Rev. Bras. Anestesiol. vol.67 número3

RevBrasAnestesiol.2017;67(3):311---313

REVISTA

BRASILEIRA

DE

ANESTESIOLOGIA

CLINICAL

INFORMATION

Sphenopalatine

ganglion

block

for

postdural

puncture

headache

in

ambulatory

setting

José

Miguel

Cardoso

_,

_Miguel

_Sá,

_Rita

_Grac

_¸a,

_Hugo

_Reis,

_Liliana

_Almeida,

Célia

Pinheiro,

Duarte

Machado

CentroHospitalardeTrás-os-MonteseAltoDouro,DepartamentodeAnestesiologiaeTerapêuticadaDor,VilaReal,Portugal

Received7July2016;accepted12September2016 Availableonline1October2016

KEYWORDS

Sphenopalatine

ganglionblock;

Postduralpuncture

headache

Abstract

Backgroundandobjectives: Postdural puncture headache (PDPH)is acommon complication followingsubarachnoidblockadeanditsincidencevarieswiththesizeoftheneedleusedandthe needledesign.Suportivetherapyistheusualinitialapproach.Epiduralbloodpatch(EBP)isthe gold-standardwhensupportivetherapyfailsbuthassignificantrisksassociated.Sphenopalatine ganglionblock(SPGB)maybeasaferalternative.

Casereport: We observed a 41 year-old female patient presenting with PDPH after a sub-arachnoidblockadeaweekbefore.Weadministrated1lofcrystalloids,Dexamethasone4mg, parecoxib40mg,acetaminophen1gandcaffeine500mgwithoutsignificantreliefafter2hours. WeperformedabilateralSPGBwithacotton-tippedapplicatorsaturatedwith0.5% Levobupi-vacaine understandard ASA monitoring. Symptomsrelief was reported 5minutes after the block.Thepatientwasmonitoredforanhourafterwhichshewasdischargedandprescribed acetaminophen1gandibuprofen400mgevery8hoursforthefollowing2days.Shewas con-tactedonthenextdayandagainafteraweekreportingnopaininbothsituation.

Conclusions: SPGBmayattenuatecerebralvasodilationinducedbyparasympatheticstimulation transmittedthroughneuronsthathavesynapsesinthesphenopalatineganglion.Thiswouldbe inagreementwiththeMonro-Kellieconceptandwouldexplainwhycaffeineandsumatriptan canhavesomeeffectinthetreatmentofPDPH.

Apparently, SPGBhasafaster onsetthanEBPwith bettersafetyprofile.Wesuggest that patientspresentingwithPDPHshouldbeconsideredprimarilyforSPGB.Patientsmayhavea rescueEBPifneeded.

©2016SociedadeBrasileiradeAnestesiologia.Publishedby ElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).

∗_{Correspondingauthor.}

E-mail:[email protected](J.M.Cardoso). http://dx.doi.org/10.1016/j.bjane.2016.09.003

312 J.M.Cardosoetal.

PALAVRAS-CHAVE

Bloqueiodogânglio

esfenopalatino;

Cefaleiapós-punc¸ão

dural

Bloqueiodogânglioesfenopalatinoparacefaleiapós-punc¸ãoduralemcontexto

deambulatório

Resumo

Justificativaeobjetivos: Cefaleiapós-punc¸ãodural (CPPD)éuma complicac¸ãocomumapós bloqueiosubaracnoideoesuaincidênciavariadeacordocomotamanhoedesenhodaagulha utilizada.Geralmente,aterapiadeapoioéaabordageminicial.Otampãosanguíneoperidural (TSP)éopadrãodeterapiaquandoaterapiadeapoiofalha,maspossuiriscossignificativos associados.Obloqueiodogânglioesfenopalatino(BGEP)podeserumaalternativamaissegura.

Relatodecaso:Atendemosumapacientede41anosdeidade,apresentando-secomCPPDapós umbloqueiosubaracnoideoumasemanaantes.Administramoscristaloides(1L),dexametasona (4mg),parecoxib(40mg),acetaminofeno(1g)ecafeína(500mg),semalíviosignificativoapós 2horas.Realizamosumbloqueiobilateraldogânglioesfenopalatino,usandoumaplicadorcom pontadealgodãosaturadacomlevobupivacaínaa0,5%sobmonitorac¸ãopadrãoASA.Oalívio dossintomasfoirelatado5minutosapósobloqueio.Apacientefoimonitoradaporumahora edepoisrecebeualtacomprescric¸ãodeacetaminofeno(1g)eibuprofeno(400mg)acada8 horasparaosdoisdiasseguintes.Apacientefoicontatadanodiaseguinteenovamenteapós umasemanae,emambososcontatos,relatounãosentirdor.

Conclusões:OBGEPpodeteratenuadoavasodilatac¸ãocerebralinduzidapeloestímulo paras-simpáticotransmitidoatravésdosneurôniosquepossuemsinapsesnogânglioesfenopalatino. EssemecanismoestariadeacordocomoconceitodeMonro-Kellieeexplicariaporqueacafeína eosumatriptanopodemteralgumefeitonotratamentodaCPPD.

Aparentemente,oBGEPtemuminíciomaisrápidoqueodoTSP,comummelhorperfilde seguranc¸a.SugerimosqueospacientesqueseapresentamcomCPPDdevamserconsiderados primeiroparaBGEP.OspacientespodemsersubmetidosaumTSPderesgate,casonecessário. ©2016SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigoOpen Accesssobumalicenc¸aCCBY-NC-ND( http://creativecommons.org/licenses/by-nc-nd/4.0/).

Background

and

objectives

PostduralPunctureHeadacheisacommoncomplication fol-lowingsubarachnoidblockade.Itsincidencevaries greatly accordingtotheusedneedlesizeandtheneedledesign.It usuallypresentsasanintensefrontalandoccipitalheadache but other areas may alsobe affected.1 _{The painis} exac-erbatedbyupright positionandisrelievedby lyingdown, which is a hallmark.2 _{Other symptoms have also been} reported including nausea and vomiting, vertigo, hearing loss and even visual disturbances. Despite approximately 90% of PDPH happening in the first 3 days after a dural puncture,itsonsetmaybedelayedforalmost2weeks.1

TheQuinckeneedleisoneofthemostusedspinalneedles worldwideandithasasharpandcuttingtip.Theincidence ofPDPH usingQuincke needles mayvaryfrom 0.4%up to 36% depending of its size. Pencil-point needles may have lowerincidenceofPDHP.1_{Rehydration,non-steroidal} anti-inflammatory drugs, acetaminophen, low dose corticoids, caffeineand even sumatriptan are all part of supportive therapy which may obviate the need for moreaggressive therapydespiteincompleterelief.3

TheEBPiscurrentlythestandardofcareafterfailureof pharmacologicaltherapiesbutitisnotdevoidedof signifi-cantrisks(meningitis,seizures,motorandsensorydeficits, etc.).4_{SomereportsoftransnasalSPGBhavebeenemerging} forthetreatmentofPDPH.5

Case

report

Weobserveda41 year-oldfemalepatientpresentingwith PDPHafterasubarachnoidblockadewitha27gaugeQuincke needle for a tension-free vaginal tape obturator a week before.Theintenseholocraneaneheadachehadstartedat the nightofsurgery andit wasaggravated bytheupright positionwithreliefbylyingdown.Thepatientalsoreferred nauseaandvomitingforthelastweek.Noneckstiffnesswas found.WeproposedabrainComputedTomography(CT)scan whichourpatientrefusedduetohavinganinfantathome fromwhomshedidnotfeelcomfortablebeingseparated.

Sphenopalatineganglionblockforpostduralpunctureheadache 313

8hforthefollowing2days.Shewascontactedthenextday andagainafteraweekreportingnopaininbothsituation.

Conclusions

DespitePDPHbeingusuallyacleardiagnosisfromthehistory ofaduralpunctureandtheclinicalfindings,otherdiagnosis must be considered ranging from migraine to meningi-tis,intracranialhaemorrhage,centralvenousthrombosisor cerebraltumor.1_{Therewasnoprevioushistoryofmigraine.} Theonsetandlackofprogressionofneurologicalsymptoms played against meningitis and intracranial haemorrhage wouldlikelypresentwithmoredramaticfeatures.We pro-posedabrainCT-scantoexcludefor othercauses butour patientrefusedit.

TheMonro-Kellieconceptstatesthattheintracranial vol-umemustremainfixed.Therefore,ifthereisacerebrospinal fluidleakageduetoaduralpuncture,theotherintracranial constituents(bloodandbraintissue)wouldhavetoincrease itsvolumesothatthe intracranialpressureand the cere-bralperfusionpressurewouldremaininthenormalrange. Sincethebraintissueisasolidconstituentwithlow capac-itytoexpanditsvolumeinanacutefashion,theremaining possibilityisfortheintracranialbloodvolumetoincrease, secondarytovasodilation.1

An hypothesis is that SPGB may attenuated cere-bral vasodilation induced by parasympathetic stimulation transmitted through neurons that have synapses in the sphenopalatineganglion.This wouldbeinagreementwith theMonro-Kellie conceptandwould alsoexplainwhy caf-feineandsumatriptancanhavesomeeffectinthetreatment ofPDPH.

Regardingwhatwasalreadydescribedelsewhere,4,5_SPGB hasapparentlyafaster onsetthan EBPwithbettersafety profile. Despite obvious contraindication in patients with basilar skullfractures, we can argue that SPGB can walk through the many contraindications for an EPD. Also, by beinganon-invasivetechnique,littleworriesmustbegiven in the case of pyrexia, hyperleukemia or know infection anywhereelsethanthenasopharynx.

WesuggestthatpatientspresentingwithPDPHshouldbe consideredprimarilyforSPGB,duetosafetyofthe proce-dure.PatientsmayhavearescueEBPifneeded.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

References

1.Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth. 2003;91:718---29.

2.Weir EC. The sharp end of the dural puncture. Br Med J. 2000;320:127---8.

3.Flaatten H, Rodt S, RoslandJ, et al. Postoperative headache in young patients after spinal anaesthesia. Anaesthesia. 1987;42:202---5.

4.Kardash K, Morrow F,Beique F.Seizures afterepidural blood patch withundiagnosed subdural hematoma.Reg Anesth Pain Med.2002;27:433---6.