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COULD EPIDURAL PATCH WITH AUTOLOGOUS PLATELET RICH PLASMA BE A SOLUTION FOR POSTDURAL PUNCTURE HEADACHE REFRACTORY TO EPIDURAL BLOOD PATCH?
Abstract Number: SU-24
Abstract Type: Case Report/Case Series
Background: The accepted treatment for confirmed severe post-dural puncture headache (PDPH) is an epidural blood patch (EBP).However, initial success rate of EBP varies from 50 to 60% which may increase up to 60-75% after 2nd EBP. In the event of incomplete recovery of the PDPH after EBP, we still need alternative solutions.
Platelet rich plasma (PRP) is a concentrated source of autologous platelets that contains and releases several different growth factors and other cytokines to stimulate healing of bone and soft tissue via degranulation of circulated platelets. Because of the potential of PRP to regenerate tissues resulting in healing through the effects of bioactive molecules, PRP therapy has gained popularity in many disciplines (1, 2).
Therefore, we aimed to present whether use of PRP for epidural patch could completely treat persistent PDPH after failed EBP via avoiding cerebrospinal fluid leakage due to healing of defect in the dura.
A 34 year-old parturient (172 cm height and 91 kg weight) who received EBP at a different institution was admitted to our unit because of persistent severe headache localized mainly to the frontal area. She has been still suffering from severe PDPH though she recently received EBP 3 days ago at the hospital where she delivered.
The patient had an unbearable headache while she was erect, which was partially relieved in the supine position in the beginning. After evaluating the severity of the pain, we have re-confirmed the clinical diagnosis of PDPH.
Before attempting another EBP, MRI of the brain and lumbar region with contrast was performed. Brain MRI showed diffuse pachymeningeal thickening and contrast enhancement with enlarged pituitary consistent with intracranial hypotension.
After obtaining written informed consent of the patient, epidural block using loss of resistance with saline was performed between L2–3 intervertebral space at the 1st attempt in the sitting position. Meanwhile, 20 ml venous blood sample from the left arm of the patient was collected under sterile conditions to prepare PRP to use for epidural patching. Increase in platelet concentration, platelet activation and growth factor concentration of PRP was verified by platelet count (7 times), beta-thromboglobulin (8.5 times) and platelet-derived growth factor (7.6 times) levels.
Then, 10 mL of autologous PRP (PRO-PRP Kit, PNC International Co. Ltd) was injected to epidural space. She was discharged after 6 hours. Clinical improvement in the severity of PDPH with decreased pachymeningeal contrast enhancement on postoperative control MRI was observed after 3 days.
Conclusion: We have presented the first successful use of PRP for epidural patch to treat persistent PDPH refractory to conventional EBP in a multiparous patient delivered under epidural analgesia.
1. Med Clin N Am 100 (2016) 199–217
2. Perfusion 2008; 23: 179–186