Incidence and risk factors of post dural puncture headache after spinal anesthesia in Tripoli Hospitals

Post Dural Puncture Headache (PDPH) remains a prominent clinical concern to the present day and common complication seen in the field of anesthesiology and pain medicine. Identification of such risk factors is a crucial step in the rational modification of anesthetic practice and evaluation of therapeutic interventions. This study was conducted to demonstrate the incidence and risk factors of PDPH in patients after spinal Anesthesia during three days' post operations at general hospital in Tripoli, Libya. In this study certain factors related to patient history, baseline clinical state or anesthetic technique might be associated with an increased risk for this side effect, so it was collected historical, physiologic, and technical data to determine their association with PDPH. Out of total of 100 patients distributed over 5 different hospitals admitted over a period (from November 2020 to April 2021) 27% of them have a PDPH, while 92.5% of cases with PDPH are females, that 55.6% of PDPH cases are between 20 and 25 years old, and this percentage getting smaller as patients get older, most of the operations were caesarean section, at a rate of 58%, followed by lower abdominal surgeries with 19% of cases, and orthopedic surgeries with 17% of cases, while the lowest percentage was for the Urologic surgeries. 55% of cases with PDPH are classified as (case I), and 44% of them are classified as (case II), 81.5% of PDPH cases used noncutting needles. In this study the PDPH remains the most problem in hospitalized patients after spinal Anesthesia at Tripoli hospitals can be caused by variety of risk factors, associated with ASA physical states, nonprofessional technique, the females are more common than males and the percentage increasing in early age group

Trans-nasal sphenopalatine ganglion block for post-dural puncture headache management: a meta-analysis of randomized trials

Abstract Objective: To evaluate the efficacy and safety of trans-nasal Sphenopalatine Ganglion (SPG) block over other treatments for Post-Dural Puncture Headache (PDPH) management. Methods: A systematic literature search was conducted on databases for Randomized Controlled Trials (RCTs) comparing trans-nasal SPG blockade for the management of PDPH over other treatment modalities. All outcomes were pooled using the Mantel-Haenszel method and random effect model. Analyses of all outcomes were performed as a subgroup based on the type of control interventions (conservative, intranasal lignocaine puffs, sham, and Greater Occipital Nerve [GON] block). The quality of evidence was assessed using the GRADE approach. Results: After screening 1748 relevant articles, 9 RCTs comparing SPG block with other interventions (6 conservative treatments, 1 sham, 1 GON and 1 intranasal lidocaine puff) were included in this meta-analysis. SPG block demonstrated superiority over conservative treatment in pain reduction at 30 min, 1 h, 2 h, 4 h after interventions and treatment failures with "very low" to "moderate" quality of evidence. The SPG block failed to demonstrate superiority over conservative treatment in pain reduction beyond 6 h, need for rescue treatment, and adverse events. SPG block demonstrated superiority over intranasal lignocaine puff in pain reduction at 30 min, 1 h, 6 h, and 24 h after interventions. SPG block did not show superiority or equivalence in all efficacy and safety outcomes as compared to sham and GON block. Conclusion: Very Low to moderate quality evidence suggests the superiority of SPG block over conservative treatment and lignocaine puff for short-term pain relief from PDPH. PROSPERO Registration: CRD42021291707.

Resultados a largo plazo del tratamiento quirúrgico de las fístulas arteriovenosas durales espinales en un centro Argentino / Surgical treatment of spinal dural arteriovenous fistulas: Management and long-term results in a series of patients operated in an Argentinian center

Resumen Introducción: La fístula dural arteriovenosa espinal (FDAVE) es una enfermedad vascular frecuentemente subdiagnosticada. El tratamiento puede ser microqui rúrgico o endovascular. Métodos: Estudio retrospectivo de una serie de pa cientes con FDAVE tratados por microcirugía entre los años 2010 y 2021. Fueron evaluados parámetros como edad, sexo, cuadro clínico pre y postoperatorio medido con las escalas de Aminoff-Logue y Rankin modificada (mRs). Los estudios diagnósticos se utilizaron para de terminar nivel lesional y resultados quirúrgicos. Resultados: Se incluyeron doce pacientes (10 hombres y 2 mujeres) con un promedio de edad de 60 años. El tiempo de evolución del cuadro clínico al diagnóstico fue menor a 12 meses salvo un caso de 32 meses. Las FDAVE fueron localizadas, 8 a nivel dorsal, 3 a nivel lumbar y una a nivel sacro. La arteria de Adamkiewicz se identificó en 5 casos en L1, 2 en D12, 2 en D10, 2 en D9 y un caso en D7. De los 12 pacientes operados, 3 fueron embolizados previamente; dos permanecieron estables en su evolución y 10 mejoraron uno o más puntos del mRs. No hubo complicaciones en el postoperatorio. Todos mostraron mejoría del edema medular en reso nancia magnética y la angiografía digital, luego de los 6 meses, fue negativa. El seguimiento promedio fue de 40 meses con un rango de 6 a 122 meses y ningún paciente presentó recidiva de la FDAVE. Conclusión: El tratamiento quirúrgico de las FDAVE es un método muy eficaz, de baja morbilidad y menor tasa de recurrencia comparado con el tratamiento en dovascular.

Abstract Introduction: Spinal dural arteriovenous fistula (SDA VF) is a rare vascular disease, of unknown etiology, fre quently underdiagnosed. Treatment can be microsurgical or endovascular. Methods: Retrospective and monocentric analysis of 12 SDAVF patients treated by microsurgery between 2010 and 2021. Parameters including age, sex, pre and postoperative clinical condition were analyzed according to modified Aminoff-Logue and Rankin scales. Diagnos tic studies such as magnetic resonance imaging (MRI), magnetic resonance angiogram (MRA) and spinal digital subtraction angiography (DSA), were evaluated for lesion level, as were surgical results. Results: Twelve patients (10 men and 2 women), average age: 60 years, were operated. The interval from symptom onset to diagnosis was <12 months in all cases except one (32 months). SDAVF locations were thoracic in 8 cases, between T6 and T12, 3 at lumbar spine (L1- L2) and at S1 in one case, with no difference regarding side. The Adamkiewicz artery was identified in 5 cases at L1, 2 at D12, 2 at D10, 2 at D9 and 1 at D7 (7 left-sided and 5 right-sided). Three of the 12 patients operated had undergone prior embolization. Postoperative neu rological outcomes showed: 2 patients remained stable and 10 improved one or more points on the mRs; no postoperative complications were observed. Follow-up MRI images improved in all cases and spinal DSA was negative at 6 months. Average follow-up was 40 months (range 6 to 122) and no patient presented recurrence. Conclusion: Microsurgical treatment of SDAVF proved to be efficient, with low morbidity and lower recurrence rates compared to endovascular results.

Prevalence, Risk Factors and Clinical Features of Post Dural Puncture Headache (PDPH): A Prospective Study

Background: Post-dural puncture headache (PDPH), formerly known as post-lumbar puncture headache, is a well-known adverse event that follows diagnostic and/or therapeutic puncture of the dura, or accidentally, following spinal anesthesia. Material & Methods: This prospective study was carried out on 152 patients at Shaheed Ziaur Rahman Medical College Hospital in Bogura, from 2013 to 2015 and North Bengal Medical College from 2016 to 2022, Bangladesh. Results: A total of 152 patients were enrolled into the study where 122(80.3%) were aged between 18-28 years, 30(19.7%) were 29-39 years, 38(25%) were male and 114(75%) were female. 122(80.3%) patients were non obese (<25) and 30(19.7%) were obese (>25). 17(11.2%) patients had previous history of anaesthesia and 17(11.2%) had previous history of PDPH. On majority 100 patients were used big size needle (18-23 G) and rest of the patients were used small (23-25G). 146 (96.1%) patients position was lateral and 92(60.5%) were used less than two or equal three drops. 61(40.1%) patients were needed one attempt, 64(42.1%) were needed two and 27(27.8%) were needed greater than two. The prevalence of PDPH was found in 44(28.9%) cases out of 152 where severity of 29(65.9%) percent was mild, 20(45.5%) cases headache onset were at the first day and mean duration of headache was 2.6. There was a statistically significant association between development of PDPH and younger age (26.3±8.7 years vs 32.6±7.4, p< 0.001), female gender (p=00.009), previous history of PDPH (p<0.001), number of attempts (3.1±1.2 vs 1.2±0.8, p<0.001), small needles (p=0.04), pre LP headache (p<0.001) and CSF RBS (2.6±2.1 vs 13.8±1.3, p= 0.48). Conclusion: This study recommends that the neurologists should be treating this population in the manner so that it may help to prevent this painful adverse event, and identification of risk variables is vital in predicting PDPH.

It's not always postdural puncture headache: a case report and note to the astute anesthesiologist

Abstract Dural puncture is either diagnosed by unexpectedly profound response to medication test dose or development of a postpartum postural headache. Epidural blood patch is the gold standard for treatment of PDPH when conservative management fails. However, postpartum headaches can be resistant to multiple epidural blood patches. In such cases, preexisting intracranial processes should be considered and ruled out. We report here the unique case of a pregnant patient who developed a resistant headache in the postpartum period related to an incidental intracranial aneurysm. Subsequent treatment with endovascular embolization adequately relieved her symptoms. Early surgical consultation and a multidisciplinary team approach involving neurology and neuroimaging is required for successful management of patients such as the one described here.

Determination of 50% effective concentration of ropivacaine plus sufentanil in dural puncture epidural analgesia for labor / 中国医师进修杂志

Objective:To determine the 50% effective concentration (EC 50) of ropivacaine plus sufentanil for labor analgesia using the dural puncture epidural technique. Methods:Using the method of prospective study, sixty parturients requiring labor analgesia in Dalian Women and Children′s Medical Group from May 2021 to May 2022 were divided into six groups using a random number table and administered 0.3 mg/L sufentanil and ropivacaine at different concentrations: 0.05% (group D1), 0.06% (group D2), 0.07% (group D3), 0.08% (group D4), 0.09% (group D5), and 0.1% (group D6). A probit model was constructed to compute the EC 50 values and 95% confidence intervals (95% CI) of ropivacaine plus sufentanil in dural puncture epidural analgesia (DPEA) for labor. The pain intensity of uterine contractions before labor analgesia and 30 min after administration was recorded and assessed on a numeric rating scale (NRS), and decreases in blood pressures and heart rates, vomiting and nausea, postpartum headaches, and fetal bradycardia were documented. Results:When using ropivacaine plus sufentanil for labor analgesia via DPE, the EC 50 was 0.061%, and the 95% CI ranged from 0.051 to 0.067; the 90% effective concentration (EC 90) was 0.081%, and the 95% CI was between 0.074 and 0.098. Among the six groups, there was one case of fetal bradycardia in group D3 and one case of decreased heart rates in group D4. No decreased blood pressure, vomiting and nausea, or postpartum headaches were reported. Conclusions:In DPEA for labor, ropivacaine plus sufentanil has an EC 50 of 0.061%, with the 95% CI falling between 0.051 and 0.067, similar to the EC 50 value in epidural analgesia.

Needle caliber and design are associated with the risk of post-dural puncture headache after diagnostic lumbar puncture / O calibre e o design da agulha estão associados ao risco de cefaleia pós-punção dural após punção lombar diagnóstica

Introduction:Post-dural puncture headache (PDPH) is defined as an orthostatic headache that develops within the first few days after performing a spinal tap and it is related to extravasation of cerebrospinal fluid (CSF) into the epidural space, resulting in CSF hypovolemia and hypotension. The risk factors for PDPH are not yet fully understood. Objective:To evaluate the risk of spontaneously reported PDPH according to the size and type of spinal tap needle. Methods:A total of 4589 patients undergoing outpatient lumbar puncture (LP) were included. All CSF collections were performed at Senne Liquor Diagnostico, a laboratory specialized in CSF collection and analysis. Patients were instructed to report by telephone if they had orthostatic headache during the first 7 days after LP to the medical team of the laboratory. Patients with previous headache were instructed to report any change in the headache pattern during the same period. Needle gauge was classified into two groups: 1) 25 G or less and 2) greater than 25 G. Two types of needles were used and compared: 1) Pencil point and 2) Quincke. Comparisons of the percentages of spontaneous reports of PDPH were made using the chi-square test. Results:141 patients (3.07%) reported PDPH to the laboratory's medical team. Needles of 25G gauge or less were used in 31.8% of cases. The percentage of patients reporting PHD in the group of 25G or less needles was 1.9% versus 3.6% in the group of larger than 25G needles (p=0.003). Pencil point needles were used in 10.6% of cases. The percentage of PHD among pencil point group was 1.4% versus 3.2% in Quincke group (p=0.026). Conclusion:25 G or finer gauge needles as well as pencil point type needles significantly reduced the risk of spontaneously reported PHD.

Introdução: A cefaleia pós-punção dural (CPPD) é definida como uma cefaleia ortostática que se desenvolve nos primeiros dias após a realização de uma punção lombar e está relacionada ao extravasamento de líquido cefalorraquidiano (LCR) para o espaço peridural, resultando em hipovolemia do LCR e hipotensão. Os fatores de risco para CPPD ainda não são totalmente compreendidos. Objetivo:Avaliar o risco de CPPD relatada espontaneamente de acordo com o tamanho e tipo de agulha de punção lombar. Métodos: Foram incluídos 4.589 pacientes submetidos à punção lombar (PL) ambulatorial. Todas as coletas de LCR foram realizadas no Senne Liquor Diagnostico, laboratório especializado em coleta e análise de LCR. Os pacientes foram orientados a relatar por telefone à equipe médica do laboratório se apresentassem cefaleia ortostática nos primeiros 7 dias após a PL. Pacientes com cefaleia prévia foram orientados a relatar qualquer alteração no padrão de cefaleia durante o mesmo período. O calibre da agulha foi classificado em dois grupos: 1) 25 G ou menos e 2) maior que 25 G. Dois tipos de agulhas foram utilizados e comparados: 1) ponta de lápis e 2) Quincke. As comparações dos percentuais de notificações espontâneas de CPPD foram feitas por meio do teste do qui-quadrado. Resultados:141 pacientes (3,07%) relataram CPPD à equipe médica do laboratório. Agulhas de calibre 25G ou menos foram utilizadas em 31,8% dos casos. A porcentagem de pacientes que relataram HDP no grupo de agulhas 25G ou menos foi de 1,9% versus 3,6% no grupo de agulhas maiores que 25G (p=0,003). Agulhas com ponta de lápis foram utilizadas em 10,6% dos casos. O percentual de DPH no grupo ponta de lápis foi de 1,4% versus 3,2% no grupo Quincke (p=0,026). Conclusão: Agulhas de calibre 25 G ou mais fino, bem como agulhas tipo ponta de lápis reduziram significativamente o risco de HP relatado espontaneamente.

Clinical significance and risk factors of redundant nerve root in patients with lumbar spinal stenosis / 中国骨伤

OBJECTIVE@#To investigate the clinical significance and screen the risk factors of redundant nerve roots(RNRs) in patients with lumbar spinal stenosis.@*METHODS@#The clinical data of 196 patients with lumbar spinal stenosis in the department of Spinal Surgery, Yijishan Hospital, Wannan Medical College from April 1, 2015 to November 30, 2020 were retrospectively analyzed. All patients were divided into RNRs positive group and RNRs negative group according to the presence of RNRs. The differences in general clinical data, imaging parameters, visual analogue scale(VAS), Oswestry disability index(ODI), and other indicators between the two groups were compared. The risk factors which are highly correlated with RNRs were screened by binary Logistic regression analysis.@*RESULTS@#There were 59 cases in the RNRs positive group, with an occurrence rate of 29.95% (59/137), and 137 cases in the RNRs negative group. The incidence rate of RNRs in 196 patients with lumbar spinal stenosis was 30.10% (59/196). VAS and ODI scores of patients in the two groups were statistically significant (P<0.05), and clinical symptoms of patients in the RNRs positive group were more severe than those in the RNRs negative group. There were significant differences in age, number of stenosis segments, average area of lumbar dural sac, area of the narrowest segment and the narrowest segment(P<0.05). Binary logistic regression analysis showed that the number of stenosis segments, the average median sagittal diameter of spinal canal, and the average area of dural sac in lumbar intervertebral space were correlated with the generation of RNRs (P<0.05). The regression coefficient of the number of stenosis segments was -1.115, the regression coefficient of the median sagittal diameter of the spinal canal was -1.707, and the regression coefficient of the mean dural sac area of the lumbar intervertebral space was 7.556.@*CONCLUSION@#The clinical symptoms of patients with lumbar spinal stenosis accompanied by RNRs are more severe than those without them. The number of narrow segments, median sagittal diameter of the spinal canal, and the area of the lumbar intervertebral dural sac are the high-risk factors for RNRs, with the area of the lumbar intervertebral dural sac has the highest correlation.

Research status of dural injury types and repair / 中国修复重建外科杂志

OBJECTIVE@#To evaluate the current status of classification and repair methods for dural injury caused by spinal surgery or trauma, providing new strategies and ideas for the clinical repair of dural injury and the development of related materials.@*METHODS@#The literature related to dural injury both at home and abroad in recent years was thoroughly reviewed and analyzed in order to draw meaningful conclusions.@*RESULTS@#There have been numerous retrospective studies on dural injury, but there is a scarcity of prospective and multi-center studies, resulting in a low level of evidence-based research. The incidence and risk factors of dural injury have primarily been studied in relation to common degenerative spinal diseases of the cervical and lumbar spine, with insufficient research on thoracic spine-related diseases. Currently, a universally recognized method for grading and classifying dural injury has not been established, which hampers the development of clinical guidelines for their repair. Furthermore, although there are repair materials and surgical strategies available to address clinical issues such as suture leakage and surgical repair of dural injury in complex locations, there is a lack of comprehensive clinical research and evidence-based data to validate their scientificity and reliability.@*CONCLUSION@#Regardless of the classification of dural injury, suture remains the most important repair method. It is important to further develop new patches or sealants that can meet clinical needs and reduce the difficulty of repair.

Intracranial Magnetic Resonance Venography of Superior Sagittal Sinus, Straight Sinus and Cerebral Venous Channels: Normal Anatomy and Variations in North Indian Population

The intracranial dural venous sinuses can be injured leading to thrombosis with in the dural sinuses causing headache, abnormal vision, weakness of the face and limbs on one side of the body, and seizures.Magne?c Resonance Venography (MRV) is one of the preferred methods of evalua?on of the cerebral venous sinus anatomy, varia?ons and pathology, par?cularly in the diagnosisof venous sinus thrombosis. The purpose of this study is to evaluate the use of MRV to depict the normal intracranial venous anatomy and its variants in North Indian popula?on which can help to avoid poten?al pi?alls in the diagnosis of dural venous sinus thrombosis, venous infarcts and venous hemorrhage. Aim:The purpose of this study is to evaluate the use of MRV to depict the normal intracranial venous anatomy and its variants in North Indian popula?on, which can help to avoid poten?al pi?alls in the diagnosis of dural venous sinus thrombosis, venous infarcts and venous hemorrhage. Materials:The present study was undertaken in the Departments of Anatomy and Radiodiagnosis at a North Indian ter?ary care teaching hospital over a period of two years. Magne?c Resonance Venograms (MRV) of pa?ents a?ending the radiology department were used to study the normal anatomy and varia?ons in the dural venous sinuses. 50 MRV scans of which 26 were of females and 24 of male, were included in the study. Anatomical varia?ons and varia?ons in drainage of the dural venous sinuses were assessed and sta?s?cal analysis was done. Results:For both superior sagi?al sinus drainage and straight sinus drainage, the propor?on of veins draining in right and le? transverse sinuses and confluence of sinuses was significantly different in the two age groups (p<0.001) in both males and females. Par?al spli?ng of superior sagi?al sinus in anterior one third or posterior one third was also seen. Sta?s?cally significant findings were observed regarding the laterality for vein of Labbe & vein of Trolard. Conclusion:MR venography is an excellent diagnos?c technique to visualise anatomy and anatomic varia?ons of venous sinuses as observed in our study. The par?al spli?ng of superior sagi?al sinus in either anterior one third or posterior one third as seen in our study, can cause misdiagnosis of thrombosis. Hence, knowledge of normal anatomy and anatomic varia?ons in the intracranial venous sinuses is very important to diagnose cerebral venous sinus thrombosis accurately.

A rare case of cerebral hemorrhage due to left fronto-parietal mixed pial-dural AV- malformation, Spleitzer Martin grade 5 - A case report

Cerebral arteriovenous malformation (AVM) is a complex network of vascular channels consisting of arterial feeders, a nidus and enlarged venous drainage. AVMs usually increase in size with time, but may rarely obliterate; spontaneous angiographic regression occurs in less than 1.5% of cerebral AVMs. Several causes of spontaneous regression have been postulated such us hemodynamic alterations due to hemorrhage, hypercoagulability, atherosclerosis, and thromboembolism from associated aneurysms. In this report we describe a case of cerebral hemorrhage due to left fronto- parietal AVM with predominant middle cerebral artery and anterior cerebral artery feeders, minor left external carotid artery feeders, mixed pial-dural AVM – Spleitzer Martin Grade 5

Dural arteriovenousfistula presenting as reversible dementia

DAVF is an abnormal connection between arteries and veins, where supply is mainly through branches arising from the external carotid artery. A 30 years old male had multiple episodes of seizures and progressive behavioral and cognitive decline, inattentionand disorientation to time, place and person, along with ptosis and ophthalmoplegia in the right eye. DSA provided a definitive diagnosis of hypervascular Dural AV fistula at the right transverse sigmoid junction with significant cortical venous hypertension. Through femoral access, both underwent transarterial embolization through the Middle Meningeal branch of the right external carotid artery using onyx, resulting in complete occlusion of fistula and resolution of venous hypertension. Post embolisation,cognitive function assessment revealed increased attention span and improved orientation with time,place and person. Thus, DAVF can be one of the rare but reversible causes of dementia. Early diagnosis and treatment may help to dramatically improve patients� clinical condition and minimize long-term disability

The clinical effect of posterior fossa decompression combined with dural reconstruction in the treatment of Chiari malformation-Ⅰ complicated with syringomyelia / 中国医师进修杂志

Objective:To investigate the clinical effect of posterior fossa decompression combined with dural reconstruction in the treatment of Chiari malformation-Ⅰ(CM-Ⅰ) complicated with syringomyelia (SM).Methods:The clinical data of 50 patients with CM-Ⅰ complicated with SM who were treated in Yan′an University Xianyang Hospital from June 2019 to January 2021 were analyzed. They were divided into the study group (27 cases) and the control group (23 cases) according to the surgical methods. The former received posterior fossa decompression combined with dural reconstruction, while the latter received posterior fossa decompression alone. The clinical symptom improvement, neurological function, cerebrospinal fluid dynamics and syringomyelia changes were compared between the two groups before and after the surgery, and postoperative complications were compared.Results:The overall clinical symptom improvement rate between the two groups had no significant difference ( P> 0.05). After the surgery, the scores of pain, sensory disturbance, dyskinesia and ataxia in the study group were higher than those in the control group: (4.56 ± 0.35) points vs. (4.28 ± 0.43) points, (3.61 ± 0.82) points vs. (3.15 ± 0.73) points, (3.81 ± 0.44) points vs. (3.59 ± 0.50) points, (4.43 ± 0.41) points vs. (4.09 ± 0.53) points, there were statistical significant ( P<0.05). After the surgery, the cerebrospinal fluid stroke volume (SV) and mean flow (MF) in the study group were higher than those in the control group: (0.05 ± 0.02) ml vs. (0.04 ± 0.01) ml, (0.05 ± 0.01) ml/s vs. (0.04 ± 0.01) ml/s; the maximum peak flow velocity (V max) of the head and tail in the study group were lower than those in the control group: (3.14 ± 1.05) mm/s vs. (3.87 ± 1.13) mm/s, (5.56 ± 1.38) mm/s vs. (6.43 ± 1.22) mm/s, there were statistical significant ( P<0.05). There were no significant differences in the rate of reduction or disappearance of syringomyelia, the rate of no change and the rate of increase of syringomyelia after the surgery between the two groups ( P>0.05). There was no significant difference in the incidence of postoperative complications between the two groups ( P>0.05). Conclusions:Posterior fossa decompression combined with dural reconstruction in CM-Ⅰ complicated with SM can better improve cerebrospinal fluid dynamics, and promote the reduction of syringomyelia without increasing postoperative complications.

A 44-year-old male Filipino with Spontaneous Acute Subdural Hematoma and Subarachnoid Hemorrhage caused by a Dural Arteriovenous Fistula of the Occipital Lobe: A case report

Introduction@#Spontaneous acute subdural hematoma (ASDH) is rare and comprises 2.6% of all ASDH. In one recent study, only 178 spontaneous ASDH were documented. However, only 1 case was attributed to dural arteriovenous fistula (dAVF). Vascular malformations cause less than 10% of subarachnoid hemorrhage (SAH). Spontaneous ASDH and SAH occurring together are extremely rare. Literature is scarce on cases with dAVF of the occipital lobe as a cause of simultaneous spontaneous ASDH and SAH. @*Objective@#This paper aims to present a case of a spontaneous acute subdural hematoma and subarachnoid hemorrhage caused by a dural arteriovenous fistula of the occipital lobe, along with its clinical presentation, diagnosis, and treatment. @*Case Summary@#A 44-year-old Filipino male with no history of trauma presented with severe headache, vomiting, and decreasing sensorium – CT scan revealed acute parenchymal bleed in the left occipital lobe with subarachnoid extension and subdural hematoma in the left fronto-parieto-temporal convexity along the tentorium cerebelli and posterior interhemispheric falx. Due to the location of the lesion seen on the CT scan and the gender distribution, Arteriovenous malformation (AVM) was initially considered, thus proceeded to computed tomography angiogram (CTA) to establish the diagnosis of vascular anomaly, however, revealed dAVF instead. Four-vessel angiogram was done to assess the tributaries of the dAVF and confirmed the diagnosis. Complete obliteration of dAVF of the occipital lobe was done with Onyx Embolization in one session. @*Conclusion@#This is the first case of Borden type II, Cognard type IIa+IIb dAVF, as reported in this institution. Although extremely rare as a cause of SAH and ASDH, dAVF should be considered a differential diagnosis in patients with no identifiable common cause of the new onset of severe headache and poor neurologic status.

Anatomic position of the asterion and implication for neurosurgical procedure / Posición anatómica del asterion y sus implicancias en el procedimiento neuroquirúrgico

SUMMARY: The asterion is the joining of the lambdoid, parietomastoid, and occipitomastoid sutures. It is classified into two types, type I shows small bones or woven bones, while in type II, woven bones are non-existent. In this study, forty cadavers were conducted and observed the asterion on both sides of skulls showing the approximate ratio of type II and type I was 3:2. The asterion was located by measuring the distances from the asterion to skull landmarks, including inion, the root of zygoma, and mastoid tip. The mean distance between asterion and inion was 62.9 ? 6.0 mm. The mean distance between asterion and the root of zygomatic arch was 58.3 ? 6.1 mm, whereas the mean distance between asterion and mastoid tip was 51.1 ? 5.3 mm. The most common location related to the asterion was the dural venous sinuses on 65 % of tested sides, followed by infratentorial dura and supratentorial dura (25 % and 10 %, respectively). However, the authors found no differences between sexes, sides, and types in any underlying structures.

RESUMEN: El asterion es la unión de las suturas lambdoidea, parietomastoidea y occipitomastoidea. Clasificado en dos tipos, el tipo I muestra huesos pequeños o hueso laminar, mientras que en el tipo II, el hueso laminar es inexistente. En este trabajo se estudiaron 40 cadáveres y se observó el asterion en ambos lados de los cráneos correspondientes, mostrando una proporción aproximada de tipo II y tipo I de 3:2. El asterion se localizó midiendo las distancias asociadas a puntos de referencia del cráneo: el inion, la raíz del arco cigomático y el ápice del proceso mastoides. La distancia media entre el asterion y el inion fue de 62,9 ? 6,0 mm. La distancia media entre el asterion y la raíz del arco cigomático fue de 58,3 ? 6,1 mm, mientras que la distancia media entre el asterion y el ápice del proceso mastoides fue de 51,1 ? 5,3 mm. La localización más común relacionada con el asterion fueron los senos venosos durales en el 65 % de los lados evaluados, seguido de la duramadre infratentorial y la dura supratentorial (25 % y 10 %, respectivamente). Sin embargo, los autores no encontraron diferencias entre sexo, lados y tipo en ninguna estructura subyacente.

New approaches and therapeutic options for post-dural puncture headache treatment / Nuevos abordajes y alternativas terapéuticas en el tratamiento de la cefalea pospunción dural

Abstract Post-dural puncture headache is a frequent complication in neuraxial approaches. It may result in disability, healthcare dissatisfaction and potentially serious complications. The traditional initial management includes general and analgesia measures with poor evidence. The treatment approach best supported by the literature is the epidural blood patch for which rates of up 70% improvement have been reported. Regional techniques have been recently described that may be helpful because they are less invasive than the epidural blood patch, under certain clinical circumstances. This article suggests an algorithm that uses such techniques for the management of this complication.

Resumen La cefalea pospunción dural es una complicación frecuente del abordaje del neuroeje. Puede producir incapacidad, insatisfacción con la atención en salud y complicaciones potencialmente graves. Tradicionalmente su manejo inicial incluye medidas generales y de analgesia las cuales tienen baja evidencia. La medida para su tratamiento, con mejor soporte en la literatura, es la realización de parche hemático, el cual informa tazas de mejoría hasta del 70 %. Recientemente se han descrito técnicas regionales, que pueden resultar útiles por ser menos invasivas que el parche hemático, en ciertos contextos clínicos. En este artículo se propone un algoritmo que permite incorporar dichas técnicas al manejo de esta complicación.

Cefalea pospunción dural mantenida en el tiempo / Persistent posdural puncture headache

Introducción: La cefalea posterior a la punción de la duramadre es una complicación que se describió conjuntamente con la primera anestesia neuroaxial. Es un cuadro clínico complejo, que con la terapéutica adecuada mejora rápidamente, pero en ocasiones persiste a pesar de los esfuerzos realizados por el equipo médico encargado de tratarla. Objetivo: Describir la evolución clínica de un caso cefalea pospunción dural. Discusión: Se presenta un caso que después de realizarle a una anestesia subaracnoidea para una cirugía de Hallux Varus, sufre una cefalea pospunción dural que persistió por más de 18 días, a pesar de los tratamientos impuestos, tanto conservadores (terapia farmacológica, hidratación, reposo) como intervencionista (hemoparche peridural y colchón hídrico, con dextran 40), el cuadro desapareció por si solo pasado el tiempo expuesto anteriormente. Conclusiones: Se concluye que este cuadro clínico ocasionado por la punción de la duramadre es de resolución rápida con el tratamiento adecuado, pero existen casos en los que a pesar de la terapéutica indicada puede persistir por más tiempo(AU)

Introduction: Headache after dura mater puncture is a complication described together with the first neuraxial anesthesia. A complex clinical picture improves rapidly with adequate therapy, but sometimes persists despite the efforts made by the medical team in charge of treating it. Objective: To describe the clinical evolution of case of postdural puncture headache. Discussion: A case is presented of a patient who, following subarachnoid anesthesia for hallux varus surgery, suffered postdural puncture headache that persisted for more than eighteen days, despite the treatments used, both conservative (pharmacological therapy, hydration, rest) and interventionist (peridural hemopatch and water mattress, with dextran 40). The clinical picture disappeared by itself after the time previously discussed. Conclusions: It is concluded that this clinical picture caused by the dura mater puncture is of rapid resolution if treated appropriately, but there are cases in which, despite the indicated therapy, it may persist for a longer time(AU)

Is There Any Correlation Between Computed Tomography (CT) Attenuation Value (Hounsfield Unit) Of Dural Venous Sinuses And Hemoglobin Level: A Prospective Observational Study

Background:In our routine practice patient were undergone CT scan of brain as well as other laboratory investigation for various traumatic brain injury and neurological complain and its management. They visit many premises for diagnosis and investigation. If we can predict the hemoglobin level from CT brain itself, we can reduce turnaround time for patient and increase throughput of patients for hospital. Keeping this in mind we had conducted this study to see the correlation between hemoglobin level and CT attenuation value of cranial Dural sinuses.Material And Methods:A prospective observational study was performed to demonstrate association between computed tomography (CT) attenuation value (Hounsfield unit (HU)) of dural venous sinuses and hemoglobin level from unenhanced CT scan of the brain. The non-contrast CT brain of total 245 patients done during October 2017 to September 2018 at medical college attached tertiary care was observed. Two measurements of HU value were taken on two adjacent slices using 10mm2 of ROI for each site, from superior sagittal sinus (SSS) and torcular herophili (TOH). The value was averaged for superior sagittal sinus, confluence of sinus and is compared with hemoglobin of patients.Result:Mean HU VALUE in SSS of females and male had 48.47 and 51.85 respectively. Mean HU VALUE in TOH of females and male had 47.46 and 50.93 respectively. Positive and significant correlation was noted between HB and SSS average, HB and TOH Average.Conclusion:Based on our result CT attenuation value (HU) value of torcular herophili and superior sagittal sinus from unenhanced CT scan of brain can be used to predict the hemoglobin level of a person. The HU value of sinus can give insight into pathology such as anemia, polycythemia or cranial sinus thrombosis.

Malformaciones vasculares cerebrales de alto flujo en pediatría: experiencia en un hospital pediátrico de alta complejidad / High-flow vascular malformations of the brain in pediatrics: Experience in a tertiary care children's hospital

Introducción. Las malformaciones vasculares cerebrales de alto flujo son poco comunes en la edad pediátrica. El objetivo del trabajo es diferenciar y agrupar estas enfermedades según edad de debut, manifestaciones clínicas y angioarquitectura.Población y método. Se realizó un estudio retrospectivo y observacional. Se analizaron las historias clínicas, los estudios por imágenes y los protocolos de procedimientos de pacientes del Hospital J. P. Garrahan con diagnóstico de malformaciones vasculares cerebrales desde enero de 2010 hasta enero de 2020.Resultados. Ciento ochenta y tres pacientes cumplieron los criterios de inclusión. Se identificaron 131 pacientes con malformaciones arteriovenosas con nido (MAV) y 52 con fístulas directas (sin nido), entre los que se hallaron 19 malformaciones aneurismáticas de vena de Galeno, 23 fístulas piales y 10 fístulas durales. La edad promedio fue de 105 meses para las MAV, 1,7 meses para las malformaciones aneurismáticas de vena de Galeno, 60,5 meses para fístulas piales y 41 meses para fístulas durales.Conclusión. Según su angioarquitectura, las malformaciones vasculares cerebrales de alto flujo tuvieron nido (MAV) o fueron fístulas directas (malformaciones aneurismáticas de vena de Galeno, fístulas piales y fístulas durales). Las MAV se manifestaron a partir de la primera infancia, sobre todo, por hemorragia intracraneana. Las fístulas directas se expresaron en la primera etapa de la vida, frecuentemente, con insuficiencia cardíaca.

Introduction. High-flow vascular malformations of the brain are uncommon in pediatrics. The objective of this study is to establish the differences among these pathologies and group them by age at onset, clinical manifestations, and angioarchitecture.Population and method. This was a retrospective and observational study. The medical records, imaging studies, and procedure protocols of patients seen at Hospital J. P. Garrahan diagnosed with vascular malformations of the brain between January 2010 and January 2020 were analyzed.Results. A total of 183 patients met the inclusion criteria. It was possible to identify 131 patients with arteriovenous malformations with a nidus (AVMs) and 52 with direct fistulas (without a nidus), including 19 vein of Galen aneurysmal malformations, 23 pial fistulas, and 10 dural fistulas. The average age of patients was 105 months for AVMs, 1.7 months for vein of Galen aneurysmal malformations, 60.5 months for pial fistulas, and 41 months for dural fistulas.Conclusion. Based on their angioarchitecture, high-flow vascular malformations of the brain presented a nidus (AVMs) or direct fistulas (vein of Galen aneurysmal malformations, pial fistulas, and dural fistulas). AVMs were observed in early childhood, especially due to intracranial hemorrhage. Direct fistulas occurred in the first stage of life, commonly with heart failure.

Microcirugía de las fístulas durales arteriovenosas espinales, más un repaso de la anatomía vascular vertebromedular / Microsurgery of spinal dural arteriovenous fistulas, plus a review of the vertebromedullary vascular anatomy

Introducción: la fístula dural arteriovenosa espinal (FDAVE) es una enfermedad vascular rara, de etiología desconocida y frecuentemente subdiagnosticada. El tratamiento puede ser microquirúrgico o endovascular. Material y Método: Análisis retrospectivo de una serie de 8 pacientes consecutivos con FDAVE tratados por microcirugía entre 2010 y 2020. Fueron evaluados parámetros como edad, sexo, cuadro clínico pre y postoperatorio medido con las escalas de Aminoff-Logue y Rankin modificada. Los estudios diagnósticos con RMN (Resonancia Magnética Nuclear), ARM (Angio Resonancia Magnética) y ADM (Angiografía Digital Medular) se utilizaron para determinar nivel lesional y resultados quirúrgicos. Resultados: Fueron operados 8 pacientes (7 masculinos y 1 femenino) con un promedio de edad de 58 años. El tiempo de evolución del cuadro clínico al diagnóstico fue menor a 12 meses salvo un caso de 32 meses. Las FDAVE fueron localizadas en: 6 a nivel dorsal entre D6 y D12, una en L2 y la última en S1 (5 derechas y 3 izquierdas). La arteria de Adamkiewicz se identificó en: 4 casos en L1, 2 en D12, 1 en D10 y un caso en D7 (6 izquierdas y 2 derechas). De los 8 pacientes operados, 3 fueron embolizados previamente. La evolución postoperatoria del cuadro neurológico fue: 2 de 8 permanecieron estables y 6 de 8 mejoraron uno o más puntos en la escala de Rankin modificada; no hubo complicaciones en el postoperatorio. Todos los pacientes mejoraron las imágenes en RMN diferida y la ADM luego de los 6 meses fue negativa. El seguimiento promedio fue de 48 meses con un rango de 11 a 116 meses, ningún paciente presentó recidiva de la FDAVE. Conclusiones: El tratamiento quirúrgico de las FDAVE es un método muy eficaz, de baja morbilidad y menor tasa de recurrencia comparado con el tratamiento endovascular.

Introduction: Spinal dural arteriovenous fistula (SDAVF) is a rare vascular disease, of unknown etiology and frequently underdiagnosed. Treatment can be microsurgical or endovascular. Material and Method: Retrospective analysis of a series of 8 SDAVF patients treated by microsurgery between 2010 and 2020. Parameters including age, sex, pre and postoperative clinical condition were analyzed according to modified Aminoff-Logue and modified Rankin scales. Diagnostic studies such as MRI (Magnetic Resonance Imaging), MRA (Magnetic Resonance Angiogram) and spinal DSA (Digital Subtraction Angiography), were evaluated for lesion level, as were surgical results. Results: Eight patients (7 male and 1 female), average age of 58 years were operated. The interval from symptom onset to diagnosis was less than 12 months in all cases except one (32 months). SDAVF locations were thoracic in 6 cases between T6 and T12, at L2 in one and at S1 in one case (5 on the right and 3 on the left). The Adamkiewicz artery was identified in: 4 cases at L1, 2 at D12, 1 at D10 and in one case at D7 (6 left-sided and 2 right-sided). Three of the 8 patients operated had undergone prior embolization. Postoperative neurological outcomes showed: 2 patients remained stable and 6 had improved one or more points on the modified Rankin scale; no postoperative complications were observed. Follow-up MRI images improved in all cases and spinal DSA was negative at six months. Average follow-up was 48 months (range 11 to 116 months), no patient presented recurrence. Conclusions: Microsurgical treatment of SDAVF proved to be efficient, with low morbidity and lower recurrence rates compared to endovascular results.