen M, Kocak M. Acute Headache in the Emergency Setting. Radiographics 2019; 39:1739-1759. [DOI: 10.1148/rg.2019190017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Melike Guryildirim
- From the Department of Diagnostic Radiology and Nuclear Medicine, Rush University Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612
| | - Marinos Kontzialis
- From the Department of Diagnostic Radiology and Nuclear Medicine, Rush University Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612
| | - Merve Ozen
- From the Department of Diagnostic Radiology and Nuclear Medicine, Rush University Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612
| | - Mehmet Kocak
- From the Department of Diagnostic Radiology and Nuclear Medicine, Rush University Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612
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12
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Dabas R, Lim MJ, Sng BL. Postdural puncture headache in obstetric neuraxial anaesthesia: Current evidence and therapy. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2019. [DOI: 10.1016/j.tacc.2019.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Cunqueiro A, Scheinfeld MH. Causes of pneumocephalus and when to be concerned about it. Emerg Radiol 2018; 25:331-340. [DOI: 10.1007/s10140-018-1595-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 02/23/2018] [Indexed: 01/05/2023]
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Brogly N, Guasch E, Alsina E, García C, Puertas L, Dominguez A, Diez J, Gómez J, Gilsanz F. Epidural Space Identification With Loss of Resistance Technique for Epidural Analgesia During Labor. Anesth Analg 2018; 126:532-536. [DOI: 10.1213/ane.0000000000002593] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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15
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Abstract
Headache after dural puncture is a common complication accompanying neuraxial anesthesia. The proposed cause is loss of cerebrospinal fluid through the puncture into the epidural space. Although obstetric patients are at risk for the development of this headache because of female gender and young age, there is a difference in the obstetric population. Women who deliver by cesarean delivery have a lower incidence of headache after dural puncture compared with those who deliver vaginally. Treatment of postdural puncture headache is an epidural blood patch. Departments should develop protocols for management of accidental dural puncture, including appropriate follow-up and indications for further management.
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Affiliation(s)
- Robert R Gaiser
- Department of Anesthesiology, University of Kentucky, Lexington, KY 40506, USA.
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Epidural Steroid Injection Complicated by Intrathecal Entry, Pneumocephalus, and Chemical Meningitis. J Emerg Med 2016; 51:265-8. [PMID: 27381953 DOI: 10.1016/j.jemermed.2016.05.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 05/06/2016] [Accepted: 05/17/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Epidural steroid injections are frequently used to treat back and extremity pain. The procedure is generally safe, with a low rate of adverse events, including intrathecal entry, pneumocephalus, and chemical meningitis. CASE REPORT We report a case of a 45-year-old woman who presented to the emergency department (ED) with headache, nausea, vomiting, and photophobia after a lumbar epidural steroid injection. She was afebrile and had an elevated white blood cell count. A non-contrast computed tomography scan of the head revealed pneumocephalus within the subarachnoid space and lateral ventricles. The patient was admitted to the ED observation unit for pain control and subsequently developed a marked leukocytosis and worsening meningismus. A lumbar puncture was performed yielding cerebrospinal fluid (CSF) consistent with meningitis (1,000 total nucleated cells, 89% neutrophils, 85 mg/dL total protein, and no red blood cells). Gram stain revealed no bacteria. The patient was admitted on empiric vancomycin and ceftriaxone. Antibiotics were discontinued at 48 h when CSF cultures remained negative and the patient was clinically asymptomatic. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should consider intrathecal entry and pneumocephalus in patients who present with a headache after an epidural intervention. The management of pneumocephalus includes supportive therapies, appropriate positioning, and supplemental oxygen. These symptoms can be accompanied by fever, leukocytosis, and markedly inflammatory CSF findings consistent with bacterial or chemical meningitis. Empiric treatment with broad-spectrum antibiotics should be initiated until CSF culture results are available.
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Jagia M, Kapoor M, Panjiar P. Pneumocephalus after epidural analgesia: Should loss of resistance with air be blown out? J Anaesthesiol Clin Pharmacol 2016; 32:272-3. [PMID: 27275068 PMCID: PMC4874093 DOI: 10.4103/0970-9185.173399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
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Hsieh XX, Hsieh SW, Lu CH, Wu ZF, Ju DT, Huh B, Wang JC, Kuo CY. A rare case of pneumocephalus and pneumorrhachis after epidural anesthesia. ACTA ACUST UNITED AC 2015; 53:47-9. [DOI: 10.1016/j.aat.2015.01.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 01/16/2015] [Indexed: 10/24/2022]
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Verdun AV, Cohen SP, Williams BS, Hurley RW. Pneumocephalus after lumbar epidural steroid injection: a case report and review of the literature. ACTA ACUST UNITED AC 2015; 3:9-13. [PMID: 25612267 DOI: 10.1213/xaa.0000000000000055] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Pneumocephalus may occur after inadvertent injection of air into the subarachnoid space while performing epidural anesthesia using a loss-of-resistance technique with air in the syringe. We report a case of pneumocephalus after an interlaminar epidural steroid injection using the loss-of-resistance to air technique. In this report, we examine the etiology, the expected course of symptoms, and resolution, as well as treatment, of pneumocephalus following a systematic literature review.
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Affiliation(s)
- Aubrey V Verdun
- From the *Department of Pain Medicine, Walter Reed National Military Medical Center, Bethesda; †Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, Baltimore; ‡Department of Anesthesiology, Kaiser Permanente, Gaithersburg, Maryland; and §Department of Anesthesiology, University of Florida, Gainesville, Florida
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Shih CC, Tsai SH, Liao WI, Wang JC, Hsu CW. Successful treatment of epidural anesthesia-induced severe pneumocephalus by hyperbaric oxygen therapy. Am J Emerg Med 2015; 33:1116.e1-3. [PMID: 25727168 DOI: 10.1016/j.ajem.2015.01.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 01/23/2015] [Indexed: 10/24/2022] Open
Affiliation(s)
- Chang-Chih Shih
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Shih-Hung Tsai
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wen-I Liao
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Jen-Chun Wang
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chin-Wang Hsu
- Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University; Department of Emergency and Critical Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
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Abstract
Lumbar epidural anesthesia is commonly used for labor analgesia. The 'loss-of- resistance' to air technique (LORA) is generally employed for recognition of the epidural space. One of the rare complications of this technique is pneumocephalus (PC). Here we describe the case of a parturient who developed a frontal headache when locating the epidural space using LORA. On the second day after epidural injection, the patient exhibited occipital headaches with gradual worsening. Computed tomography scans of the brain indicated PC. Following symptomatic treatment, our patient was discharged on the 13th day. We concluded that the amount of air used to identify the epidural space in LORA should be minimized, LORA should not be used after dural puncture and the use of saline avoids PC complications.
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Affiliation(s)
- Beatriz Nistal-Nuño
- Department of Anaesthesiology and Perioperative Medicine, Complexo Hospitalario Universitario A Coruña (CHUAC), A Coruña, 15006, Spain
| | - Manuel Ángel Gómez-Ríos
- Department of Anaesthesiology and Perioperative Medicine, Complexo Hospitalario Universitario A Coruña (CHUAC), A Coruña, 15006, Spain
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Antibas PL, do Nascimento Junior P, Braz LG, Vitor Pereira Doles J, Módolo NSP, El Dib R. Air versus saline in the loss of resistance technique for identification of the epidural space. Cochrane Database Syst Rev 2014; 2014:CD008938. [PMID: 25033878 PMCID: PMC7167505 DOI: 10.1002/14651858.cd008938.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The success of epidural anaesthesia depends on correct identification of the epidural space. For several decades, the decision of whether to use air or physiological saline during the loss of resistance technique for identification of the epidural space has been governed by the personal experience of the anaesthesiologist. Epidural block remains one of the main regional anaesthesia techniques. It is used for surgical anaesthesia, obstetrical analgesia, postoperative analgesia and treatment of chronic pain and as a complement to general anaesthesia. The sensation felt by the anaesthesiologist from the syringe plunger with loss of resistance is different when air is compared with saline (fluid). Frequently fluid allows a rapid change from resistance to non-resistance and increased movement of the plunger. However, the ideal technique for identification of the epidural space remains unclear. OBJECTIVES • To evaluate the efficacy and safety of both air and saline in the loss of resistance technique for identification of the epidural space.• To evaluate complications related to the air or saline injected. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 9), MEDLINE, EMBASE and the Latin American and Caribbean Health Science Information Database (LILACS) (from inception to September 2013). We applied no language restrictions. The date of the most recent search was 7 September 2013. SELECTION CRITERIA We included randomized controlled trials (RCTs) and quasi-randomized controlled trials (quasi-RCTs) on air and saline in the loss of resistance technique for identification of the epidural space. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. MAIN RESULTS We included in the review seven studies with a total of 852 participants. The methodological quality of the included studies was generally ranked as showing low risk of bias in most domains, with the exception of one study, which did not mask participants. We were able to include data from 838 participants in the meta-analysis. We found no statistically significant differences between participants receiving air and those given saline in any of the outcomes evaluated: inability to locate the epidural space (three trials, 619 participants) (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.33 to 2.31, low-quality evidence); accidental intravascular catheter placement (two trials, 223 participants) (RR 0.90, 95% CI 0.33 to 2.45, low-quality evidence); accidental subarachnoid catheter placement (four trials, 682 participants) (RR 2.95, 95% CI 0.12 to 71.90, low-quality evidence); combined spinal epidural failure (two trials, 400 participants) (RR 0.98, 95% CI 0.44 to 2.18, low-quality evidence); unblocked segments (five studies, 423 participants) (RR 1.66, 95% CI 0.72 to 3.85); and pain measured by VAS (two studies, 395 participants) (mean difference (MD) -0.09, 95% CI -0.37 to 0.18). With regard to adverse effects, we found no statistically significant differences between participants receiving air and those given saline in the occurrence of paraesthesias (three trials, 572 participants) (RR 0.89, 95% CI 0.69 to 1.15); difficulty in advancing the catheter (two trials, 227 participants) (RR 0.91, 95% CI 0.32 to 2.56); catheter replacement (two trials, 501 participants) (RR 0.69, 95% CI 0.26 to 1.83); and postdural puncture headache (one trial, 110 participants) (RR 0.83, 95% CI 0.12 to 5.71). AUTHORS' CONCLUSIONS Low-quality evidence shows that results do not differ between air and saline in terms of the loss of resistance technique for identification of the epidural space and reduction of complications. Applicability might be compromised, as most of the results described in this review were obtained from parturient patients. This review underlines the need to conduct well-designed trials in this field.
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Affiliation(s)
- Pedro L Antibas
- Hospital Sírio LibanêsDepartment of AnaesthesiologySão Paulo Serviços Médicos de AnestesiaRua Moraes de Barros, 854 ap.41São PauloSão PauloBrazil04614‐001
| | - Paulo do Nascimento Junior
- Botucatu Medical School, Universidade Estadual Paulista (UNESP)Department of AnaesthesiologyDistrito de Rubião Júnior, s/nBotucatu, São PauloBrazil18603‐970
| | - Leandro G Braz
- Botucatu Medical School, Universidade Estadual Paulista (UNESP)Department of AnaesthesiologyDistrito de Rubião Júnior, s/nBotucatu, São PauloBrazil18603‐970
| | - João Vitor Pereira Doles
- Botucatu Medical School, UNESP–Universidade Estadual PaulistaDistrito de Rubião Júnior, s/nBotucatu, São PauloBrazil18618‐970
| | - Norma SP Módolo
- Botucatu Medical School, Universidade Estadual Paulista (UNESP)Department of AnaesthesiologyDistrito de Rubião Júnior, s/nBotucatu, São PauloBrazil18603‐970
| | - Regina El Dib
- Botucatu Medical School, Universidade Estadual Paulista (UNESP)Department of AnaesthesiologyDistrito de Rubião Júnior, s/nBotucatu, São PauloBrazil18603‐970
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Angle PJ, Hussain K, Morgan A, Halpern SH, Van der Vyver M, Yee J, Kiss A. High quality labour analgesia using small gauge epidural needles and catheters. Can J Anaesth 2013; 53:263-7. [PMID: 16527791 DOI: 10.1007/bf03022213] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Inadvertent epidural needle punctures represent the leading cause of severe postdural puncture headache (PDPH) in parturients. Use of small gauge (G) epidural needles for continuous analgesia has received little attention despite possible important reductions in PDPH. We report the first study to examine the feasibility of using small G Tuohy needles and 23 G catheters for labour analgesia. METHODS Healthy parturients <or= 6 cm dilated were recruited. Epidural analgesia was established using a 19 G Tuohy epidural needle, a 23 G single port 40 cm catheter and bupivacaine 0.08% with fentanyl 2 microg x mL(-1) (15-20 mL). Breakthrough pain was treated by protocol. There was no formal in-training period for anesthesiologists. The primary outcome was the combined failure rate for initiation (failed needle/catheter placement or failed block <or= 30 min of drug administration). Secondary out-comes included late block failure (> 30 min), recognized dural puncture, PDPH, patient assessment of analgesia within 24 hr of delivery, complications and anesthesiologist satisfaction. RESULTS Twenty-seven parturients were recruited. Successful blocks were initiated and maintained in 24/27 who rated overall analgesia from good to excellent (19/24 very good to excellent). Three block failures occurred at the initiation phase only (two unilateral, one absent). There was no evidence of catheter kinking after placement. One patient developed PDPH after unrecognized dural puncture which was self-treated with acetaminophen for four days, followed by complete symptom resolution. CONCLUSION It is feasible to provide high quality labour analgesia using small G epidural needles and catheters. The effect of small G epidural needles on PDPH warrants future study.
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Affiliation(s)
- Pamela J Angle
- Department of Anesthesia, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, Ontario M5S 1B2, Canada.
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Sleth JC, Servais R, Javitary W. [Pneumocephalus following a blood patch with saline loss of resistance technique: is there a take-home message?]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2013; 32:624-625. [PMID: 23953320 DOI: 10.1016/j.annfar.2013.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 06/27/2013] [Indexed: 06/02/2023]
Affiliation(s)
- J-C Sleth
- Polyclinique Saint-Roch, 43, rue du Faubourg-Saint-Jaumes, 34967 Montpellier cedex, France.
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Abstract
Headache following dural puncture is a typical complication of neuraxial analgesia and can impair the ability to perform activities of daily living up to incapacitation. The use of thin, atraumatic needles and special puncture techniques (e.g. reinsertion of the stylet) can prevent the majority of post-dural puncture headaches (PDPH). One of the most effective measures to prevent headache after accidental dural puncture is the intrathecal or epidural administration of morphine. When the diagnosis of PDPH is confirmed after excluding relevant differential diagnoses, some of which are potentially life-threatening, caffeine, theophylline and non-opioid analgesics are effective agents to reduce the severity of the symptoms. Traditional measures, such as strict bed rest and hyperhydration can no longer be recommended. If invasive treatment of the headache is warranted an epidural blood patch is still the method of choice with a high rate of success.
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Affiliation(s)
- K Radke
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Dresden, Deutschland
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BRADBURY CL, SINGH SI, BADDER SR, WAKELY LJ, JONES PM. Prevention of post-dural puncture headache in parturients: a systematic review and meta-analysis. Acta Anaesthesiol Scand 2013; 57:417-30. [PMID: 23278515 DOI: 10.1111/aas.12047] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2012] [Indexed: 02/01/2023]
Abstract
Post-dural puncture headaches (PDPHs) present an important clinical problem. We assessed methods to decrease accidental dural punctures (ADPs) and interventions to reduce PDPH following ADP. Multiple electronic databases were searched for randomised clinical trials (RCTs) of parturients having labour epidurals, in which the studied intervention could plausibly affect ADP or PDPH, and the incidence of at least one of these was recorded. Forty RCTs (n = 11,536 epidural insertions) were included, studying combined spinal-epidurals (CSEs), loss of resistance medium, prophylactic epidural blood patches, needle bevel orientation, ultrasound-guided insertion, epidural morphine, Special Sprotte needles, acoustic-guided insertion, administration of cosyntropin, and continuous spinal analgesia. The RCTs for CSE, loss of resistance medium, and prophylactic epidural blood patches were meta-analysed. Five methods reduced PDPH: prophylactic epidural blood patch {four trials, median quality score = 2, risk difference = -0.48 [95% confidence interval (CI): -0.88 to -0.086]}, lateral positioning of the epidural needle bevel upon insertion (one trial, quality score = 1), Special Sprotte needles [one trial, quality score = 5, risk difference = -0.44 (95% CI: -0.67 to -0.21)], epidural morphine [one trial, quality score = 4, risk difference = -0.36 (95% CI -0.59 to -0.13)], and cosyntropin [one trial, quality score = 5, risk difference = -0.36 (95% CI -0.55 to -0.16)]. Several methods potentially reduce PDPH. Special Sprotte needles, epidural morphine, and cosyntropin are thus far each supported by a single, albeit good quality trial. Prophylactic blood patches are supported by three trials, but these had flawed methodology. Mostly, trials were of limited quality, and further well-conducted, large studies are needed.
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Affiliation(s)
- C. L. BRADBURY
- Department of Anesthesia & Perioperative Medicine; Schulich School of Medicine & Dentistry; St Joseph's Health Care London; London; ON; Canada
| | - S. I. SINGH
- Department of Anesthesia & Perioperative Medicine; Schulich School of Medicine & Dentistry; St Joseph's Health Care London; London; ON; Canada
| | - S. R. BADDER
- Department of Anesthesia & Perioperative Medicine; Schulich School of Medicine & Dentistry; St Joseph's Health Care London; London; ON; Canada
| | - L. J. WAKELY
- Department of Anesthesia & Perioperative Medicine; Schulich School of Medicine & Dentistry; St Joseph's Health Care London; London; ON; Canada
| | - P. M. JONES
- Department of Anesthesia & Perioperative Medicine; Schulich School of Medicine & Dentistry; St Joseph's Health Care London; London; ON; Canada
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A preoperative headache. Anesthesiology 2013; 119:1210. [PMID: 23314166 DOI: 10.1097/aln.0b013e3182815967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hollister N, Todd C, Ball S, Thorp-Jones D, Coghill J. Minimising the risk of accidental dural puncture with epidural analgesia for labour: a retrospective review of risk factors. Int J Obstet Anesth 2012; 21:236-41. [PMID: 22633623 DOI: 10.1016/j.ijoa.2012.01.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Revised: 01/27/2012] [Accepted: 01/31/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Accidental dural puncture has a quoted incidence of between 0.19% and 3.6% of obstetric epidurals and is associated with significant morbidity. We set out to determine possible factors associated with an increased risk of accidental dural puncture. METHODS We performed a retrospective review of 18385 epidurals, performed over a 15-year period. Factors analysed were: time of day of insertion, loss-of-resistance technique, maternal position, cervical dilatation, grade of anaesthetist and depth to the epidural space. RESULTS Using univariate analyses we found no association between the risk of accidental dural puncture and the following variables: time of day of insertion (P=0.71), loss-of-resistance technique (P=0.22), maternal position for insertion (P=0.83), degree of cervical dilatation (P=0.41) and grade of anaesthetist performing the epidural (P=0.34). Conversely, we found that the risk of accidental dural puncture increased with increasing depth to the epidural space. This was confirmed using a logistic regression analysis, from which it was estimated that, for every 1-cm increase in depth, the risk of accidental dural puncture increased by approximately 19% (P=0.019; 95% CI for OR: 1.029-1.38). CONCLUSION We conclude that the risk of accidental dural puncture increases with increasing depth to the epidural space. We suggest further study is required to correlate this risk with increasing body mass index.
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Affiliation(s)
- N Hollister
- Department of Anaesthesia, Derriford Hospital, Plymouth, UK.
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Paech M. Iatrogenic headaches: giving everyone a sore head. Int J Obstet Anesth 2012; 21:1-3. [DOI: 10.1016/j.ijoa.2011.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Accepted: 11/10/2011] [Indexed: 11/28/2022]
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López Correa T, Garzón Sánchez J, Sánchez Montero F, Muriel Villoria C. Cefalea postpunción dural en obstetricia. REVISTA ESPAÑOLA DE ANESTESIOLOGÍA Y REANIMACIÓN 2011; 58:563-73. [PMID: 22279876 DOI: 10.1016/s0034-9356(11)70141-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Iseri T, Nishimura R, Nagahama S, Mochizuki M, Nakagawa T, Fujimoto Y, Zhang D, Sasaki N. Epidural spread of iohexol following the use of air or saline in the ‘loss of resistance’ test. Vet Anaesth Analg 2010; 37:526-30. [DOI: 10.1111/j.1467-2995.2010.00562.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Gómez-Ríos MA, Nieto Serradilla L. [Comments on the letter "Pneumocephalus as a complication of accidental spinal puncture during epidural anesthesia"]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2010; 57:603-604. [PMID: 21155344 DOI: 10.1016/s0034-9356(10)70290-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Helbig GM, Cohen-Gadol AA. The use of intraoperative suprasellar pneumocisternogram for resection of large pituitary tumors. Clin Neurol Neurosurg 2010; 112:897-9. [PMID: 20674152 DOI: 10.1016/j.clineuro.2010.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2009] [Revised: 06/11/2010] [Accepted: 07/04/2010] [Indexed: 11/20/2022]
Abstract
Adequate removal of large pituitary tumors with significant suprasellar extension remains a challenge through the trans-sphenoidal corridor because of this route's limited working window. The application of intracisternal air and intraoperative fluoroscopy is explored as a form of intraoperative imaging to maximize tumor resection and to confirm adequate suprasellar tumor decompression. The authors confirmed adequate decompression of suprasellar space using this technique of fluoroscopy with the present intrathecal air for 10 of 12 patients with giant, non-functioning pituitary tumors. Intraoperative cerebrospinal fluid fistulae prevented the use of intrathecal air in the remaining two patients.
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Affiliation(s)
- Gregory M Helbig
- Clarian Neuroscience, Goodman Campbell Brain and Spine, Indiana University, Department of Neurological Surgery, Indianapolis, IN 46202, United States
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Gentile A, Germain A, Ouattara A, Janvier G. Pneumocephalus following thoracic surgery: the implication of the epidural anesthesia is still exceptional. Interact Cardiovasc Thorac Surg 2010; 11:515-7. [PMID: 20603275 DOI: 10.1510/icvts.2010.241604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Epidural analgesia is the gold standard for the management of pain after thoracopulmonary surgery. However, it is not without side-effects and complications. We report the case of a 52-year-old man who underwent left lower lobectomy for a carcinoid tumor. He received multimodal anesthesia combining epidural thoracic anesthesia and balanced intravenous general anesthesia. He presented with pneumocephalus on the 10th postoperative day. Etiological assessment consisted of isotopic cisternography and cerebromedullar magnetic resonance imaging (MRI), revealing a breach in the fourth left spinal dural nerve sheath. Although it was initially suspected, the thoracic epidural was eventually excluded as the cause. Management consisted of prompt surgical repair.
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Affiliation(s)
- Ariane Gentile
- Department of Anesthesiology and Critical Care, Hôpital du Haut-Lévêque, Centre Hospitalier Universitaire (CHU) Bordeaux, Pessac, France
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Van de Velde M. Modern neuraxial labor analgesia: options for initiation, maintenance and drug selection. ACTA ACUST UNITED AC 2010; 56:546-61. [PMID: 20112546 DOI: 10.1016/s0034-9356(09)70457-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
In the present review we outline the state-of-the-art of neuraxial analgesia. As neuraxial analgesia remains the gold standar of analgesia during labor, we review the most recent literature on this topic. The neuraxial analgesia techniques, types of administration, drugs, adjuvants, and adverse effects are investigated from the references. Most authors would agree that central neuraxial analgesia is the best form to manage labor pain. When neuraxial analgesia is administered to the parturient in labor, different management choices must be made by the anesthetist: how will we initiate analgesia, how will analgesia be maintained, which local anesthetic will we use for neuraxial analgesia and which adjuvant drugs will we combine? The present manuscript tries to review the literature to answer these questions.
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Affiliation(s)
- M Van de Velde
- Department of Anesthesiology, University Hospitals Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium.
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Segal S, Arendt KW. A Retrospective Effectiveness Study of Loss of Resistance to Air or Saline for Identification of the Epidural Space. Anesth Analg 2010; 110:558-63. [DOI: 10.1213/ane.0b013e3181c84e4e] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Schier R, Guerra D, Aguilar J, Pratt GF, Hernandez M, Boddu K, Riedel B. Epidural Space Identification: A Meta-Analysis of Complications After Air Versus Liquid as the Medium for Loss of Resistance. Anesth Analg 2009; 109:2012-21. [DOI: 10.1213/ane.0b013e3181bc113a] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Shehu BB, Ismail NJ, Hassan I. Management of pneumocephalus in a resource limited environment: Review from sub-Saharan Africa. Brain Inj 2009; 21:1217-23. [DOI: 10.1080/02699050701727882] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Kim YJ, Baik HJ, Kim JH, Jun JH. Pneumocephalus Developed during Epidural Anesthesia for Combined Spinal-Epidural Anesthesia. Korean J Pain 2009. [DOI: 10.3344/kjp.2009.22.2.163] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Youn Jin Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Hee Jung Baik
- Department of Anesthesiology and Pain Medicine, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Jong Hak Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Joo Hyun Jun
- Department of Anesthesiology and Pain Medicine, School of Medicine, Ewha Womans University, Seoul, Korea
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Lomax S, Qureshi A. Unusually early onset of post-dural puncture headache after spinal anaesthesia using a 27G Whittacre needle. Br J Anaesth 2008; 100:707-8. [DOI: 10.1093/bja/aen039] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Nafiu OO, Bullough AS. Pneumocephalus and headache after epidural analgesia: should we really still be using air? Anesth Analg 2007; 105:1172-3; author reply 1173. [PMID: 17898416 DOI: 10.1213/01.ane.0000278619.58392.f3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Nafiu O, Urquhart J. In reply. Int J Obstet Anesth 2007. [DOI: 10.1016/j.ijoa.2006.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
PURPOSE OF REVIEW Postdural puncture headache remains the most frequent complication of neuraxial anesthesia. It can occur following uncomplicated spinal anesthesia as well as unintended dural puncture during epidural anesthesia. RECENT FINDINGS The incidence following accidental dural puncture is not as high as previously thought--approximately 50%. There are not many maneuvers that prevent postdural puncture headache. The most promising is an intrathecal catheter as it avoids further dural puncture and seals the hole during the time it is in place, decreasing cerebrospinal fluid loss. Several means to treat a postdural puncture headache exist. Medications that increase cerebral vascular resistance are the ones advocated. Methergine (methylergonovine maleate) has been advocated for postdural puncture headache following spinal anesthesia; it has not been studied for accidental dural puncture with a large bore needle. Epidural blood patch remains the treatment of choice. SUMMARY An epidural blood patch should not be performed until 24 h after dural puncture to increase its success; however, it should not be delayed beyond that period in the symptomatic patient, as this delay increases the amount of time the patient suffers.
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Affiliation(s)
- Robert Gaiser
- Pharmacology, Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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Smarkusky L, DeCarvalho H, Bermudez A, González-Quintero VH. Acute Onset Headache Complicating Labor Epidural Caused by Intrapartum Pneumocephalus. Obstet Gynecol 2006; 108:795-8. [PMID: 17018506 DOI: 10.1097/01.aog.0000209185.54752.48] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Epidural placement for obstetric anesthesia is a common procedure. Pneumocephalus, the introduction of air into the cranial cavity after epidural placement, is a rare complication encountered when air is used for identification of the epidural space. CASE A 42-year-old primipara undergoing epidural placement reported sudden onset of severe headache with associated neurologic symptoms and nuchal rigidity. Emergent CT scan revealed pneumocephalus. With conservative management, her symptoms resolved with interval resumption of the air collection evidenced on interval CT. CONCLUSION Acute onset headache after epidural placement can present with impressive neurologic signs and symptoms. Prompt identification of the cause of this pathology is of vital importance to delineate pneumocephalus from potentially treatable or life-threatening disorders.
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Affiliation(s)
- Loren Smarkusky
- Department of Obstetrics, Division of Maternal Fetal Medicine and Anesthesia, University of Miami School of Medicine/Jackson Memorial Hospital, Miami, FL 33101, USA
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Adachi YU, Sanjo Y, Doi M, Sato S. Depth of the thoracic epidural space in 1776 patients using the paramedian approach. J Clin Anesth 2006; 18:396; author reply 396-7. [PMID: 16905089 DOI: 10.1016/j.jclinane.2005.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2005] [Accepted: 10/27/2005] [Indexed: 10/24/2022]
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Nafiu OO, Urquhart JC. Pneumocephalus with headache complicating labour epidural analgesia: should we still be using air? Int J Obstet Anesth 2006; 15:237-9. [PMID: 16798452 DOI: 10.1016/j.ijoa.2005.10.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2005] [Accepted: 10/01/2005] [Indexed: 11/16/2022]
Abstract
Pneumocephalus is a rare complication of epidural block which typically occurs when the loss of resistance to air technique is used to identify the epidural space. We present a case of pneumocephalus with headache in a parturient following apparently uncomplicated labour epidural analgesia.
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Affiliation(s)
- O O Nafiu
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan 48109, USA.
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Angle P, Tang SLT, Thompson D, Szalai JP. Expectant management of postdural puncture headache increases hospital length of stay and emergency room visits. Can J Anaesth 2005; 52:397-402. [PMID: 15814755 DOI: 10.1007/bf03016283] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
PURPOSE This retrospective cohort study examined hospital length of stay (LOS) and emergency room (ER) visits in parturients diagnosed with postdural puncture headache (PDPH) following recognized dural puncture (DP). All cases were managed expectantly. Outcomes were compared with matched controls with uneventful labour epidurals. METHODS After Ethics Committee approval, the hospital perinatal database was used to identify healthy parturients with recognized DP during labour epidural placement from 1996-2001. Women developing PDPH after expectant management were matched with women with uneventful epidurals and no evidence of PDPH, as well as by parity, delivery mode and admission date. All women delivered term singletons. The primary outcome was LOS (hours) from delivery to discharge. Secondary outcomes included: number (#) nights in hospital, #ER visits for PDPH, epidural blood patch (EBP) timing (pre vs post discharge), EBP location (ward vs ER) and blood volumes used. RESULTS 26 cases and 26 controls were identified. Precise discharge times were found for 23 cases and 23 controls. In cases, the LOS was increased by a mean of 17 +/- 23.8 (SD) hours; [95% conficence interval (CI) = 8, 26; P = 0.0012] and # nights in hospital was increased by a mean of 0.62 +/- 0.94 nights (95% CI, 0.26, 0.98, P = 0.0027). Nineteen cases (73% 19/26) received at least one EBP. Sixteen cases received at least one EBP prior to discharge with 38% (6/16) returning to ER for re-assessment/repeat EBP. Forty-four percent (4/9) of cases without an EBP prior to discharge returned to ER for further assessment/EBP. CONCLUSION PDPH leads to a significant increase in hospital LOS and ER visits. Studies of preventive therapy are warranted.
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Affiliation(s)
- Pamela Angle
- Department of Anesthesiology, Women's College Hospital Campus, Sunnybrook and Women's College Health Sciences Center, 76 Grenville Street, Toronto, Ontario M5S 1B2, Canada.
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