case report

Management of Postdural Puncture Headache with Pseudotumor Cerebri

Drs. Ali, Tariq and SulemanBy Anita Akbar Ali, MD; Sarah Tariq, MD; M-Irfan Suleman, MD
University of Arkansas for Medical Sciences Arkansas Children’s Hospital
Little Rock, Arkansas

Corresponding Author: M-Irfan Suleman, MD
Assistant Professor of Anesthesiology
Director of Pediatric Regional Anesthesia Division of Pediatric Anesthesia and Pain Medicine
Arkansas Children’s Hospital and University of Arkansas for Medical Sciences

Postdural puncture headache (PDPH) is one of the complications seen after spinal tap but it becomes a problematic diagnosis if the primary condition is also known to cause similar symptomatology. Pseudotumor cerebri or idiopathic intracranial hypertension (IIH) is one such disorder. It affects primarily obese women of childbearing age but IIH is also described in children.1 Patients with IIH receive therapeutic spinal taps to decrease intracranial pressure, which in turn, can lead to PDPH caused by low cerebrospinal fluid (CSF) volume post drainage. Postdural puncture headache has been described as a paradoxical headache due to increased CSF before and decreased CSF after the spinal tap.1 Effective treatment modalities for PDPH in pediatric patients are unclear because of the rare occurrence.1,2 Here we present a pediatric case with IIH developing PDPH after a therapeutic spinal tap that was successfully managed conservatively. Our institution does not require IRB approval for case reporting unless the patient’s identifiable information is released; in this case report no patient identifiable information is provided.

Our patient was a 13-year-old African-American female who developed a headache after her second therapeutic spinal tap for the treatment of IIH. She was obese, hypertensive, and had been recently diagnosed with IIH. She presented with a frontal headache that was throbbing in nature and radiated to her neck and shoulder. This was associated with nausea, vomiting, dizziness, and photophobia. Her headache improved in the supine position but was aggravated by upright posture, noise, and light. No other neurological deficits were present. The first diagnostic spinal tap was performed a month previously and revealed an opening pressure of 39cm H2O. She was discharged home to follow up in clinic. Subsequently, she developed a similar headache over the next several days and presented to the Emergency Department. After an initial workup, which included noncontrast computed tomography (CT) of the head and neurology and ophthalmology assessment, she was scheduled for another therapeutic spinal tap by interventional radiology physicians.

Opening and closing pressures were 12.5cm and 9.5cm H2O, respectively. She tolerated the procedure well and was admitted to intermediate care unit for overnight observation. The primary care team also administered 500mg oral acetazolamide every six hours and 20mg oral furosemide. Within 12 hours of the procedure, the patient again complained of headache and was administered 800mg oral ibuprofen every six hours as needed and acetaminophen every six hours as scheduled; however, no improvement resulted. The patient then received 2 intramuscular doses of 25mg promethazine every hour hours as needed for nausea and 75mg of meperidine every four hours as needed.

The pediatric pain team was consulted for a blood patch by the primary team. No new symptoms or changes in physical examination were noted. Due to similar nature of the headache, it was difficult to distinguish it from high versus low pressure headache. We decided to start conservative management. The patient was managed with bed rest, and she received 650mg of oral acetaminophen every six hours, 30mg of ketorolac every 6 hours, and oral caffeine in the form of soda, tea, or coffee. All diuretics were discontinued. Her symptoms started to resolve within 24 hours and were completely resolved in 48 hours. We followed her clinically for one additional day after which she was discharged home.

Idiopathic intracranial hypertension (IIH) is defined as the syndrome of increased intracranial pressure without any mass or lesion with normal CSF composition.3 Headache is the most common presenting complaint but nausea, vomiting, and visual changes including photophobia, retrobulbar pain, and diplopia are also frequently seen.1,4 Spinal tap is one of the frequent interventions performed for diagnostic and therapeutic purposes in these patients. Surgical interventions like optic nerve fenestration, lumboperitoneal or ventriculoperitoneal shunt, and venous sinus stenting are usually reserved for cases failing conservative therapy

Postdural puncture headache (PDPH) is a known complication after spinal tap.5 According to International Headache Society ICHD-II, PDPH is defined as a “headache that worsens within 15 minutes after sitting or standing and improves within 15 minutes after lying.” Headache develops within 5 days after a lumbar puncture and it “resolves either spontaneously within one week” or “within 48 hours after effective treatment of the spinal fluid leak (usually by epidural blood patch).” The patient should also have at least 1 associated symptom including neck stiffness, tinnitus, hypacusia, photophobia, or  nausea.6

PDPH is thought to occur due to a slow leak of cerebrospinal fluid leading to intracranial hypotension and tension created on the meninges by downward sagging of the brain.7,8 Several risk factors like gauge, type and orientation of the needle are described as important for the development of PDPH.9 Once diagnosis is made, conservative therapy is recommended for 48 hours followed by an epidural blood patch to ameliorate the debilitating symptoms.10

Numerous studies have described conservative as well as invasive approach for the treatment of PDPH. Ebinger et al5 mentioned resolution of PDPH symptoms in pediatric patients within the first week with conservative measures, whereas Kokki et al9 indicated EBP as a highly effective intervention following lumbar puncture in pediatric patients. Haruna et al11 also described successful treatment of PDPH in a 5-year-old with EBP but it was after inadvertent dural puncture during placement of an epidural catheter under general anesthesia for orthopedic surgery. An epidural blood patch was performed under general anesthesia and resolved the symptoms.

Although development of PDPH and its treatment is fairly documented in both adult and pediatric patients5,7,9,11-14 there is a paucity of data regarding PDPH in IIH patients after therapeutic lumbar puncture. To our knowledge, only 1 case report has been published to date addressing the treatment of PDPH with epidural blood patch (EBP) in a pediatric patient with IIH.1

General anesthesia might be warranted for pediatric patients undergoing EBP, which in turn exposes the patient to the risks of general anesthetic. Infection, bleeding, local anesthetic toxicity, or inadvertent injection of local anesthetic or blood in the sub-arachnoid space can occur during placement of an EBP.12 Collier et al15 reported the risk of epidural space scarring with blood patch with resulting failure in recurrent epidural anesthesia applications. Therefore, the risks of EBP should be considered, especially in patients with IIH. As these patients undergo frequent spinal punctures, there is an increased likelihood of developing PDPH in this population.

Our patient was treated conservatively with intravenous and oral hydration, caffeine, and analgesics. Diuretics were discontinued for the initial part of the treatment and resumed after resolution of headache. Complete resolution of symptoms was noted with conservative treatment within two days, which might advocate for a longer conservative approach in pediatric population with IIH. Epidural blood patch would have been our next option.

The limited information of the present case is insufficient to explain the optimal treatment in patients with IIH developing PDPH. It is, therefore, difficult to draw a conclusion. Longer duration (>48 hours) of conservative treatment might be beneficial in this population before EBP is considered if symptoms are tolerable.


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