Spontaneous intracranial hypotension and the obstetric anaesthetist.

Introduction

Obstetric anaesthetists are expert and managing intracranial hypotension in the context of a recent 'lumbar puncture'. As the ICD-11 reminds us... 'The syndrome of intracranial hypotension is a single pathophysiological entity of diverse origin'1. Guidelines were published last year for the diagnosis and management of spontaneous intracranial hypotension (SIH) (i.e. not following lumbar puncture) which recommends 'non-targeted' epidural blood patch (EBP) after two weeks of conservative management2. It is a condition that obstetric anaesthetists need to be aware of as they may be asked to help with therapeutic interventions.

Case series

The author's institution was involved with six patients with SIH in 2023. All were women. Five were referred to the author from neurology and the sixth was referred from the patient's GP.

Many of the women had some kind of preceding event - often it was lifting a heavy object:

Only the women with radiological signs of complications from SIH went onto have an EBP.

It's interesting to see that in this small cohort advancing age appears to be a poor prognostic indicator - the youngest had spontaneous resolution of symptoms and the oldest had the least effect from her EBP. Resolution of symptoms was often associated with resolution of radiological signs.

Discussion

Obstetric anaesthetists are key to this service although it definitely falls outside our maternity service brief. It seems to fit better into the CEPOD emergency service although that service isn't designed to accommodate urgent medical problems.

A small number of operators reduced the challenges to provision of the EBP - consent, location and documentation. The author found that the newly commissioned medical day-case unit was the ideal location for these procedures. A referral pathway is being developed.