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Lumbar Puncture Headache (See also page 159) This is a well-known phenomenon, attributable to a lowering of ICP by leakage of CSF through the needle track into the paravertebral muscles and other tissues Once begun, the headache may last for days or, rarely, even weeks Most characteristic is the relation of the headache to upright posture and its relief within moments after assuming the recumbent position Actually, the syndrome includes more than headache There may be pain at the base of the skull posteriorly and in the back of the neck and upper thoracic spine, stiffness of the neck, and nausea and vomiting At times the signs of meningeal irritation are so prominent as to raise the question of post lumbar puncture meningitis, although lack of fever usually excludes this possibility In addition to a low or unmeasurable CSF pressure if another spinal tap is performed (the CSF pressure is found to be in the range of 0 to 60 mmH2O), there are occasionally a few to a dozen white cells in the CSF, which may further raise concern of meningitis In the infant or young child, stiffness of the neck may be accompanied by irritability, unwillingness to move, and refusal of food If the headache is protracted, recumbency still reduces it, but a feeling of dull pressure may remain, which the patient continues to report as pain Many patients also report that shaking the head produces a cephalic pain Occasionally there will be a sixth nerve palsy or a self-audible bruit from turbulence in the intracranial venous system It has been recognized that low CSF pressure is associated on the MRI with prominent dural enhancement by gadolinium (Fig 30-4) and, when the syndrome is protracted and severe, there may be small subdural effusions (see below, under Spontaneous Intracranial Hypotension ) The use of a 22- to 24-gauge needle and the performance of a single clean (atraumatic) tap seemingly reduces the likelihood of a post lumbar puncture headache, as discussed in Chap 2 A period of enforced recumbency, though widely practiced as a means of preventing headache, probably does not lessen its incidence (Carbaat and van Crevel) The ingestion of large volumes of uids
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brain and dilation of cerebral and spinal epidural veins They propose that the buoyancy provided by the spinal uid is lost in these cases Aside from the headaches, there are few adverse effects of lumbar puncture; these are described in Chap 2 Spontaneous Intracranial Hypotension This is a less well known syndrome, in which the same problem of low pressure as that which follows lumbar puncture occurs after straining, a nonhurtful fall, or for no known reason The cardinal feature is orthostatic headache and only rarely are there other neurologic complaints such as diplopia from sixth nerve palsy or a self-audible bruit In these cases the CSF pressure is low (60 mmH2O or less) or not measurable; the uid may contain a few mononuclear cells but is most often normal A few cases have presented with stupor as a result of downward transtentorial displacement of the diencephalic region (Pleasure et al) or an upper cervical myelopathy caused by downward deformation and displacement of the spinal cord (Miyazaki et al) In many such patients, there has been a tear in the delicate arachnoid surrounding a nerve root, with continuous leakage of CSF The site of the leak is dif cult to ascertain except when it occurs into the paranasal sinuses (CSF rhinorrhea) In a series of 11 patients with spontaneous intracranial hypotension, a putative leak was found by radionuclide cisternography or CT myelography (the preferred procedure) in the cervical region or at the cervicothoracic junction in 5 patients, in the thoracic region in 5, and the lumbar region in 1 (Schievink et al) In the patients who underwent surgical repair, a leaking meningeal diverticulum (a so-called Tarlov cyst) was found and could be ligated This seems to be the most common cause A blood patch, as described above, may also be useful and should be attempted before resorting to surgery Recumbency for a few days thereafter permits the pressure to build up, and there has been no recurrence in the cases that we have encountered Others, however, have reported repeated episodes of orthostatic headache As noted above, a helpful diagnostic sign is prominent dural enhancement with gadolinium on the MRI (Fig 30-4), a phenomenon attributed by Fishman and Dillon to dural venous dilatation; this nding may extend to the pachymeninges of the posterior fossa and the cervical spine According to Mokri and colleagues, biopsy of the dura and underlying meninges in these cases shows broblastic proliferation and neovascularity with an amorphous subdural uid There may be subdural effusions and mass effect, either on the cerebral convexities, temporal lobes, optic chiasm, or cerebellar tonsils Using ultrasound, Chen and colleagues have also described an enlarged superior ophthalmic vein and increased blood ow velocity in this vessel, both of which normalize after successful treatment Rarely, a case of intracranial hypotension becomes chronic; the headache is then no longer responsive to recumbency Mokri and colleagues have also made the point that orthostatic headache and diffuse pachymeningeal enhancement on MRI may occur in the presence of normal CSF pressures; observation of these characteristic features should prompt a search for the site of CSF leakage despite the normal pressure The use in hydrocephalus of a one-way shunt valve may be complicated by a syndrome of low CSF pressure Reference has already been made to this syndrome and to the slit ventricles in children who have been treated for hydrocephalus Usually the valve setting is too low, and readjustment to maintain a higher pressure is corrective Also appropriate to mention here are CSF leaks that occur
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Figure 30-4 MRI after gadolinium infusion (T1 sequence) showing the widespread dural enhancement that is typical of low CSF pressure after lumbar puncture, spontaneous CSF leakage, or shunt overdrainage Similar changes may be found in the spinal dura
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and the infusion of 1000 to 2000 mL of 5% glucose are usually recommended but are of uncertain bene t The most dependable treatment is a blood patch (spinal epidural injection of a few milliliters of the patient s own blood) At least 75 percent of patients are thus relieved of the headache, according to Safa-Tisseront and colleagues; they report that after a second injection, improvement is effected in 97 percent Many patients have transient back or radicular pain (sciatica) following the blood patch Curiously, the headache is often relieved almost immediately even if the blood is injected at some distance from the original puncture (although the procedure is usually done at the same level as the previous spinal tap) Moreover, the volume of blood injected, usually about 20 mL, is not related to the chances of success The mechanism of this rapid improvement may not simply be the plugging of a dural leak A number of patients fail to bene t or have only transient effects; it is then unclear whether repeating the procedure is helpful The administration of caffeine-ergotamine preparations or intravenous caffeine may also have a salutary though temporary effect on the headache The addition of analgesic medication is required if the patient must get up to care for himself or to travel In protracted cases, patience is called for, since most headaches will resolve in 2 weeks or less As to mechanism, Panullo and colleagues have shown that there is a downward displacement of the upper brainstem and posterior fossa contents when the patient assumes the upright position; but, as pointed out in Chap 17, only rarely are there associated signs of brain herniation, the exceptions being some of the unusual cases discussed below Miyazawa and colleagues have forwarded the interesting ndings that hypovolemia of the CSF, rather than lowered pressure, is the cause of downward displacement of the
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