Treatment of post-dural puncture headache using epidural injection of fibrin sealant as an alternative to autologous epidural blood patch (case report)

1 Introduction

In most cases, post dural puncture headache (PDPH) is resolved within 2 weeks and no invasive therapy is needed [1]. Autologous epidural blood patch (EBP) is the treatment of choice for persistent headache symptoms after dural puncture. For patients who fail EBP, percutaneous computed tomography-guided epidural fibrin glue injection can be considered to seal the dural puncture sites [2]. Patients with malignant or infectious diseases present a clinical dilemma, as using autologous blood to patch the dura may introduce the malignant cells or the infectious agent into the intrathecal and epidural spaces [3].

2 Case report

We present a case of a 49-year-old male with a history of human immunodeficiency virus and hepatitis C co-infection who was admitted to the hospital because of a severe throbbing PDPH that persisted for 4 days. The headache started 1 day after a diagnostic lumbar puncture performed as part of his evaluation for neurosyphilis. The patient was diagnosed with human immunodeficiency virus 13 years prior and was non-adherent with the prescribed medical therapy. His viral load 4 days prior to admission was 33406 copies/ml, CD4 absolute count was 8-cells/cu mm, and rapid plasma reagin titre (used to detect infection with syphilis) was 1:64. His headache was positional, exacerbated when standing and alleviated when recumbent. He had episodes of nausea and vomiting but denied chills, numbness or weakness. Cerebrospinal fluid (CSF) analysis showed no evidence for meningoencephalitis. Brain magnetic resonance imaging showed only meningeal enhancement typical in the post-dural puncture state. Conservative management, including bed rest, intravenous fluids and caffeine, was tried with no improvement and the patient was unable to return to work due to the severity of the headache. The pain service was then consulted for possible epidural blood patch.

Given the theoretical risk of seeding the meninges with human immunodeficiency virus and/or hepatitis C during the procedure, an alternative method to seal the dura was sought. After consulting with the neurology, infectious diseases and neurosurgical services, use of the fibrin sealant was deemed a sound alternative. After explaining the risks and benefits of both options, the patient preferred to proceed with use of the fibrin sealant.

The patient was placed in the prone position, then prepped and draped in sterile fashion. Using a para-median, inter-laminar approach and fluoroscopic guidance, a 17 g Tuohy needle was inserted at the level of L3–4 and advanced into the epidural space using a loss of resistance to saline technique. Loss of resistance was encountered at 5.5 cm. After injection of non-ionic contrast, visualization of contrast spread was confirmed in both anterior–posterior and lateral views. Ten millilitres of fibrin sealant (TISSEEL^®) was slowly injected into the epidural space, during which the patient noted a mild sensation of increasing head pressure, as is often seen with a traditional blood patch. After removing the needle, the patient was placed in the supine position and gradually, incrementally raised into an upright, sitting position. His headache resolved within 1 h of the procedure. He remained free of headache until discharge from the hospital. We followed up with the patient 1 month after discharge. At follow up with Infectious Diseases 3 months after discharge he denied any further headaches or untoward effects.

3 Discussion

Several treatment modalities have been proposed for the treatment of post-dural puncture headache. Epidural blood patch is currently accepted as the most effective treatment modality [4,5,6]. The injection of autologous blood into the epidural space was initially suggested by Gormley [7] in 1960 and established in practice in 1970 by DiGiovanni and Dunbar [8]. There are two theories to explain the efficacy of epidural blood patch in the treatment of post dural puncture headaches. One suggests that the injection of blood into the epidural space creates a clot that occludes the dural hole and prevents further loss of cerebrospinal fluid [9,10,11]. The other says that the volume of blood injected into the epidural space increases intrathecal pressure and reduces traction of meningeal brain, leading to relief of symptoms [12,3].

Much has been studied in the way of post dural puncture headache, risk factors for its development, and the various prophylactic and therapeutic treatment options. Common risk factors include female gender, younger age (31–50 years old), perpendicular bevel orientation, and low body mass index, and previous history of post dural puncture headache [13]. Higher risk has been conferred to large gauge (22 g or greater), medium bevel, and cutting spinal needles. Very small gauge needles (29 g), while showing very low incidence of post dural puncture headache, can be technically difficult to use, making 25 and 26 gauge pencil point needles most optimal [14]. Prophylactic conservative and interventional treatment options have been addressed, should intentional or unintentional dural puncture be noted. According to the Cochrane Database, there is no evidence from randomized controlled trials that suggests routine bed rest or fluid supplementation reliably prevents development of post dural puncture headache [15,16]. Additional conservative measures are vast and include intravenous or oral caffeine supplementation, oral opioid analgesics, oral gabapentin or theophylline, rectal indomethacin, intravenous dexamethasone, hydrocortisone, or cosyntropin, and intramuscular adrenocorticotropic hormone [17,18,19,20], and sumatriptan [21,22,23,24,25]. Administration of spinal or epidural opioids has also been suggested. Measures that have shown some promise include epidural morphine, intravenous cosyntropin and aminophylline, all of which seem to reduce the number of study subjects developing a post dural puncture headache. However, while research suggests epidural morphine may be effective, there is a higher incidence of adverse effects (i.e. nausea, vomiting, and pruritis) [17].

Prophylactic blood patching has in the past been considered in cases of known or suspected dural puncture in hopes of avoiding the development of a headache. While studies suggest that this practice does not reliably decrease the number of patients subsequently becoming symptomatic, firm conclusions about the inefficacy of this approach are limited due uncertainties about trial methodology and small study populations. Therapeutic epidural blood patch, however, has been shown in multiple studies to provide benefit when compared to conservative treatment, and remains the gold standard of treatment in refractory headaches [26]. Alternative injectable materials include dextran, colloid and normal saline [27]. Epidural fibrin sealant has been used only in cases resistant to autologous blood patch [28,29]. The use of the sealant has been reported to cause aseptic meningitis when used for post-spinal surgery CSF leaks [30]. However, this was not encountered in our patient.

The evidence for the safety of epidural blood patch in patients with human immunodeficiency virus is limited. HIV patients are known to have central nervous system manifestations that may be due either to the direct action of HIV itself in the CNS or due to secondary, opportunistic disease. Beards et al. [31] demonstrated definite translocation of blood into the subarachnoid space using magnetic resonance imaging in patients who had a dural puncture and subsequent blood patch. This demonstrated possible breaching of the blood brain barrier. Therefore, the use of epidural blood patch in HIV patients has been debated [32], given concern of the possible injection of infected blood into the cerebrospinal fluid. A number of HIV-positive patients have received EBP without neurological sequelae [33,34,35]. Still, some authors advocate caution with this technique in these patients [36,37]. Fibrin sealant was used in our patient to avoid the possibility of injecting blood with HIV and Hepatitis C into the epidural and subarachnoid spaces.

Fibrin sealant is a two-component fibrin sealant made from pooled human plasma. When combined, the two components, sealer protein and thrombin, mimic the final stage of the coagulation cascade. Sealer protein is a sterile, non-pyrogenic, vapour heated and solvent/detergent-treated preparation made from pooled human plasma. The active ingredient in sealer protein is fibrinogen. Sealer protein solution contains a fibrinolysis inhibitor, synthetic aprotonin, which delays fibrinolysis. Thrombin is a protease that transforms fibrinogen into fibrin. Both solutions are provided in two-chamber syringe that mixes together upon injection. Upon mixing sealer protein and thrombin, soluble fibrinogen is transformed into fibrin, forming a rubber-like mass that adheres to the dural surface and seals the CSF leak. Fibrin sealant mimics the final coagulation cascade step as it has all relevant components to form a clot [38,39].

Fibrin glue has been widely used by otolaryngologists and neurosurgeons to seal the dura and has proved to be a satisfactory solute for stopping cerebrospinal fluid leakage in a series of twenty consecutive craniofacial resections with dural defects [40,41]. Percutaneous fibrin sealing also has been applied successfully in cases of subcutaneous cerebrospinal fluid fistulae after operations to the brain and the spinal cord [42], thereby obviating repeated operation. Fibrin glue clots do not retract because of the lack of corpuscular blood components. The fibrin in the clot also has a special affinity for collagen fibres. A previous animal study suggests that there are no signs of an inflammatory response [43]. Dural specimens examined after application of fibrin glue showed a clot adhering to the epidural side [44] forming a sheath localized around the puncture hole, extending over the outer surface of the dura and sometimes over the inner surface [45].

In our case the patient failed conservative treatment. Because of the patient’s co-infection with HIV/hepatitis C, significant HIV viral load and the theoretical risk of seeding the CSF with infection, we used fibrin sealant as an alternative. To the best of the authors’ knowledge, fibrin sealant has never been used as an alternative to blood. Fibrin has always been used in subsequent treatment only after traditional epidural blood patch failed to control post dural puncture headaches. This case was unique specifically because we used fibrin sealant as first-line treatment to avoid the risk of inoculating the intrathecal space with human immunodeficiency virus and hepatitis C. The complication of aseptic meningitis was not encountered in our patient.

4 Conclusion

Fibrin sealant is a possible alternative to autologous blood in patients with active infections such as human immunodeficiency virus or hepatitis C to avoid the theoretical risk of meningeal seeding during the procedure.

Highlights

• Post-Dural-Puncture headache is caused by CSF-leakage through hole in the dura.

• Epidural injection of 10-20 ml autologous blood stops the CSF-leakage.

• Bacteremia or viremia is a relative contraindication to such autologous blood patch.

• Fibrin sealant was successfully used to patch the dural hole in this case.