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A Case of Prolonged Delayed Postdural Puncture Headache in a Patient with Multiple Sclerosis Exacerbated by Air Travel

DOI: 10.1155/2013/253218

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Abstract:

The developments of new spinal needles and needle tip designs have reduced the incidence of postdural puncture headache (PDPH). Although it is clear that reducing the loss of CSF leak from dural puncture reduces the headache, there are areas regarding the pathogenesis, treatment, and prevention of PDPH that remain controversial. Air travel by itself may impose physiological alteration in central nervous system that may be detrimental to patients with PDPH. This case report highlights a case of a young female patient who suffered from a severe incapacitating PDPH headache during high-altitude flight with a commercial jet. 1. Introduction The first case report of postdural puncture headache (PDPH) was described in about 100 years ago by Bier and his assistant [1]. It was later postulated that PDPH is triggered by leakage of cerebrospinal fluid through the dural rent, but the cause of the pain is probably due to intracranial arterial and venous dilatation [2]. PDPH remains one of the major complications of spinal tap performed for diagnostic purposes. Other adverse events after lumbar puncture include dysesthesia, backache, nerve palsies, infectious processes, and bleeding disorders [3]. The patterns of development of PDPH depend on a number of procedure and nonprocedure-related risk factors. Knowledge of procedure-related factors supports interventions designed to reduce the incidence of PDPH. Despite the best preventive efforts, PDPH may still occur and be associated with significant morbidity [4, 5]. The potential risks for developing PDPH include female gender [6], young adults, repeated attempt with multiple dural punctures, and the size/type and orientation of the needle [7]. Gender is believed to be an independent risk factor for the development of PDPH as demonstrated by the recent meta-analysis by Wu et al. [6]. Clinical presentation of the PDPH or “spinal headache” is usually described as a severe, dull pain, usually frontal occipital, which is irritated in the upright position and decreased in the supine position. It may or may not be accompanied by nausea, vomiting, and visual/auditory disturbances. The onset of PDPH is between 2 to 72 hours, and latency period of up to 15 days has generally been described in the literature [8, 9]. 2. Case Report This is unique case of a young 23 years old middle Eastern female who developed an acute unilateral eye pain and generalized headache with visual disturbances associated with fatigue and weakness in lower extremities for two days. She presented to a local community hospital and was examined by a

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