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Recurrent headache following an epidural blood patch - diagnosing rebound intracranial hypertension versus persistent intracranial hypotension
Abstract Number: S5D-1
Abstract Type: Case Report/Case Series
Meticulous assessment of a patient developing a headache after an epidural blood patch (EBP) is crucial to guide further management. We describe the case of a patient who developed a new headache following an EBP. This was uncharacteristic of a low intracranial pressure headache. Instead, it resembled a headache with features associated with intracranial hypertension, a rare complication of EBP.
A 27-year-old primigravida had labour induced at term. Epidural analgesia was established with technical difficulty. Caesarean section for labour arrest was subsequently performed under spinal anaesthesia.
On days 2 and 3 post-procedure, she reported a debilitating fronto-occipital-nuchal headache of increasing severity and nuchal stiffness with postural exacerbation, typical features of a classical post-dural puncture headache (PDPH). Neurological examination and brain computerised tomography were unremarkable. Expectant management failed and on day 4, an EBP with 20mls autologous blood was performed with immediate relief.
Within the next hour however, she reported a different,severe frontal inter-orbital headache associated with severe hypertension greater than 190mmHg systolic pressure, requiring anti-hypertensive therapy and intravenous opioid analgesia. Her headache persisted over 2 days, was constant, and exacerbated when recumbent. She was mildly hyper-reflexic. A pre-eclampsia screen was negative. Then, her headache resolved and her blood pressure normalised without further treatment.
This patient initially described a classical PDPH which was treated with an EBP. She then reported a new and characteristically different headache that was worse supine, associated with severe hypertension and hyper-reflexia. A medical physician review concluded these features were consistent with cerebral irritability following her EBP.
We believe her second headache to be related to rebound intracranial hypertension (RIH), a rare complication of an EBP, with limited reports in the obstetric literature. There are subtle clinical characteristics that can help in differentiating rebound intracranial hypertension from refractory intracranial hypotension. Clinicians should be aware of RIH so that it is not mistaken for persistent intracranial hypotension due to failure of an EBP, where treatment is very different and when administering a second EBP could have detrimental consequences.