Epidural blood patch is the gold standard treatment for dural puncture headache

Abstract

Editor—We read with interest the correspondence in two recent issues of the BJA relating to patients with known dural punctures.1Fiala A Furgler G Baumgartner E Paal P Delayed subdural haematoma complicated by abducens nerve palsy and cortical vein thrombosis after obstetric epidural anaesthesia.Br J Anaesth. 2012; 108: 705-706Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar 2Loures V Savoldelli GL Alberque C Haller G Post-dural puncture cerebrospinal fluid leak presenting as an acute psychiatric illness.Br J Anaesth. 2012; 108: 529-530Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar In the first report, the patient had a known dural puncture with an 18 G Tuohy needle and developed a headache later that day, but did not receive a blood patch until day 11 post-puncture and remained in hospital until day 19. A cerebral magnetic resonance imaging was performed on day 7 due to concerns over worsening neurology (bilateral subdural haematoma and diffuse meningeal swelling consistent with intracerebral hypotension)1Fiala A Furgler G Baumgartner E Paal P Delayed subdural haematoma complicated by abducens nerve palsy and cortical vein thrombosis after obstetric epidural anaesthesia.Br J Anaesth. 2012; 108: 705-706Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar and repeated on day 17, by which time she had developed a cortical vein thrombosis. The second patient, received a combined spinal–epidural, developed a dural puncture headache and received an epidural blood patch shortly afterwards, although the exact time is not mentioned. The headache resolved and the patient was discharged home 2 days later. She presented again 4 weeks later with a dural puncture headache and psychiatric symptoms and intracranial hypotension confirmed on computed tomography. She underwent a lumbar puncture, confirming a low cerebrospinal fluid pressure but was not offered a repeat blood patch. She was discharged home 17 days later. In UK practice, blood patches are recommended as the gold standard for treatment of dural puncture headaches.3Boonmark P Boonmark S Epidural blood patching for preventing and treating post-dural puncture headache.Cochrane Database Syst Rev. 2010; (CD001791)Google Scholar Our usual practice would be to offer a blood patch to a patient with a known dural puncture and symptoms of a low-pressure headache, normally on the day after the dural puncture. If symptoms remain, a repeat patch would be offered, usually 24 h later. In the first case, the patient developed a subdural bleed secondary to meningeal traction. If a blood patch had been performed 24 h post-puncture, it may have led to a complete resolution of symptoms and may have prevented the excessive dural stretch leading to this bleed. Prevention of ongoing meningeal stretch may also have prevented the thrombosis formation. When the patient finally received a blood patch on day 11, all her symptoms resolved. It is not clear why the blood patch was not performed earlier. Similarly, in the second case, a blood patch caused resolution of all neurological symptoms initially. On return of similar problems, albeit complicated by the psychiatric disturbance, the authors performed a lumbar puncture. Lumbar punctures are reported to cause dural puncture headaches in at least 32% of non-obstetric patients.4Hammond E Wang Z Bhulani N et al.Needle type and the risk of post-lumbar puncture headache in the outpatient neurology clinic.J Neurol Sci. 2011; 306: 24-28Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar A repeat blood patch on this day might have resolved all of the symptoms. Both cases are sad situations where a new mother is unable or incapable of looking after her baby as a direct result of an anaesthetic intervention. A blood patch performed earlier might have allowed these families to return home sooner, care for and bond sooner with their babies, and settle quicker into normal family life. Do both of these cases illustrate differences in the management of patients with known dural punctures between the UK and other parts of the EU? More prompt epidural blood patching may prevent other more serious complications—it is interesting to consider what might underlie these differences in approach. None declared.