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///2013 Abstract Details
2013 Abstract Details2019-08-02T16:57:45-05:00

Rebound intracranial hypertension after epidural blood patch in a patient with cystic hygromas

Abstract Number: F 40
Abstract Type: Case Report/Case Series

Lori Suffredini DO1 ; Sarah Wyhs MD2; Martin Slodzinski MD3

Epidural blood patch for postdural puncture headache is generally safe and well tolerated. Rebound intracranial hypertension after epidural blood patch has not been widely reported. A 35-year-old woman, G2P1, received lumbar epidural analgesia for labor and vaginal delivery. The next day, the patient developed a classical postdural puncture headache that responded to conservative therapy. Eleven days later, the patient returned with worsening symptoms of postdural puncture with bilateral cystic hygromas. After 48 hours of conservative therapy, the patient elected for an epidural blood patch, which was successful. One week later, the patient returned with recurrent headache and visual changes. Imaging demonstrated new bilateral subdural hematomas. The patient underwent a second blood patch. Her symptoms resolved. Two weeks later, the patient presented with headache, diplopia and neck stiffness. Exam revealed papilledema. Repeat imaging showed chronic subdural hematomas and new subarachnoid bleeding with evidence of intracranial hypertension. Acetazolamide therapy improved her symptoms over the following weeks. Our patient’s subdural hygromas probably occurred due to passive effusion of fluid into the space within the cranium due to decreased intracranial pressure. Hygromas may evolve into subdural hematomas if intracranial hypotension is not corrected, which is what we suspect happened here. (1,2) Concerns have been raised about performing epidural blood patches in patients with subdural hematomas due to the potential for rebound hypertension, especially in patients without age related atrophy who are less able to compensate for an increase in CSF. (3,4) The mechanism of late rise in ICP may be related to an increase in CSF production brought about by the prolonged depletion or disturbed CSF production and absorption mechanisms. (5) Epidural blood patches in patients with cystic hygromas or subdural hematoma may be vulnerable to rebound intracranial hypertension.

1. Lee KS. The pathogenesis and clinical significance of traumatic subdural hygroma. Brain Inj 1998: 12: 595-603

2. Verdu M, Alonso B, Burguillos S, Martinez-Lage J. Postpartum Hygroma after Epidural Analgesia. Anesthesiology 1999; 91:869-72

3. Zeidan, O. Farhat, H. Maaliki, A. Baraka. Does Postdural puncure headache left untreated lead to subdural hematoma? Case report and review of the literature. International Journal of Obstetric Anesthesia (2006) 15, 50-58

4. Gomez-Rioz MA, Serradilla LN, Bilateral interhemispheric subdural hematoma after accidental lumbar puncture and epidural blood patch. Arch Gynecol Obstet 2012. 286:531-532

SOAP 2013