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Abstract Dural puncture is either diagnosed by unexpectedly profound response to medication test dose or development of a postpartum postural headache. Epidural blood patch is the gold standard for treatment of PDPH when conservative management fails. However, postpartum headaches can be resistant to multiple epidural blood patches. In such cases, preexisting intracranial processes should be considered and ruled out. We report here the unique case of a pregnant patient who developed a resistant headache in the postpartum period related to an incidental intracranial aneurysm. Subsequent treatment with endovascular embolization adequately relieved her symptoms. Early surgical consultation and a multidisciplinary team approach involving neurology and neuroimaging is required for successful management of patients such as the one described here.

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Abstract Background Postdural puncture headache (PDPH) is a common complication of neuraxial techniques which delays patients' discharge. Sphenopalatine ganglion block (SPGB) is a safe bedside technique with comparable efficacy to Epidural Blood Patch, the gold-standard treatment. There is no evidence on the ideal timing for SPGB performance. We aimed to evaluate the difference between early versus late SPGB concerning efficacy, symptom recurrence and hospital length of stay. Methods We present an observational study with 41 patients diagnosed with PDPH who were submitted to SPGB with ropivacaine 0,75%. The study sample (n = 41) was divided in two groups: an early (less than 24 hours after diagnosis) and a late (more than 24 hours after diagnosis) SPGB group. Pain was evaluated 15 minutes after the block and follow up occurred daily until patients were discharged. Patients' demographic characteristics, neuraxial technique, timing of SPGB, qualitative pain relief and post-SPGB length of stay were registered and analyzed with SPSS statistics (v26) software. Results Early SPGB resulted in a significant reduction in length of stay (p = 0,009) and symptom recurrence (p = 0,036), showing equally effective pain relief, compared to late SPGB. Conclusions SPGB was equally effective in both groups. Data showed that early SPGB reduces length of hospital stay and symptom recurrence, which potentially allows early resumption of daily activities and a reduction in total health costs.

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Dural puncture is either diagnosed by unexpectedly profound response to medication test dose or development of a postpartum postural headache. Epidural blood patch is the gold standard for treatment of PDPH when conservative management fails. However, postpartum headaches can be resistant to multiple epidural blood patches. In such cases, preexisting intracranial processes should be considered and ruled out. We report here the unique case of a pregnant patient who developed a resistant headache in the postpartum period related to an incidental intracranial aneurysm. Subsequent treatment with endovascular embolization adequately relieved her symptoms. Early surgical consultation and a multidisciplinary team approach involving neurology and neuroimaging is required for successful management of patients such as the one described here.

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BACKGROUND: Postdural puncture headache (PDPH) is a common complication of neuraxial techniques which delays patients.ÇÖ discharge. Sphenopalatine ganglion block (SPGB) is a safe bedside technique with comparable efficacy to Epidural Blood Patch, the gold-standard treatment. There is no evidence on the ideal timing for SPGB performance. We aimed to evaluate the difference between early versus late SPGB concerning efficacy, symptom recurrence and hospital length of stay. METHODS: We present an observational study with 41 patients diagnosed with PDPH who were submitted to SPGB with ropivacaine 0,75%. The study sample (n=41) was divided in two groups: an early (less than 24hours after diagnosis) and a late (more than 24hours after diagnosis) SPGB group. Pain was evaluated 15minutes after the block and follow up occurred daily until patients were discharged. PATIENTS: ÇÖ demographic characteristics, neuraxial technique, timing of SPGB, qualitative pain relief and post-SPGB length of stay were registered and analyzed with SPSS statistics (v26) software. RESULTS: Early SPGB resulted in a significant reduction in length of stay (p=0,009) and symptom recurrence (p=0,036), showing equally effective pain relief, compared to late SPGB. CONCLUSIONS: SPGB was equally effective in both groups. Data showed that early SPGB reduces length of hospital stay and symptom recurrence, which potentially allows early resumption of daily activities and a reduction in total health costs.

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BACKGROUND: Postdural puncture headache (PDPH) develops due to puncture of the dura mater. The risk factors that influence PDPH incidence are Body Mass Index (BMI), sex, spinal needle type, history of headache, and loss of Cerebrospinal fluid (CSF) volume, yet there is no consensus on these risk factors. The pathophysiology of PDPH is poorly understood. The molecular pathways that may lead to PDPH are unknown. In this study, CSF - derived microRNAs (miRNAs) were investigated for their potential to predispose to PDPH in a population of pregnant women. METHODS: Pregnant women going under cesarean section via spinal anesthesia were included in the study with the criteria of the subjects presenting American Society of Anesthesiologists (ASA) physical status I. Patients were classified into two groups as with PDPH (n = 10) and without PDPH (n = 12) based on International Headache Society's PDPH definition. CSF-derived microRNAs were investigated for their differential expression levels in PDPH patients compared with the healthy controls using microfluidic gene expression platform. RESULTS: Out of seventy-six miRNAs, two miRNAs, namely miR-142-3p and miR-17-5p, were significantly downregulated in PDPH patients (Mann-Whitney U test, p < 0,05). BMI and age did not influence PDPH occurrence. The mean visual analogue scale (VAS) of the PDPH patients was 6,8 out of 10. CONCLUSION: We have shown that downregulation of miR-142-3p and miR-17-5p may predispose pregnant women to PDPH upon spinal anesthesia. However, which genes are targeted by miR-142-3p and miR-17-5p-mediated effect on PDPH remains to be elucidated.

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Intracranial hematoma after spinal anesthesia is a rare complication. It generally presents with posture-dependent headache that becomes persistent. We describe the case of patient submitted to spinal anesthesia for cesarean section who presented a non-posture-dependent headache, resistant to clinical treatment, that progressively worsened and with symptoms of intracranial hypertension. The patient had a history of head trauma without symptoms. The CT-scan revealed a chronic bilateral parietal hematoma with a recent bleeding component, treated surgically. We concluded that spinal puncture led to chronic hematoma to rebleed. We have reported the case to draw attention to the importance of investigating atypical headache after spinal anesthesia.

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BACKGROUND AND OBJECTIVES: The Sphenopalatine Ganglion Block (SGB) is an effective, low-risk treatment option for Postdural Puncture Headache (PDPH) refractory to conservative management. CASE REPORT: This report presents four complex cases of patients with headache related to low cerebrospinal fluid pressure. Three of them were successfully treated with the application of local anesthetic topical drops through the nasal cavity. CONCLUSION: The novel approach described in this report has minimal risks of discomfort or injury to the nasal mucosa. It is quick to apply and can be administered by the patient himself.

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Abstract Background and objectives The Sphenopalatine Ganglion Block (SGB) is an effective, low-risk treatment option for Postdural Puncture Headache (PDPH) refractory to conservative management. Case report This report presents four complex cases of patients with headache related to low cerebrospinal fluid pressure. Three of them were successfully treated with the application of local anesthetic topical drops through the nasal cavity. Conclusion The novel approach described in this report has minimal risks of discomfort or injury to the nasal mucosa. It is quick to apply and can be administered by the patient himself.

Resumo Justificativa e objetivos: O Bloqueio do Gânglio Esfenopalatino (BGEP) é opção de tratamento efetivo associado a baixo risco para Cefaleia Pós-Punção Dural (CPPD) refratária às medidas conservadoras. Relato de caso: Este relato apresenta quatro pacientes com alta complexidade que apresentaram cefaleia relacionada à baixa pressão do líquido cefaloraquidiano. Três pacientes foram tratados com sucesso pela instilação de gotas de anestésico local tópico na cavidade nasal. Conclusões: A nova abordagem descrita neste relato apresenta riscos mínimos de desconforto ou lesão à mucosa nasal. A aplicação é rápida e pode ser administrada pelo próprio paciente.

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INTRODUCTION: Postdural puncture headache is one of the most frequent complications that occurs after the puncture of the dura mater, resulting in the spinal fluid leakage, through the same and subsequent traction of brain structures. OBJECTIVE: To compare cutting spinal needle and pencil point spinal needle in the incidence of postural dural puncture headache. MATERIALS AND METHODS: A literature search of scientific articles published since 2006 was carried out in the Pubmed, Science Direct, Clinical Key and EBSCO databases, which evaluates the incidence of postdural puncture headache in spinal needles with conical tip and cutting bevel, additionally, experts will be consulted in the area that should suggest literature related to this topic, which would not have been included in the search methods previously described. RESULTS: In total, 14 studies were selected in the population that suffered puncture of the dura mater after accidental, therapeutic or diagnostic lumbar puncture (LP) and the presentation of postdural puncture headache was measured according to the ICHD-3 beta criteria. It was found that there is a decrease in the incidence of postdural puncture headache with conical tip spinal needles, compared to spinal needles of cutting bevel. CONCLUSIONS: Current evidence indicates that postdural puncture headache occurs less frequently, with low intensity and short duration in patients operated with a conical spinal needle, compared to the cutting bevel. In addition, according to the recently described pathophysiology, it is contradictory that conical spinal needles are called "atraumatic", so this review proposes a change in nomenclature that is most useful for the clinical anesthesiologist.

INTRODUCCIÓN: La cefalea postpunción dural es una de las complicaciones más frecuentes que se presenta posterior a la punción de la duramadre, lo cual produce salida de líquido cefalorraquídeo, a través de la misma y posterior tracción de las estructuras cerebrales. OBJETIVO: Comparar la aguja espinal de bisel cortante y la aguja espinal de punta cónica en la incidencia de presentación de cefalea postpunción dural. MATERIALES Y MÉTODOS: Se realizó una búsqueda bibliográfica de artículos científicos publicados desde el año 2006, en las bases de datos Pubmed, Science Direct, Clinical Key y EBSCO, que evaluaran la incidencia de cefalea postpunción dural en agujas espinales de punta cónica y bisel cortante, adicionalmente se consultó con expertos en el área que pudieran sugerir literatura relacionada con este tema, la cual no hubiese sido incluida en los métodos de búsqueda previamente descritos. RESULTADOS: En total se seleccionaron 14 estudios realizados en población que sufrieron punción de la duramadre luego de punción lumbar (PL) accidental, terapéutica o diagnóstica y se midió la presentación de cefalea postpunción dural según los criterios ICHD-3 beta. Se encontró que hay una disminución de la incidencia de cefalea postpunción dural con las agujas espinales de punta cónica, en comparación con las agujas espinales de bisel cortante. CONCLUSIONES: La evidencia actual indica que la cefalea postpunción dural se presenta con menor frecuencia, baja intensidad y corta duración en pacientes intervenidos con aguja espinal de punta cónica, en comparación con la aguja espinal de bisel cortante. Adicionalmente, según la fisiopatologia recientemente descrita, es contradictorio que las agujas espinales de punta cónica sean llamada "atraumáticas", por lo que esta revisión propone un cambio en la nomenclatura que resulta de mayor utilidad para el anestesiólogo clínico.

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BACKGROUND: This double-blind, randomized trial compared dural puncture epidural analgesia (DPEA) for labor using 25-gauge and 27-gauge pencil point spinal needles. We hypothesized that both needle sizes would result in similar onset time (equivalence margin=2.5 min) and therefore designed the study as an equivalence trial. METHODS: One hundred and forty patients undergoing labor were randomized to DPEA with 25-gauge (n=70) or 27-gauge (n=70) pencil point spinal needles. After the placement of the epidural catheter, a bolus of 20 mL of bupivacaine 0.125% and fentanyl 2 µg/mL was administered to all subjects. Thereafter, patients received boluses of 12 mL of bupivacaine 0.125% every 2 hours as needed.A blinded investigator recorded the onset time (defined as the temporal interval required to achieve a pain score ≤1 on a 0-10 scale), S2 block, sensory block height (30 min after the initial bolus of local anesthetic), presence of motor block (30 min after the initial bolus of local anesthetic), number of top-up doses required during labor and incidence of postural headache. RESULTS: Out of the 140 recruited patients, 135 were retained for analysis. Compared with their 27-gauge counterparts, 25-gauge pencil point spinal needles provided a 1.6 min shorter DPEA onset (95% CI of the difference of the means: -3.2 to -0.1 min). However, there were no intergroup differences in terms of S2 block, sensory block height, motor block, number of top-up doses and incidence of postural headache. CONCLUSION: Dural puncture epidural analgesia with 25-gauge pencil point spinal needles provides a 1.6 min shorter onset time than DPEA with 27-gauge spinal needles. Although statistically significant, such a difference may not be clinically relevant. Further investigation is required to compare 25-gauge and 27-gauge spinal needles for DPEA in the setting of different local anesthetic infusion strategies. TRIAL REGISTRATION NUMBER: NCT03389945.