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Poster displayed – Chronic pain management
P188 Headache management in spontaneous intracranial hypotension (SIH) after a whiplash in a car
  1. Andrea Choque Campero1,
  2. Cecilia Nobre2,
  3. Leandro Aurelio Santana1,
  4. Laiz Gomes Carneiro Novaes3 and
  5. Luiza Nobre4
  1. 1Anesthesiologist, Rio de Janeiro University State UERJ, Rio de Janeiro, Brazil
  2. 2Anesthesiologist Pain Management Specialist, Rio de Janeiro University State, Rio de Janeiro, Brazil
  3. 3Academic, Rio de Janeiro University State UERJ, Rio de Janeiro, Brazil
  4. 4Academic, Estacio de Sa University, Rio de Janeiro, Brazil

Abstract

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Background and Aims Spontaneous Intracranial Hypotension (SIH) results from non-iatrogenic cerebrospinal fluid (CSF) leakage, causing CSF hypovolemia. Characterized by orthostatic headaches that worsen upright and relieve when lying down, SIH is diagnosed through clinical history, symptoms, and imaging showing low CSF pressure (

Methods A 49-year-old female health professional developed severe holocranial headaches one week post- forceful, rapid back-and-forth movement of the neck, worsened in upright posture (EVN 10) and relieved when supine (EVN zero). Empirical meningitis treatment failed, and cisternography confirmed a CSF fistula. Initial treatment included rest, hydration, and analgesics: dipyrone (1g q4h), ibuprofen (600mg/day), pregabalin (up to 300mg/day), and escitalopram (10mg/day). Persistent symptoms led to hospitalization, venous hydration (2000ml/day), and a fluoroscopy-guided epidural blood patch (25ml blood at L1-L2 and L4-L5). The patient maintained EVN zero post-procedure and was discharged after 48 hours. Six months later, the patient developed kinesiophobia and catastrophizing behavior, avoiding rehabilitation and work despite continuing escitalopram. Psychological and physiotherapy support initiated after three months led to gradual improvement. One year post-accident, the patient regained autonomy and returned to work.

Conclusions SIH management requires a multidisciplinary approach addressing physical and psychological aspects. Initial imaging should include contrast-enhanced MRI of the skull and spine, with myelography if needed. Predisposing factors include dural weaknesses, connective tissue disorders (e.g., Marfan syndrome, Ehlers-Danlos syndrome), and hormonal influences, with women more frequently affected. Comprehensive care is crucial for optimal recovery.

Abstract P188 Figure 1
Abstract P188 Figure 1

Imaging Findings: Cisternography revealed ascending radiotracer flow in the perimedullary arachnoid space and base cisterns. Radiotracer presence was significant at L2-L4 levels, suggesting a CSF fistula. The imaging study confirmed a CSF fistula at the lumbar spine (L2-L4) due to the high concentration of radiotracer outside the spinal canal at these levels

  • Spontaneous Intracranial Hypotension
  • blood patch
  • cerebro fluid spinal (CFS)

https://doi.org/10.1136/rapm-2024-ESRA.308

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