Abstract TP111: Pterygopalatine Fossa Blockade As Novel, Narcotic-sparing Treatment For Headache In Patients With Spontaneous Subarachnoid Hemorrhage - A Case Series

Abstract

Background & Purpose: Severe headache is a hallmark of spontaneous subarachnoid hemorrhage (SAH), affecting nearly 90% of patients during index hospitalization. In addition, up to 25% of SAH-survivors experience chronic headaches. Despite its high prevalence, means of management of headaches are limited, largely reliant on opioids, and often ineffective. Urgent efforts to reduce opioid use require innovative treatment strategies for the management of post-SAH headaches. Methods: This is a retrospective cohort comprising 12 adults who received bilateral pterygopalatine fossa (PPF) blockade from 9/2018 to 3/2021 for refractory headaches after spontaneous SAH. We examined pain scores, analgesic requirements and transcranial doppler ultrasound (TCD) parameters before and after the block placement. Descriptive statistics were calculated for all variables. Results: Twelve patients (mean age 54 years, 66% females, nine aneurysmal and three non-aneurysmal SAH) received PPF-block on post-bleed day 2 to 11 (median 6.5) during hospitalization in the neurointensive care unit. Hunt and Hess scores ranged from 1-3. Pain scale scores from 24-hour period before the block (8.8 ±1.4; mean, SD) decreased significantly to a mean of 5.1 (SD ± 3.0) until 20 hours post-block (p = 0.0156). Opioid use also decreased significantly from median (range) oral morphine equivalent dose (mg) administered in the 24h before the block of 22.5 (0-75) vs. 7.5 (0-45) after PPF-block (p=0.0391). Five (41%) patients had radiographic (but not clinical) vasospasm by TCD criteria before PPF-block; in four of these patients, TCD velocities improved on the day after PPF-block, in one patient velocities were increased on the day after PPF-block. The block was well tolerated with no adverse events of bleeding, infection, pain, or numbness at the injection site. Conclusion: These results demonstrate that PPF-blockade might be a promising alternative for managing post-SAH headaches. Further prospective controlled randomized powered to address the safety and efficacy of the PPF-block are warranted.