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NEUROSURGICAL ANESTHESIA

The Mechanisms of Intracranial Pressure Modulation by Epidural Blood and Other Injectates in a Postdural Puncture Rat Model

Department of Anesthesiology, Rush Medical College at Rush-Presbyterian-St. Luke’s Medical Center, Chicago, Illinois

Address correspondence to Jeffrey S. Kroin, PhD, Department of Anesthesiology, Rush Medical College, 1653 W. Congress Parkway, Chicago, IL 60612. Address e-mail to jkroin{at}rush.edu

The epidural blood patch is considered effective in treating postdural puncture headache. We have developed a postdural puncture model in rats for quantitative evaluation of the magnitude and duration of changes in cerebrospinal fluid (CSF) pressure in the cisterna magna in response to the administration of epidural blood or other moieties. This model was used to compare the efficacy of various methods of epidural injection for restoring and maintaining CSF pressure for up to 240 min. After lumbar dural puncture, CSF pressure declined 3.6 ± 0.2 mm Hg. Epidural saline (100 µL) injected at the puncture site initially increased pressure by 7.2 ± 0.7 mm Hg, but it rapidly (7.8 ± 0.6 min) returned to postdural puncture baseline. A similar initial increase of CSF pressure was observed with equal volumes of all other epidural injectates, but the duration of pressure increase varied greatly. Hetastarch and dextran 40 produced results similar to saline. Only whole blood or fibrin glue consistently increased CSF pressure for the entire 240-min observation period. Whole blood mixed with anticoagulant or injected 20-mm cephalad to the puncture site did not sustain pressure. After laminectomy, direct application of blood or adhesive to the dural defect caused no pressure increase. Continuous infusion of saline after bolus could maintain pressure increase for 180 min, but within 60 min of stopping infusion, pressure returned to baseline. These results confirm the efficacy of the epidural administration of blood or fibrin glue to correct CSF hypotension after dural puncture and also provide insight into the mechanisms of intracranial pressure modulation. Sealing the dural defect does not effectively correct CSF pressure unless an epidural tamponade effect is also maintained.

IMPLICATIONS: A rat model was developed to evaluate different drugs that may be injected epidurally to treat postdural puncture headache. Epidural injection of blood or fibrin glue was the most effective method of maintaining increased cerebrospinal fluid pressure after dural puncture. Sealing the dural defect does not effectively correct cerebrospinal fluid pressure unless an epidural tamponade effect is maintained.

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