Therapeutic Lumbar Puncture Research Articles

The effect of therapeutic lumbar punctures on acute mortality from cryptococcal meningitis.

Cryptococcal meningitis is the most common cause of adult meningitis in sub-Saharan Africa. Raised intracranial pressure (ICP) is common in cryptococcosis. Prior studies suggest elevated ICP is associated with mortality, and guidelines recommend frequent lumbar punctures (LPs) to control ICP. However, the magnitude of the impact of LPs on cryptococcal-related mortality is unknown. In sum, 248 individuals with human immunodeficiency virus (HIV)-associated cryptococcal meningitis, screened for the Cryptococcal Optimal ART Timing (COAT) trial in Uganda and South Africa, were observed. Individuals received an LP to diagnose meningitis, and subsequent therapeutic LPs were recommended for elevated ICP (>250 mmH2O) or new symptoms. We compared survival, through 11 days, between individuals receiving at least 1 therapeutic LP with individuals not receiving therapeutic LPs. The COAT trial randomized subjects at 7-11 days; thus, follow-up stopped at time of death, randomization, or 11 days. Seventy-five (30%) individuals had at least 1 therapeutic LP. Individuals receiving therapeutic LPs had higher cerebrospinal fluid (CSF) opening pressures, higher CSF fungal burdens, and were more likely to have altered mental status at baseline than those with no therapeutic LPs. Thirty-one deaths (18%) occurred among 173 individuals without a therapeutic LP and 5 deaths (7%) among 75 with at least 1 therapeutic LP. The adjusted relative risk of mortality was 0.31 (95% confidence interval: .12-.82). The association was observed regardless of opening pressure at baseline. Therapeutic LPs were associated with a 69% relative improvement in survival, regardless of initial intracranial pressure. The role of therapeutic LPs should be reevaluated.

Therapy of AIDS-Related Cryptococcal Meningitis

Cryptococcal meningitis is a common and severe opportunistic infection in advanced HIV, with the highest burden of disease in resource-poor settings in sub-Saharan Africa. It is invariably fatal if left untreated, and carries a high mortality even with treatment. High fungal burden, raised intracranial pressure, and reduced level of consciousness at presentation are associated with poorer outcomes. The recommended treatment strategy consists of a two-week induction phase, then eight weeks of consolidation therapy, followed by long-term maintenance therapy until restoration of immune function by antiretroviral therapy (ART) for HIV. Induction treatment should consist of a rapidly fungicidal drug. Amphotericin B has demonstrated superiority to fluconazole both in terms of fungicidal activity and mortality outcomes. A combination of amphotericin B at 1 mg/kg/day plus flucytosine 100 mg/kg/day has been associated with a reduction in mortality as compared to amphotericin B alone. This regimen should be used where available, with fluconazole as an acceptable alternative second agent if flucytosine is unavailable. In resource-limited settings where both amphotericin B and flucytosine are often unavailable, fluconazole monotherapy is still often used. In this setting, high-dose fluconazole at 1,200 mg/day should be used as induction therapy, although fungal clearance with this regimen is inferior to amphotericin B-based therapy. Consolidation and maintenance therapy with fluconazole is recommended. Aggressive management of raised intracranial pressure by repeated therapeutic lumbar puncture is an essential adjunct to antifungal chemotherapy. Surgical intervention, such as ventriculoperitoneal shunting for refractory raised intracranial pressure, is rarely required. In patients who are not already on ART, this should be commenced no earlier than four weeks after starting induction treatment for cryptococcal meningitis, as earlier initiation of ART may be associated with immune reconstitution inflammatory syndrome (IRIS). There are ongoing efforts to evaluate fluconazole and flucytosine combination therapy as an alternative induction regimen, as well as shorter courses of amphotericin B, in resource-poor settings with limited access to antifungal agents.

G368(P) Dural Sinus Thrombosis in a child with steroid dependent nephrotic syndrome: A case discussion

Cerebral venous thrombosis is rare and often under diagnosed in children with nephrotic syndrome. MRI with venography is an essential tool in its diagnosis. Both early diagnosis and the commencement...

Magnetic resonance imaging in pseudotumor cerebri: A case report

Idiopathic intracranial hypertension (IIH) is characterized by symptoms of raised intracranial tension (ICT) as headache and visual disturbances due to raised cerebrospinal fluid pressure, however without any ventricular enlargement or space occupying lesion. The characteristic findings include papilledema which is usually bilateral, however which may be unilateral or asymmetrical. We report a case of 35-year-old female patient who came with complaints of headache and diplopia. She underwent magnetic resonance imaging of the brain which showed changes in bilateral globes, optic nerves and sella, which were suggestive of increased ICT. The ventricles and basal cisterns were normal. No other abnormality was seen. The magnetic resonance venogram was also normal. Thus, we concluded the diagnosis of IIH. The patient underwent therapeutic lumbar puncture after which she showed significant improvement in symptoms.

Intracranial hypertension presenting with severe visual failure, without concurrent headache, in a child with nephrotic syndrome

BackgroundIdiopathic intracranial hypertension is a condition typically characterised by headache, normal level of consciousness, papilloedema and raised cerebrospinal fluid pressure. Children often present with visual loss and atypical features of raised pressure, posing a diagnostic and management challenge. A range of renal disorders can predispose to developing this raised intracranial pressure syndrome. We present a case of severe visual failure in a child with nephrotic syndrome, with no headache when elevated pressure was proven. In nephrotic syndrome, visual failure related to elevated intracranial pressures without concurrent headache symptoms has not been reported previously.Case presentationWe discuss a 5-year-old Caucasian girl with steroid sensitive nephrotic syndrome who went on to become a late non-responder and presented with intracranial hypertension. Following initial response to steroids, she had a relapse of her nephrotic syndrome; her proteinuria did not resolve on steroid treatment, requiring addition of cyclosporine therapy to manage her nephrotic syndrome. Three months following this, she presented with visual failure in the right eye with bilateral central scotoma and papilloedema. At the time of presentation of visual impairment, she was otherwise well, with no symptoms of a raised intracranial pressure syndrome or associated systemic illness. Medical management was initiated following confirmation of a raised intracranial pressure. Her intracranial pressure remained elevated requiring serial therapeutic lumbar punctures before some improvement in visual acuity was observed. Later in the clinical course, she presented with worsening of her visual impairment with further deterioration of the vision in the left eye, again associated with elevated intracranial pressure. An urgent surgical cerebrospinal fluid diversion procedure was performed. At review, three years after presentation our patient has severe visual impairment with no perception of light in her right eye and 6/36 Snellen acuity in the left secondary to optic atrophy.ConclusionOur case demonstrates the occurrence of intracranial hypertension in nephrotic syndrome, highlighting the atypical presentation of severe visual failure without concurrent headache at presentation. This demonstrates the management complexities and the need for clear guidelines for ophthalmological surveillance to aim to reduce permanent visual impairment.

Drug therapy for preventing post-dural puncture headache.

Post-dural (post-lumbar or post-spinal) puncture headache (PDPH) is one of the most common complications of diagnostic, therapeutic or inadvertent lumbar punctures. Many drug options have been used to prevent headache in clinical practice and have also been tested in some clinical studies, but there are still some uncertainties about their clinical effectiveness. To assess the effectiveness and safety of drugs for preventing PDPH in adults and children. The search strategy included the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2012, Issue 5), MEDLINE (from 1950 to May 2012), EMBASE (from 1980 to May 2012) and CINAHL (from 1982 to June 2012). There was no language restriction. We considered randomised controlled trials (RCTs) that assessed the effectiveness of any drug used for preventing PDPH. Review authors independently selected studies, assessed risks of bias and extracted data. We estimated risk ratios (RR) for dichotomous data and mean differences (MD) for continuous outcomes. We calculated a 95% confidence interval (CI) for each RR and MD. We did not undertake meta-analysis because participants' characteristics or assessed doses of drugs were too different in the included studies. We performed an intention-to-treat (ITT) analysis. We included 10 RCTs (1611 participants) in this review with a majority of women (72%), mostly parturients (women in labour) (913), after a lumbar puncture for regional anaesthesia. Drugs assessed were epidural and spinal morphine, spinal fentanyl, oral caffeine, rectal indomethacin, intravenous cosyntropin, intravenous aminophylline and intravenous dexamethasone.All the included RCTs reported data on the primary outcome, i.e. the number of participants affected by PDPH of any severity after a lumbar puncture. Epidural morphine and intravenous cosyntropin reduced the number of participants affected by PDPH of any severity after a lumbar puncture when compared to placebo. Also, intravenous aminophylline reduced the number of participants affected by PDPH of any severity after a lumbar puncture when compared to no intervention, while intravenous dexamethasone increased it. Spinal morphine increased the number of participants affected by pruritus when compared to placebo, and epidural morphine increased the number of participants affected by nausea and vomiting when compared to placebo. Oral caffeine increased the number of participants affected by insomnia when compared to placebo.The remainder of the interventions analysed did not show any relevant effect for any of the outcomes.None of the included RCTs reported the number of days that patients stayed in hospital. Morphine and cosyntropin have shown effectiveness for reducing the number of participants affected by PDPH of any severity after a lumbar puncture, when compared to placebo, especially in patients with high risk of PDPH, such as obstetric patients who have had an inadvertent dural puncture. Aminophylline also reduced the number of participants affected by PDPH of any severity after a lumbar puncture when compared to no intervention in patients undergoing elective caesarean section. Dexamethasone increased the risk of PDPH, after spinal anaesthesia for caesarean section, when compared to placebo. Morphine also increased the number of participants affected by adverse events (pruritus and nausea and vomiting)There is a lack of conclusive evidence for the other drugs assessed (fentanyl, caffeine, indomethacin and dexamethasone).These conclusions should be interpreted with caution, owing to the lack of information, to allow correct appraisal of risk of bias and the small sample sizes of studies.

Unique Case of “Post‐Lumbar Puncture Headache”

Lumbar puncture (LP) is associated with complications that include post-LP orthostatic headache, local bleeding, and subdural hematoma. We report a unique case of a spontaneous frontal epidural hematoma following a therapeutic lumbar puncture in a patient with a history of idiopathic intracranial hypertension. This case highlights the importance of symptomatology in patients following LPs by revealing a rare intracranial presentation that would be devastating if not discovered promptly and appropriately managed.

Pseudotumor cerebri caused by uncontrolled Graves’ disease in an adolescent

Introduction: Hyperthyroidism causing pseudotumor cerebri is very rare in children. case report: We are reporting a case of a 17-year-old girl with uncontrolled Graves’ disease presenting with pseudotumor cerebri (Ptc). Patient initially did not respond to common management of Ptc with therapeutic lumbar puncture and acetazolamide, but improved after treating hyperthyroidism by radioablation therapy. conclusion: We emphasize that uncontrolled hyperthyroidism should be suspected as a secondary cause of pseudotumor cerebri in children and treated aggressively to avoid its dreaded complications.

Cerebral Venous Thrombosis in Adolescents and Young Adults with Classical Hodgkin Lymphoma

AbstractAbstract 4784 BackgroundPatients with classical Hodgkin Lymphoma (cHL) have a relatively high risk of venous thrombo-embolism (VTE); reported incidence 4.6–7% in adults and up to 11.5% in children and adolescents. Most VTE episodes are peripheral or related to central venous catheters, with very limited data on central or life-threatening thromboses in adolescents. There is only 1 reported case series on cerebral venous thrombosis (CVT) in adolescents. We report 4 cases of CVT from our centre, all treated with chemo-radiotherapy. Chemotherapy comprised OEPA (vincristine, prednisolone, doxorubicin, etoposide) and COPP/COPDAC (cyclophosphamide, vincristine, prednisolone, procarbazine/dacarbazine respectively).Table 1:Clinical detailsPatientAge at diagnosis of cHLStageChemotherapyPeripheral VTEOn LMWH at time of CVT112IIAE2 OEPANoNo217IIIBE2 OEPA + 4 COPPYes PICC associated during OEPA #2No318IVBE2 OEPA + 4 COPDACNoNo423IIB2 OEPA + 2 COPPYes PICC associated during OEPA #1No ResultsAll patients received involved field radiotherapy (IFRT) 19.8 – 30Gy on completing chemotherapy. All were female, aged 12–23. All received norethisterone contraception. All had indwelling central venous catheters (PICC). Patient 4 alone had a raised body mass index. All were exposed to steroids; Patient 4 completed steroid therapy several weeks before developing CVT symptoms. Patients 2 and 4 received treatment dose low molecular weight heparin (LMWH) for 6 weeks after diagnosis of PICC-associated thrombosis, and were not on anticoagulation or thromboprophylaxis when CVT was diagnosed. Regarding other risk factors, 3/4 had no documented prothrombotic tendency. Patient 4 was found to have a moderately positive IgM anti beta 2 glycoprotein antibody present 12 weeks apart, consistent with antiphospholipid syndrome.Table 2:Clinical DetailsPatientTreatment at time of CVTClinical PresentationImaging reportAcute Treatment1OEPA #2Dizzy spell, loss of vision right eye, right hyperacusis, right sided headache, hoarse voice, left 6th cranial nerve palsy, raised intracranial pressureRight transverse sinus and superior sagittal sinus thrombosisLMWH, acetazolamide, therapeutic lumbar punctures2COPP #2Severe headache, bilateral papilloedema, tonic clonic seizures, raised intracranial pressureSuperior sagittal sinus thrombus with extension into left transverse and left sigmoid sinusLMWH, acetazolamide + bicarbonate, therapeutic lumbar punctures, phenytoin3OEPA #1Malaise, headache, weakness left upper and lower limbs, tonic clonic seizuresSuperior sagittal sinus and right transverse sinus thrombosis extending into cortical veins with right parietal intracranial haematomaLMWH, thrombectomy with tissue plasminogen activator, phenytoin4Post RadiotherapyHeadache, photophobia, blurred vision, drowsiness, recurrent collapse, ataxiaSuperior sagittal sinus thrombosis, extension into transverse venous sinuses, with involvement of right sigmoid sinus and internal jugular veinLMWH with warfarin loadingAll patients were therapeutically anticoagulated for 6 months to 1 year. LMWH of choice at our centre was dalteparin. Patient 1 was switched to warfarin upon completion of chemo-radiotherapy, and Patient 4 was commenced on warfarin with dalteparin cover at diagnosis of CVT as she had completed treatment.Patients 1 and 2 had raised intracranial pressure on lumbar puncture, and required therapeutic lumbar punctures and acetazolamide.Patients 2 and 3 both required anticonvulsant therapy for 1 year. Patient 2 was initially treated with phenytoin, and switched to carbamazepine. Patient 3 was also initially managed with phenytoin, and switched to levetiracetam. Neither patient had any subsequent seizures.All 4 patients have recovered completely from CVT with no residual neurological deficits or further thromboses. ConclusionCVT is a rare and potentially life threatening complication in adolescents and young adults with cHL with paucity of data. The risk factors are unclear however all patients in our series were female, received steroids and were on norethisterone. Only 1 patient had a prothrombotic tendency detected on thrombophila screening. CVT is treatable, and complete resolution of signs and symptoms can be expected. More studies are required to elucidate risk factors which may help develop thromboprophylaxis guidance in this group of patients. Disclosures:No relevant conflicts of interest to declare.

Venous sinus stenting for idiopathic intracranial hypertension: a review of the literature

Idiopathic intracranial hypertension (IIH) is characterized by headache, papilledema, visual field changes and tinnitus with elevated cerebral spinal fluid opening pressures on lumbar puncture. Left untreated, this condition can lead...

Cryptoccocal meningitis and HIV in the era of HAART in Côte d’Ivoire

ObjectiveThe authors had for aim to describe the management of cryptococcal meningitis in HIV infected adults, in Ivory Coast. Patients and methodsA retrospective study was made from January 1, 2005 to December 31, 2008 on the files of consecutive hospitalized patients presenting with cryptococcal meningitis, at the Treichville University Hospital, Infectious and tropical diseases department (Abidjan). The socio-demographic, clinical, and biological aspects as well as the outcome were analyzed. ResultsEighty patients presenting with cryptococcal meningitis, (2.6% of hospitalized patients) were included: 41 men (51.25%) and 39 women (48.75%); mean age: 40 years (range 26 to 58 years). The delay before consultation was 5.4 days, range 2–12 days). The mains symptoms were headache (83.7%), fever (63.7%), and consciousness disorders (60%). Meningo-encephalitis accounted for 75% of the clinical presentations; 54 patients (67.5%) were naive of antiretroviral treatment (mean CD4: 45/mm3 (range 5–103/mm3), while 26 (32.5%) had received antiretrovirals before presenting with cryptococcal meningitis (Nadir CD4=81/mm3). Amphotericin B relayed by fluconazole was prescribed to 86.2% of the patients, associated with a therapeutic lumbar puncture for 30 patients. The death rate was 41.2%. ConclusionIn spite of antiretroviral treatment availability in Ivory Coast, cryptococcal meningitis remains frequent with a high death rate. This study stresses the importance of early management to improve the prognosis.

Management of pediatric patients with pseudotumor cerebri

The care of patients with pseudotumor cerebri (idiopathic intracranial hypertension) involves ophthalmologists, neurologists and neurosurgeons. Its clinical characteristics in the pediatric population are distinct from those in adult patients. Fifty-nine patients diagnosed with pseudotumor cerebri were identified from the neurosurgery and neurology databases at Children's Hospital, Birmingham, AL, USA. Clinical data were collected from the ophthalmology, neurology and neurosurgery departments. The average age of patients at diagnosis was 11.4 years (range 3-17). The average opening pressure of lumbar puncture (LP) was 37 cm of water. Most of the patients responded well to therapeutic LPs and medical management. Neurosurgical interventions included intracranial pressure monitoring and shunt insertion in nine patients. In three patients who presented with acute visual decline, two recovered and one remains legally blind. The care of patients with pseudotumor cerebri requires a multiple-disciplinary approach. Neurosurgical interventions are sometimes needed for diagnostic and treatment purpose. Prompt and accurate communication among specialists is necessary to ensure timely treatment and optimal outcomes.

An Unusual Transudative Pleural Effusion Succeeded by Pulmonary and Brain Edema and Death

Here we report a 22-year old woman with massive and bilateral transudative effusion succeeded by pulmonary edema and brain edema and death. Investigations for systemic disorders were negative. Exacerbation of dyspnea after intravenous fluid infusion was a main problem. As effusion was refractory to medical treatment, the patient was referred for surgical pleurodesis and bilateral surgical pleurodesis were done separately. Postsurgically, dyspnea exacerbation occurred after each common cold infection. Vertigo and high intracranial pressure were also a problem postsurgically. CSF pressure was 225 mm/H2O. Therapeutic lumbar puncture was done in two sequential weeks, and the patient was on acetazolamide 250 mg/trivise a day. Despite the medical treatment, progressive dyspnea, headache, and high intracranial pressure followed by death nine months after pleurodesis. As there is a gradient of pressure between pleura and CSF, after pleurodesis brain edema must be a consequence of inversing this gradient. In conclusion, when there are any abnormalities about fluid volume or pressure in any of these cavities, we have to study other cavities.

Neurosyphillis presenting with normal pressure hydrocephalus in a 76 year old man

SummaryBackground:Normal pressure hydrocephalus (NPH) is composed of gait abnormalities, urinary incontinence and decline in mentation. It is uncommonly induced by syphilitic infection.Case Report:A 76 year-old male present with gait disturbances, urinary incontinence, declining vision and cognition, with a known diagnosis of NPH. He underwent therapeutic lumbar puncture (LP), which demonstrated leukocytosis and elevated protein. Venereal disease research laboratory testing (VDRL) was reactive in a 1:64 dilution with positive fluorescent Treponemal Antibody (FTA-Abs). The subject was treated with 14 days of Intravenous (IV) Penicillin 3 million units for 3 weeks and intramuscular benzathine PCN for 2 shots, with marked clinical improvement.Conclusions:The incidence of Tabes Dorsalis is limited in the age of penicillin, especially in subjects without HIV. Subjects are diagnosed with either LP RPR or VDRL, confirmed with FTA-Abs. Common treatment is IV PCN 1.4–3 mU for 10–14 days.

Image-Guided Therapy May Reduce the Risk of Traumatic or Failed Lumbar Punctures in Children with Acute Lymphoblastic Leukemia,

Abstract 3582▪▪This icon denotes a clinically relevant abstract Introduction:Children with acute lymphoblastic leukemia (ALL) undergo diagnostic and therapeutic lumbar punctures (LPs) with the administration of intrathecal chemotherapy as part of their cancer treatment. Difficult LPs may result in trauma (≥ 10 RBCs/μL) or a failed attempt to obtain cerebrospinal fluid (CSF). There can be several negative consequences of a difficult LP. For patients with newly diagnosed ALL, a traumatic lumbar puncture (TLP) that contains blasts obscures the correct determination of CNS status, leads to a requirement for additional therapy, and is associated with a poorer event-free survival. A failed lumbar puncture (FLP) provides inadequate diagnostic material, can be associated with pain, and leads to a delay in administering intrathecal chemotherapy. There is a need to identify interventions that can help reduce difficult lumbar punctures. At the Hospital for Sick Children (SickKids), children with difficult LPs may be referred to undergo the procedure under image-guided therapy (IGT) with fluoroscopy. We hypothesized that the use of IGT may reduce the risk of difficult LPs. The primary objective of this study was to investigate whether the use of IGT could reduce the risk of difficult LPs defined as TLPs and FLPs in children with ALL. The secondary objective was to determine whether IGT could reduce the risk of macroscopically bloody LPs (≥ 500 RBC/μl). Methods:The health records of all children less than 18 years of age with newly diagnosed ALL at SickKids from 2005 to 2009 inclusive were retrospectively reviewed. Data was collected on patients referred for at least one IGT procedure. The proportion of difficult LPs with and without IGT were compared. We used univariate and multiple conditional logistic regression (repeated-measures) analysis to examine the association between IGT and difficult LPs. The potential covariates analyzed included age at procedure (younger vs. older than 10 years), body mass index percentile (less vs. more than 95), platelet count (less vs. more than 100 × 109/L), previous TLP (yes vs. no), days since previous LP (less vs. more than 15 days), and phase of treatment (before vs. after the start of maintenance). In order to create multiple regression models, covariates that changed the beta-coefficient of the IGT effect by more than 10% were included in the model. Results:Among 267 children diagnosed with ALL in the study period, 25 patients (9.4%) had at least one image-guided LP. Of these 25 patients, 52% were over 10 years old, 64% were female and 28% were obese. These patients had a total of 542 LPs, of which 229 (42%) were performed with image-guidance and 313 were performed using the standard palpation method. Among all LPs, 149 (28%) were traumatic and 19 (4%) were failed. In univariate analysis, the use of IGT significantly lowered the odds of a difficult LP (TLP or FLP), with an odds ratio (OR) of 0.44 (95% confidence interval (CI) 0.26 to 0.76; p=0.003). The other covariates that were significant in univariate analysis included days since previous LP (OR 0.55, 95% CI 0.36 to 0.83; p=0.005) and phase of treatment (OR 0.60, 95%CI 0.39 to 0.91; p=0.017). Multivariable analysis adjusting for days since previous LP and phase of treatment demonstrated that the effect of IGT remained significantly independently associated with a reduction in difficult LPs (OR 0.49, 95% CI 0.29 to 0.86; p=0.012). In a secondary analysis, we defined bloody lumbar punctures (BLP) as ≥ 500 RBCs/μL. The effect of IGT in reducing BLP or FLP was larger, with an OR of 0.11 (95% CI 0.04 to 0.28, p<0.0001). Conclusions:This retrospective cohort study suggests that image-guidance may reduce the risk of traumatic and failed LPs in children with ALL. IGT may be more effective in reducing macroscopic trauma. Therefore, IGT may be able to provide a potential intervention for children with ALL anticipated to have difficult lumbar punctures at diagnosis, or found to have difficult subsequent procedures. Future work should focus on the development of better models to identify children at highest risk of difficult LPs and non-radiation based image-guided manoeuvres to facilitate LPs in these children. Disclosures:No relevant conflicts of interest to declare.

Iatrogenic Spinal Epidermoid Cyst After Lumbar Puncture Using Needles with Stylet

Iatrogenic spinal epidermoid tumors are extremely rare and may be caused by implanted skin fragments in the spinal canal, most commonly due to lumbar punctures using hollow needles without a stylet. The authors report for the first time an iatrogenic spinal epidermoid tumor that developed 26 months after several lumbar punctures, performed using disposable spinal needles with stylet, in an 8-year-old boy with persistent lower back pain. The authors hypothesize that an ill-fitting stylet compounded by multiple therapeutic lumbar punctures and young age as possible risk factors for the development of the tumor in the present case. A total excision of the tumor with laminectomy yielded good symptomatic recovery.

Effect of pregabalin on post-dural-puncture headache following spinal anesthesia and lumbar puncture

In this study, we aimed to investigate the effect of pregabalin on post-dural-puncture headache (PDPH). Forty patients who developed PDPH after spinal anesthesia or diagnostic and/or therapeutic lumbar puncture were divided into two groups and followed for 5 days. The first group received 150 mg/day oral pregabalin for the first 3 days, then 300 mg/day for a further 2 days. The second group received a placebo for the same length of time. Patient headaches were scored using the visual analog scale, and diclofenac sodium and pethidine requirements were recorded. Relative to the placebo group, the group administered pregabalin had significantly lower visual analog scale scores after the second day of treatment, and had significantly lower diclofenac sodium requirements. Our results indicate that pregabalin may be useful for the management of PDPH.

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Idiopathic intracranial hypertension; immediate resolution of venous sinus “obstruction” after reducing cerebrospinal fluid pressure to < 10 cmH 2O

It has been postulated that cerebral venous outflow “obstruction” is a precipitating factor for many cases of idiopathic intracranial hypertension (IIH). We describe a 17-year-old woman with IIH, and “venous obstruction” repeatedly demonstrated on magnetic resonance venography (MRV) that within minutes resolved partially when the cerebrospinal fluid (CSF) pressure was reduced to 11 cmH 2O and completely when the pressure was reduced to 8 cmH 2O. These findings further support the view that raised pressure is the cause of the “obstruction”, rather than the obstruction being the primary cause of the IIH. It also raises questions about how low the CSF pressure should be reduced at therapeutic lumbar puncture.

Hypertension intracrânienne bénigne secondaire à la prise de doxycycline

Idiopathic intracranial hypertension is a rare disorder characterized by elevated intracranial pressure without hydrocephaly or intracranial process. Its mechanism is poorly understood. Most cases of benign intracranial hypertension are presumed to be idiopathic but some of them may be related to some treatment. We report a 26-year-old female with benign intracranial hypertension due to tetracycline, revealed by headaches and gradual visual loss. Standard investigations were unremarkable and favourable outcome after therapeutic lumbar puncture confirmed the diagnosis.