Prevention of post-puncture complications by rotation of the puncture needle by 90 degrees

We investigated whether the incidence of post-lumbar puncture headache could be reduced by using a new technique. By rotating the puncture needle the spinal meninges become penetrated with the bevel adjusted parallel to the main fibre direction. Therefore the fibres are only dissociated and not cut. We used this method in 20 patients and only 2 of them complained of headache. By contrast 14 out of another group of 20 patients suffered from headache after conventional lumbar puncture. These results demonstrate that post-lumbar puncture headache can be prevented in a high percentage of patients without using special puncture needles or sophisticated techniques.     

Significant reduction in post-lumbar puncture headache using an atraumatic needle. A double-blind, controlled clinical trial

A characteristic headache occurs in about 36–55% of patients after lumbar puncture, and many of these patients need bed rest for one or more days to get relief. In a double-blind randomized trial we compared a new 22-gauge atraumatic puncture needle with the most widely used 20-gauge "conventional" needle. In 49 patients randomized to the atraumatic needle, post-lumbar puncture headache occurred in 6%, whereas in the 50 patients randomized to the conventional needle this occurred in 32% ( p =0.001). On the basis of these results we recommend use of the atraumatic needle in order to diminish the frequency of post-lumbar puncture headache.     

Duration of Postural Headache After Lumbar Puncture: Effect of Needle Size

SYNOPSIS
The effect of needle size on postural headache after diagnostic lumbar puncture was studied in 300 patients at the Outpatient Department of Neurology, University of Helsinki. In three groups of 100 patients a needle size of 0.9mm (20 gauge), 0.7mm (22 gauge) and 0.6mm (23 gauge) were used, respectively. The total number of days with incapacitating postural headache in the groups diminished significantly with the decreasing needle size from 282 through 181 to 76 days. An analysis of CT scans performed in 95 patients showed that the incidence of post-lumbar puncture headache significantly decreased with brain atrophy seen on CT independently of the needle size. The results suggest that the thinnest needle (0.6mm) usable without special techniques should be chosen for diagnostic lumbar punctures at outpatient departments.     

Cerebral venous thrombosis after lumbar puncture and high steroid cycle in a patient with multiple sclerosis

The present case report underlies the importance of modifications in the characteristics of post-lumbar puncture headache, which led us to diagnose cerebral venous thrombosis in a 34-year-old woman affected by multiple sclerosis. The patient underwent a lumbar puncture for diagnostic purposes and successively was treated with megadoses of methylprednisolone (1 g intravenously for 6 days). After lumbar puncture, the patient developed an orthostatic headache sue to cerebrospinal fluid (CSF) hypotension. Eight days later, and two days after finishing the cycle of methylprednisolone, the headache worsened, became diffuse and persisting, and was longer modified by postural changes. This was associated with psychomotor slowing and, the day after, a partial epileptic status. Magnetic resonance imaging showed an alteration in the signal corresponding to the sagittal superior, transverse and sigmoid sinuses, indicative of venous thrombosis. The potential role of lumbar puncture, steroid treatment and other associated risk factors, and the importance of considering modifications in post-puncture headache as a condition which needs specific neuroradiological examinations are discussed. Received: 19 October 2000 / Accepted in revised form: 9 January 2001     

Lumbar puncture: risks and complications

Lumbar puncture is a procedure commonly performed in the emergency department. This paper reviews the indications, contraindications and the complications of lumbar puncture such as post-lumbar puncture headache, traumatic tap and cerebral herniation. As well as highlighting the particular risks of lumbar puncture in different disease processes, this paper aims to provide physicians with an understanding of the procedure that will assist them in their clinical decision making. The role of computed tomography and medico-legal aspects of lumbar puncture are also discussed.     

Reduced flow velocity in the internal carotid artery independently of cardiac hemodynamics in patients with cerebral ischemia

PURPOSE: To retrospectively investigate the relationships between carotid flow velocities, clinical features and cardiac hemodynamics to assess the meaning and significance of reduced carotid flow velocities in patients with cerebral ischemic symptoms. METHODS: We selected the files from patients who had undergone duplex Doppler sonographic examination of extracranial carotid arteries, echocardiography, and MR angiography, and in whom the following parameters were available: peak systolic (PSV) and end diastolic (EDV) flow velocity, pulsatility index (PI), and diameter of the left and right common (CCA) and internal (ICA) carotid arteries, intima-media thickness (IMT) of the left and right CCA, left ventricle (LV) mass, peak flow velocity on LV outflow tract, and fractional shortening (FS). Patients with stenosis of the carotid artery or its main intracranial branches were excluded, as were patients with major cerebral infarction, severe intracranial abnormality, or heart function disorder. The remaining 59 patients were subdivided according to the presence or absence of cerebral ischemic symptoms, diabetes mellitus, arterial hypertension, and hyperlipidemia for multivariate analyses and stepwise regressions. RESULTS: Women had smaller diameters and lower PI in the left and right CCA, and smaller LV mass than men. Age, CCA diameter, and IMT showed an inverse correlation with carotid flow velocities in several arterial segments. There was a positive correlation between PSV in the left CCA and ICA and FS, and between PSV in the left CCA and peak velocity on LV outflow tract. Flow velocities in the left and right ICA were significantly slower in patients with than in patients without cerebral ischemic symptoms. CONCLUSIONS: Cardiac hemodynamics and carotid flow velocities are significantly related, only on the left side, probably due to larger hemodynamic stress. Increased intracerebral circulatory resistance is probably involved in the decrease in carotid flow velocity and increase in PI in patients with cerebral ischemic symptoms.     

Hypersensitivity to Substance P in the Etiology of Postlumbar Puncture Headache

Objective.-Postlumbar puncture headache may represent a model which could be used to test the hypothesis that headache pain is caused by the release of substance P in patients who are predisposed to headache due to hypersensitivity to substance P.
Methods.-We measured substance P in CSF and plasma in 37 patients undergoing diagnostic lumbar puncture. In 9 patients, plasma samples were obtained before lumbar puncture, in 28 patients plasma was obtained after lumbar puncture. Patients were followed up by telephone to determine if they developed postlumbar puncture headache. Patients were also asked about a history of chronic or recurrent headaches. Substance P was determined by radioimmunoassay.
Results.-The mean plasma substance P levels obtained before lumbar puncture was 1.0 ± 0.1 pg/mL and 1.3 ± 1.2 after lumbar puncture (P<0.0005). The mean plasma substance P levels in subjects who developed postlumbar puncture headache was 0.6 ± 0.6 pg/mL compared with 1.4 ± 1.5 in subjects who remained headache-free ( P <0.05). The mean CSF substance P levels in subjects who developed postlumbar puncture headache was 0.7 ± 0.5 pg/mL compared with 1.2 ± 0.8 in subjects who remained headache-free ( P <0.05). There were no significant differences in substance P levels between chronic headache sufferers and nonheadache subjects.
Conclusions.-Postlumbar puncture headache may be mediated by the release of substance P triggered by lumbar puncture, in patients predisposed to headache by a hypersensitivity to substance P. Hypersensitivity to substance P may also represent a mechanism for headache pain in other headache disorders.     

儿童腰椎穿刺术后两种体位的对比研究

目的:探讨儿童腰椎穿刺术后两种卧位的舒适性及并发症发生情况。方法:将230例行腰椎穿刺术患儿随机分为观察组和对照组各115例,观察组术后交替采取去枕平卧位和平头侧卧位,对照组术后去枕平卧4~6h,观察术后头痛、腰背痛、脑疝等并发症发生情况。结果:两组患儿头痛、脑疝发生情况比较无显著性差异,观察组术后腰背疼痛的发生率明显低于对照组(P<0.01)。结论:腰椎穿刺术后交替采取去枕平卧与平头侧卧位,不仅具有传统卧位使头痛发生率低的优点,而且可减少腰背疼痛的发生率,提高患儿舒适度。     

Changing pattern of headache pointing to cerebral venous thrombosis after lumbar puncture and intravenous high-dose corticosteroids

OBJECTIVE: To emphasize the diagnostic importance of change in the headache pattern which pointed to cerebral venous thrombosis in two patients after lumbar puncture and high-dose intravenous methylprednisolone for suspected multiple sclerosis. RESULTS: Both patients had a diagnostic lumbar puncture for suspected multiple sclerosis and were treated with high-dose intravenous methylprednisolone. Both developed a postlumbar puncture headache that was initially postural, typical of low cerebrospinal fluid pressure. Three days later, the headache became constant, lost its postural component, and was associated with bilateral papilledema. Magnetic resonance imaging of the brain disclosed superior sagittal and lateral sinuses thrombosis. The diagnostic difficulties of such cases and the potential role of lumbar puncture and corticosteroids as risk factors for cerebral venous thrombosis are discussed. CONCLUSIONS: When a typical postdural puncture headache loses its postural component, investigations should be performed to rule out cerebral venous thrombosis, particularly in the presence of other risk factors.     

Cerebrovascular reactivity in migraineurs as measured by transcranial Doppler

Transcranial Doppler ultrasound is a relatively new diagnostic modality which allows the noninvasive assessment of intracranial circulation. A total of 10 migraine patients were studied and compared to healthy controls without headaches. Migraineurs during the headache-free interval demonstrated excessive cerebrovascular reactivity to CO2, evidenced by an increase in middle cerebral artery blood flow velocity of 47% +/- 15% compared to 28% +/- 14% in controls (p = 0.026). Differences between the two study groups revealed no significant decrease in middle cerebral artery blood flow velocity with hypocapnia. However, the differences between middle cerebral artery blood flow velocity during hyperventilation and CO2 inhalation were significantly different (p = 0.004) comparing migraineurs and controls. Instability of the baseline blood flow velocities was also noted in migraineurs during the interictal period. Characteristics which may allow differentiation of migraineurs from other headache populations could possibly be obtained from transcranial Doppler ultrasound flow studies.     

Cerebral Blood Flow in Migraine with Aura: A Transcranial Doppler Sonography Study

Transcranial Doppler sonography examination was performed on 44 patients with migraine with aura and 88 controls. All patients were investigated in headache-free periods and 10 of them also during a migraine attack. During the headache-free period a not significant increase of mean flow velocity in patients compared to controls was obtained. The pulsatility index (PI) mean values were also higher in patients than in controls and the differences were significant in the MCA (p < 0.05). No difference between right and left side was observed. During the attack the mean flow velocity (MFV) decreased in all arteries but the decrease was significant only in MCA and ACA (p < 0.05). The mean PI increased in all arteries but not significantly. These variations were observed both on the headache and contralateral side. Nevertheless, the MFV decrease in all arteries was observed in four patients only. In four patients the MFV decrease was found in the anterior arteries and the MFV increase in the posterior arteries, while in two patients the MFV increase was observed both in the anterior and posterior arteries. The correlation between the variations of MFV values during the attacks and the time interval from the onset of attacks showed that the PCA and BA flow velocities were increased in patients examined between 0.5 and 3 hours, while an increase in MCA and ACA flow velocities were observed only in patients examined after 1.5 hours.     

Epidural blood patch in the treatment of post-lumbar puncture headache

Post-lumbar puncture headache is a common complication of dural puncture. Treatment of severe cases with an epidural ‘blood patch’—injection of 10–20 ml autologous blood into the epidural space at the site of the dural puncture—is an effective and safe method with few and generally mild complications. The method has been used by anesthesiologists for many years with good results, but only rarely by radiologists, neurologists and other specialists who often perform lumbar punctures. The technique of ‘blood patching,’ its indications, effects, and complications and the epidural blood patch as post-lumbar puncture headache prophylaxis are discussed.     

Intracranial Haemodynamics in Cluster Headache

SYNOPSIS
It is now possible to obtain information about intracranial blood flow velocity by the use of transcranial doppler. We investigated transcranial doppler flow velocities in 42 cluster headache patients, and 41 controls. Interhemispheric asymmetry was significantly greater in the cluster headache group. Within the patient groups, velocities in the middle cerebral artery and posterior cerebral artery, were significantly faster on the headache side and slower in the anterior cerebral artery.
Prophylactic medication seems to block these changes.     

连续腰椎穿刺引流在动脉瘤性蛛网膜下腔出血栓塞术后的作用

目的探讨连续腰椎穿刺引流对动脉瘤性蛛网膜下腔出血（a SAH）患者血管栓塞治疗后的作用。方法 42例a SAH患者接受颅内动脉栓塞治疗后,根据是否采取连续腰椎穿刺分为观察组20人和对照组22人。观察2组患者迟发性缺血性神经功能缺陷（DIDN）、头痛缓解和Rankin评分差异。结果观察组患者头痛缓解天数短于对照组（P〈0.05）;治疗期内,观察组患者DIDN发生率低于对照组（P〈00.05）,14 d时Rankin评分低于对照组（P〈0.05）。结论 a SAH患者栓塞治疗后行早期连续腰椎穿刺引流,能降低DIND发生风险,促进神经和认知功能早期恢复。     

Biofeedback-assisted relaxation in migraine headache: relationship to cerebral blood flow velocity in the middle cerebral artery

OBJECTIVE: To determine if migraineurs with aura respond differently to biofeedback/relaxation than those without aura and, if so, whether the variability in outcome can be explained by blood flow velocity. Background.-The relationship between cerebral blood flow velocity and treatment response to biofeedback/relaxation in migraine with and without aura is uncertain. METHOD: Twenty migraineurs underwent 12 sessions of biofeedback/relaxation therapy, while 20 controls simply were told to relax on their own. Cerebral blood flow velocity was measured bilaterally in the middle cerebral artery with transcranial Doppler. RESULTS: The biofeedback group showed significant (P <.05) reductions in pain, depression, and anxiety compared to the control group. Patients with and without aura did equally well. There were significant (P <.05) left to right blood flow velocity differences only in the migraine with aura group. Maximum blood flow velocities were significantly higher (P <.05) in the migraine with aura group than in the cohort without aura. There was an inverse correlation between indicators of anxiety and blood flow velocity, perhaps related to hyperventilation-induced constriction in the small vessels distal to the middle cerebral artery. CONCLUSION: The positive treatment response to biofeedback/relaxation in migraine headache is not related to presence of aura, nor to changes in blood flow velocity, but may be associated with reduction in anxiety and depression.     

Reversal of Cluster Headache Side Following Treatment of Arteriovenous Malformation

We describe the case of a forty-four year old man who had typical right sided cluster headaches and an arteriovenous malformation supplied mainly by the right anterior cerebral artery. Following endovascular embolisation of this artery the AVM was supplied mainly by the left anterior cerebral artery. Subsequent headaches have always been on the left. Transcranial Doppler studies now suggested an increase of middle cerebral artery flow velocity. We suggest that the change in haemodynamics was responsible for the change in headache side.     

Blood flow and flow resistance in the vertebral arteries of patients with and without carotid atherosclerosis

In the present prospective study colour duplex ultrasound was used to investigate the vertebral arteries in 117 patients referred for carotid duplex examination. The study aimed to identify flow abnormalities and factors influencing blood flow haemodynamics by calculating the resistance index (RI) in the vertebral and common carotid arteries. Vertebral artery RI was decreased in patients with severe carotid artery disease (> or =80% stenosis or occlusion) caused mainly by an increased diastolic flow velocity. By contrast, patients without severe carotid artery disease showed an age-related increase in vertebral artery RI. The RI in the common carotid artery was increased in patients with local atherosclerosis in the carotid bulb, and was increased with age. There was significantly better visualization of the right vertebral artery origin than of the left (75% versus 62%, P<0.05). Stenotic lesions were found in 15% of the carotid bifurcations and in 7% of the vertebral arteries. It is concluded that vertebral artery haemodynamics can be evaluated using colour duplex ultrasound; however, there are difficulties in visualizing the vertebral artery origin, especially on the left side. Even at advanced age, the vertebral arteries can reduce flow resistance to maintain cerebral blood flow in patients with occluded or severely stenosed carotid arteries. RI in vertebral arteries in patients without severe carotid occlusive disease, and in common carotid arteries, is mainly affected by local atherosclerosis and age, which increase the flow resistance.     

Diagnostic lumbar puncture. Comparative study between 22–gauge pencil point and sharp bevel needle

Post-lumbar puncture headache is a frequent clinical problem. Needle design is expected to reduce post-puncture headache. In this study, we compared two different lumbar puncture needle designs in diagnostic lumbar puncture and analysed post-dural puncture headache (PDPH) and social and economical harm associated with the diagnostic lumbar puncture procedure. This prospective, controlled study consisted of 80 consecutive adult patients requiring elective diagnostic lumbar puncture due to various neurological symptoms. Lumbar puncture was completed either with Spinocan 22 G sharp bevel needle or Whitacre 22G pencil point needle. Patients were asked about previous headache symptoms and pain provoked by puncture. One week after the lumbar puncture all patients were interviewed by telephone and occurrence and type of headache, headache intensity, medication and frequency of impairment in activities of daily living were asked. Need for epidural blood patch was also recorded. Thirty-three of 78 (42%) patients experienced headache after diagnostic lumbar puncture and in 26 (33%) the headache could be classified as PDPH. There were no statistically significant differences between needle types in the frequency of common headache, PDPH, puncture pain intensity, need for epidural blood patch or sick leave. Also, there were no other complications except local back pain or headache. In this study, the needle design did not affect the frequency of PDPH. Also, PDPH was common, occurring in 33% cases and caused a considerable amount of disturbance in daily activities. Seeking help for this condition was insufficient and only part of these PDPH patients were treated with epidural blood patch.     

老年患者腰椎穿刺后两种卧位的效果对比

目的探讨提高老年患者腰穿术后舒适且又安全的合适卧位。方法将符合条件的64例老年患者随机分成两组:对照组(34例)患者腰穿术后采取去枕平卧4~6 h;观察组(30例)患者术后6 h内可左右交替侧卧或平卧,但避免坐起、抬高床头。观察两组患者出现头痛、腰背酸痛、皮肤压红及血压升高的情况。结果两组患者头痛的发生率及程度无统计学差异(P>0.05);而观察组患者出现腰背酸痛、皮肤压红的程度及术后4 h和6 h血压升高的例数均低于对照组(P<0.05)。结论老年患者腰穿术后6 h采取行左右交替侧卧或平卧的改良方式,既能保证患者的安全、减少不良反应,又能满足其生理需求,提高舒适度。     

Sumatriptan and Cerebral Blood Flow Velocity Changes During Migraine Attacks

Transcranial Doppler studies on the effects of sumatriptan on cerebral hemodynamics have shown conflicting results. We evaluated blood flow velocity changes in 21 patients suffering from migraine with (n = 4) or without aura (n = 17) during a spontaneous attack, before and after treatment with sumatriptan. Flow velocity in the internal and external carotid, middle cerebral, and basilar arteries was measured by means of transcranial Doppler. During the attack, measurements were taken before subcutaneous sumatriptan injection, then after 30 minutes, 2 hours, and 24 hours. An additional measurement was taken 1 week later, in a headache-free state. We found a significant reduction of flow velocity during the attack in the middle cerebral artery on both sides (P < 0.05). After sumatriptan administration, flow velocity increased in the internal carotid artery on both sides (P < 0.05) and in the middle cerebral artery on the headache side (P = 0.0001), but not in the external carotid and basilar arteries (P > 0.05). Flow velocity changes may reflect the vasodilation present at the onset of the migraine attack followed by vasoconstriction in the internal carotid and middle cerebral arteries after sumatriptan treatment. Since vasoconstriction occurs in responders and nonresponders to treatment, it is unlikely to be the primary mechanism by which sumatriptan relieves headache.