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Does magnetic resonance imaging of epidural cerebrospinal fluid spread correlate with severity of headache following accidental dural puncture: a-proof-of-concept observational multi centre study
Abstract Number: T-37
Abstract Type: Original Research
Currently the decision for performing an epidural blood patch (EBP) to treat post dural puncture headache (PDPH) relies mainly on subjective clinical judgement as there is no validated pathway to guide treatment. An evidence base protocol may be of value in identifying those women most likely to develop a severe PDPH necessitating EBP. The use of magnetic resonance imaging (MRI) in characterising cerebrospinal fluid (CSF) spread in the epidural space and its association with severity of PDPH has been proposed. Our study aimed to investigate a potential link between CSF spread after accidental dural puncture (ADP), using a MRI score, and the development/severity of PDPH in obstetric patients.
The MRiADP group, a collaboration of 10 National Health Service hospitals was formed to recruit patients for this study. Parturients who had an ADP complicating a labour epidural underwent a T1 & T2 weighted sagittal MRI scan of the lumbar spine and brain within 48 hours following ADP. All women were followed up for the development of PDPH for one week. Each patient had a daily PDPH score calculated using a 4 point visual analogue scale (none, mild, moderate and severe), with additional points given for visual, auditory, nausea/vomiting. All MRI scans were reported by a blinded neuroradiologist using a predefined scoring system (one point for every vertebral level covered vertically by CSF and one point for circumferential spread). Data are presented as count (%) and median (range). Kendall τ and Spearman rs correlations were used to assess the relationships between PDPH symptom severity and MRI findings. Significance was defined at (P<0.05 two -sided).
Twenty two patients were recruited. The majority developed a PDPH (n=19, 86%) after ADP. The onset time of PDPH was 24 (4-126) hours. An EBP was performed on 47% (n=9) of patients, which resolved the PDPH in 88% (n=8). Eight participants had a spinal catheter inserted for PDPH prophylaxis following ADP, of which 75% (n=6) developed a PDPH, but only 25% (n=2) needed an EBP which resolved the PDPH. The PDPH and MRI scores were 10 (0-21) and 2.5 (0-10) respectively. Kendall τ and rs correlations for PDPH and MRI scores were 0.35 (95%CI: 0.06-0.59, P=0.038) and 0.46 (95%CI: 0.04-0.74, P=0.017) respectively.
Our preliminary results confirm previous findings that characteristics of CSF spread in the epidural space correlates with PDPH severity, although, statistically the correlation remains weak to moderate. Patterns of CSF leak are not understood. Further research should be directed at developing a validated MRI scoring system that could predict severity of PDPH to guide clinical management.
1. Wang YF, Fuh JL, Limg JF et al. Cerebrospinal fluid leakage and headache after lumbar puncture: a prospective non-invasive imaging study. Brain 2015; 138(6): 1492-98.