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A Patient with Pseudotumor Cerebri Being Treated w/ Therapeutic Lumbar Punctures Suffers Post-Dural Puncture Headache and Experiences Relief w/ Sphenopalatine Ganglion Block
Preet Patel, MD, Shaul Cohen, MD, Geza Kiss, MD
Department of Anesthesiology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ 08901
HPI: A 34 year old AA obese female (5‘7”, 300 lbs.) with PMHx significant for HTN and left breast cancer s/p chemotherapy and radiation, currently on tamoxifen, presented to the ED on the advice of her ophthalmologist for evaluation of papilledema in both eyes, OD > OS on funduscopic exam. Notably, the patient reported sudden onset of sharp, right eye pain that was followed by two minutes of blurry vision two weeks prior while in the standing position. Patient stated that since this initial event, she has woken up from night sleep with blindness in the right eye that lasts approximately 3-4 minutes with spontaneous resolution. Associated symptoms include nausea and right parieto-temporal and occipital throbbing headache. The patient previously presented to a local urgent care center for these symptoms and was diagnosed with migraine headaches and administered butalbital-acetaminophen-caffeine capsules and a 6-day course of steroids which were completed. Symptoms continued to persist despite these medications.
Pertinent labs/radiology: ESR <50; Intracranial & Neck CTA: WNL; MRI Brain: No GAD enhancement.
Treatment: Following therapeutic lumbar puncture under fluoroscopic guidance (opening pressure > 35 cm H20) for Idiopathic Intracranial Hypertension (IIH) formerly known as Pseudotumor Cerebri, the patient developed a positional headache that was relieved by lying down. A presumed diagnosis of post-dural puncture headache (PDPH) was made. The gold-standard treatment for PDPH is the epidural blood patch (EBP). However, in this setting, administration of an EBP would be counterintuitive as the goal of therapeutic lumbar puncture is to decrease idiopathic intracranial hypertension . Thus, our anesthesiologists used a novel technique for the treatment of PDPH, the sphenopalatine ganglion block (SPGB).
Discussion: SPGB is a noninvasive anesthetic intervention with minimal adverse effects and high efficacy . It can be performed by inserting a cotton-tipped applicator saturated with 5% water-soluble lidocaine ointment through each nares bilaterally and positioning the end of the applicator tip just superior to the middle turbinate and anterior to the pterygopalatine fossa and sphenopalatine ganglion (SPG) for 10 minutes with the patient in supine or Trendelenburg position. Block of the SPG with local anesthetic (1 cc of 4% lidocaine) requires good anatomical and physiological placement and leads to rapid termination of severe headache.