1. PDPH Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics PhD (physio), FICA

2. In August 1898, Karl August Bier, a German surgeon, injected cocaine 10 - 15 mg into the subarachnoid space of seven patients, himself All had headache Bier postulated that it was due to CSF leak Has it changed now ??

3. 1900 – incidence down to 50 % 1951 – whitacre found his spinal needle Yes it has come down a lot may be 2-3 %

4. 30 % - 50 % following CSF analysis Upto 30 % in therapeutic lumbar punture 50 -80 % Accidental Dural puncture in obstetrics – 1- 5 % spinal

5. Definition Headache that develops less than 7 days after a spinal puncture, occurs or worsens less than 15 minutes after assuming the upright position and improves after less than 30 minutes in the recumbent position. The headache should disappear within 14 days after a spinal puncture; if it persists it is called a CSF fistula headache.

6. Need not be the same Can come earlier Can last longer

7. PATHOGENESIS AND ANATOMY Dural tear CSF leakage exceeds production More than 10 % loss of CSF Reflex venodilation traction of the cranial structures Occipital – vagus Cervical – c1 c2 c3 Fifth cranial nerves-frontal Sixth - visual Headache Who is monroe kellie

8. Leakage and sagging Can this leakage theory ok ?? Low CSF pressure is not found in all cases of PDPH MRI shows no sagging in some cases IJV compression – headache worsens Cerebral vasoconstrictors like caffeine betters ?? So is low CSF pressure the cause ?? Is it a tension headache ??

9. One more PDPH is probably a vascular type headache and epidural blood patch relieves the headache by its vaso-constrictive action Seals !!

10. How it heals !! Dural tear Heal by fibroblastic proliferation of dural edge ?? But by fibroblastic proliferation of damage to pia, Arachnoid and bloody clots – yes So be happy about traumatic spinals At least we will have less PDPH

11. Symptoms postural, frontal, fronto temporal, or occipital headache, worsened by ambulation improved by assuming the supine occurring within 48 hours after dural puncture nausea, vomiting and neck stiffness. tinnitus and hyperacusis. Photophobia and diplopia Diplopia may start later than 3 weeks to persist for a few months !!

12. Other signs Pressure over the abdomen with the woman in the upright position may give transient relief to the headache by raising intracranial pressure secondary to a rise in intrabdominal pressure (Gutsche sign). Coughing,straining decrease pain

13. The same sagging can cause arm pain with dysesthesia Blindness 3 rd,4 th, 6 th, 7 th, and 8 th cranial nerves palsies 1 in 1,00,000 Spontaneous resolution Subdural hematoma reported – sagging and rupture of vessels

14. Diagnosis Clinical MRI may show any other lesion !!

15. Differential diagnosis Tension headache : It is typically a dull, persistent pain that extends over the entire head. Onset is gradual and the headache may persist for a long time. Migraine → unilateral throbbing Caffeine withdrawal → moderate regular consumer Lactation headache → breast feeding time only Tumour → constant seizures- MRI Preeclampsia → history – albumin – edema

16. SIH Spontaneous Intracranial hypotension is a condition with symptoms and patho physiology indistinguishable from PDPH. a rare clinical entity and is thought to be due to rupture of a perineural cyst of the spine

17. Postural "all symptoms disappeared immediately when I laid horizontally but came back when I got upright".

18. Risk factors !! Age --- 20 – 40 lesser incidence of PDPH in elderly individual is due to decrease in the elasticity of cranial structures Age - Less than ten – no - why ?? Less CSF pressure and no alteration with position !! May be low reporting !!

19. Obstetric patients Previously it was thought that they have increased incidence Bearing down, postpartum decrease in epidural pressures were thought of as reasons But now – may be the same incidence !!

20. Risk factors History of migraine History of motion sickness  Fatigue, haste, shift work and stress are other important factors which may contribute to PDPH. Following diagnostic lumbar puncture, replacing the stylet prior to removing the needle may reduce the risk of headache

21. Size and type of the needle Incidence ranged from 18% with a 16 gauge needle to 5% with 26 gauge needle Pencil point needles are supposed to cause less trauma and less incidence of PDPH Recently questioned ?? Dural fibres are longitudinal ?? Complex interlacing collagen – not longitudinal But bevel facing up less tension on the dural hole !!

22. The rate of CSF loss through the dural perforation (0.08 to 4.5 ml/ s) is generally greater than the rate of CSF production (0.35 ml /min), particularly with needle sizes larger than 25G. Perpendicular orientation of needle really matters ?? Why someone don’t get headache after accidental dural puncture – not known

23. Management Prophylactic Therapeutic Restore the pressure changes in epidural and intrathecal compartments

24. Prophylactic Size of needle, type of needle First and only puncture..( no pepper potting dura) Angle of insertion Epidural morphine Epidural blood or saline Intrathecal catheter 10 ml intrathecal saline IV decadron

25. Psychological support √ Abdominal binders √ ? Bed rest √ ? Prone position √ ( can it be done ?? )

26. Drugs Routine drugs Paracetomol NSAIDs Opioids Antiemetics Steroids Pregabalin

27. Intravenous saline 1 liter of IV saline fast 30 – 60 minutes supine Effective May be by increasing CSF production

28. Caffeine IV caffeine 0.5 gram two doses ( in RL) Oral 300 mg tds ( less effective ) Cerebral stimulation + vasoconstriction In Some withdrawal syndrome is reversed Effective but does it affect low CSF pressure ?? Maternal arrhythmias, seizures → Recent Neonatal irritability →Recent

29. Triptans Sumatriptan is a 5-HT1D receptor agonist that promotes cerebral vasoconstriction, in a similar way to caffeine 6 mg sc bd Theophylline also used

30. ACTH ACTH is thought to work by increasing CSF production after accidental dural puncture decreased the incidence of PDPH from 68.9% to 33.3% Some glucocorticoid activity also intravenous infusion of ACTH 1.5u/kg in 250 ml of normal saline ( alternate)

31. Epidural blood patch Diagnosis Two people Get the space below Aseptic precautions – 15 -20 ml unheparinized blood ( LOR saline – no pneumocephalus ) Inject to epidural space 70-98 % relief in first attempt Pressure (immediate )– clot ( few hours ) – fibroblasts ( few days ) Separate slides Mechanism of EBP

32. EBP ?? In patients with leukemia In HIV patients Can we do EBP and seed the cells or viruses ?? NO

33. Epidural fibrin glue In the case of lumbar dural perforation, the fibrin glue may be placed blindly or using CT-guided percutaneous injection. Risk of aseptic meningits Epidural dextran 40

34. Surgery ?? There are case reports of persistent CSF leaks, that are unresponsive to other therapies, being treated successfully by surgical closure of the dural perforation…. But the last resort

36. Summary Definition Diagnosis Risk factors Prevention Treatment Protocol

37. Thank you all