Abstract
Background
Severe headache is a hallmark clinical feature of spontaneous subarachnoid hemorrhage (SAH), affecting nearly 90% of patients during index hospitalization, regardless of the SAH severity or presence of a culprit aneurysm. Up to 1 in 4 survivors of SAH experience chronic headaches, which may be severe and last for years. Data guiding the optimal management of post-SAH headache are lacking. Opioids, often in escalating doses, remain the guideline-recommended mainstay of acute therapy, but pain relief remains suboptimal.
Methods
This study is a case series of adult patients who received bilateral pterygopalatine fossa (PPF) blockade for the management of refractory headaches after spontaneous SAH (aneurysmal and non-aneurysmal) at a single tertiary care center. We examined pain scores and analgesic requirements before and after block placement.
Results
Seven patients (median age 54 years, 3 men, four aneurysmal and three non-aneurysmal) received a PPF-block between post-bleed day 6–11 during index hospitalization in the neurointensive care unit. The worst pain recorded in the 24-h period before the block was significantly higher than in the period 4 h after the block (9.1 vs. 3.1; p = 0.0156), and in the period 8 h after the block (9.1 vs. 2.8; p = 0.0313). The only complication was minor oozing from the needle insertion sites, which subsided completely with gauze pressure within 1 min.
Conclusions
PPF blockade might constitute a promising opioid-sparing therapeutic strategy for the management of post-SAH headache that merits further prospective controlled randomized studies.
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Acknowledgments
Dr. Carolina B. Maciel has received the Claude D. Pepper Older Americans Independence Center Junior Scholar award that supports preclinical studies of mechanisms of secondary brain injury in a rodent cardiac arrest model. Gerard Garvan produced the graphs using R software.
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Cameron R. Smith and Katharina M. Busl: Conception and design of the study, data interpretation, drafting of the article, critical revision of the article, final approval of the version to be published. Cynthia Garvan: Data analysis and interpretation, critical revision of the article. W. Christopher Fox and Carolina Maciel: conception of the study, data interpretation, critical revision of the article. Marc-Alain Babi, Michael A. Pizzi, Christopher P. Robinson: data interpretation, critical revision of the article. Erica Lobmeyer, Alberto Bursian: data collection, data interpretation, critical revision of the article.
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Smith, C.R., Fox, W.C., Robinson, C.P. et al. Pterygopalatine Fossa Blockade as Novel, Narcotic-Sparing Treatment for Headache in Patients with Spontaneous Subarachnoid Hemorrhage. Neurocrit Care 35, 241–248 (2021). https://doi.org/10.1007/s12028-020-01157-1
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DOI: https://doi.org/10.1007/s12028-020-01157-1