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Epidural blood patch reduces the incidence of post lumbar puncture headache.

In 50 patients, aged 16 to 58, an autologous blood patch was injected into the epidural space immediately after diagnostic lumbar puncture. The incidence of postpuncture headache was 22%, which was significantly lower than in a control group (40 patients, aged 17 to 54), where it amounted to 45%. Compared to the control group, the patients with epidural blood patch had significantly less postpuncture complaints between the 1st and 3rd day following lumbar puncture. Lower back pain as the only side effect was experienced by 30 to 40% of the patients in each of the 2 groups. We conclude that the epidural blood patch is practicable and effective in the prophylaxis of postpuncture headache, but cannot prevent its occurrence in all cases.

Adolescent↗

Persistence of septal defects after transeptal puncture for pulmonary vein isolation procedures.

Pulmonary vein isolation (PVI) is widely practiced as a means of potentially curing atrial fibrillation (AF). Transeptal puncture is performed for PVI procedures, often two such punctures are performed. We sought to examine the prevalence of medium- to long- term iatrogenic septal defects after such procedures. Thirty-one patients who were undergoing their second PVI procedure were studied with transesophageal echocardiography (TEE) with two-dimensional imaging and color Doppler, examining the fossa ovalis for defects. Mean time from the original PVI to the time of TEE was 35 weeks. Two patients were discovered to have iatrogenic septal defects. The interval between the first PVI procedure and the TEE showing a septal defect was 33.7 weeks in one patient and 14.3 weeks in the other. Iatrogenic septal defects may occur in the medium- to long-term in patients undergoing PVI procedures for AF. The clinical implications of such defects are unknown.

Adult↗

Percutaneous suture closure for brachial artery puncture.

Percutaneous suture closure for femoral artery hemostasis has gained broad use over the last few years since its introduction. The appeal of suture closure is the immediate and definitive hemostasis that it achieves, even in anticoagulated patients. Described is the use of the Perclose Techstar XL 6Fr suture closure device for the management of brachial artery puncture after diagnostic and therapeutic catheterization. A 6Fr Perclose Techstar device was used for hemostasis during ten procedures in eight patients. In addition, 6Fr and 7Fr sheaths were used. Hemostasis was achieved in all but one patient, in whom hemostasis was not achieved and surgical repair was necessary. The Perclose Techstar device is useful for selected patients for achieving brachial arterial puncture site hemostasis. The large excursion of the foot of the new closer device may not be as applicable in arteries as small as the brachial artery. Patients who are obese may be best suited for this approach.

Adult↗

A prospective double-blind clinical trial, comparing the sharp Quincke needle (22G) with an "atraumatic" needle (22G) in the induction of post-lumbar puncture headache.

Posture-dependent, post-lumbar puncture headache is most likely caused by continuous leakage of cerebrospinal fluid through the dura mater perforation with a consecutive downward sagging of the intracranial content and an irritation of pain-sensitive structures of meninges and blood vessels. A psychogenic co-factor may also play a role. It is generally acknowledged that the incidence and intensity of the headache correlate significantly with the diameter of the needles used. A second factor, the shape of the needle point plays a crucial role as is shown in our prospective, double-blind, clinical trial with 75 patients: employment of the "atraumatic" Sprotte needle with a rounded off point significantly reduced the incidence of post-puncture headache from 36% to 4%. Beside the discussion of pathogenic factors, remarks on a rational therapy are made.

Double-Blind Method↗

Low frequency of post-lumbar puncture headache in demented patients.

The frequency of post-lumbar puncture headache (PLPH) was registered prospectively in 395 consecutive demented patients at a dementia diagnostic unit. The incidence of PLPH was low, occurring in only 8 patients (2.0%), the severity was mild, and the duration was less than 2 days in all cases but one. The reasons for this low frequency of PLPH in patients with dementia disorders may include disease- and/or age-related low pain sensitivity, rigid dural fibres and arteriosclerotic vessels, and large CSF space due to cerebral atrophy. Analysis of CSF is essential to identify secondary causes of dementia, preferentially chronic infections. The low frequency and severity of PLPH found in the present study shows that, with low risk of complications, lumbar puncture can be included in the routine clinical examination of demented patients.

Adult↗

MMPI profiles in post-lumbar puncture headache.

From the original material of 300 patients, of whom 37.3% had experienced a post-lumbar puncture headache (PPH), a total of 20 males and 50 females were evaluated with the Minnesota Multiple Personality Inventory (MMPI). The test was administered on average 33 months after the lumbar puncture (range 13-51), at a time when anxiety and depression related to the original investigation for a possible organic neurologic disease were expected to affect the results minimally. In the present material PPH was experienced by 45.7% of the patients, 40% of the males, and 48% of the females. Patients without PPH were used as controls. The selected material was a representative sample of the original material both as to distribution of age, proportion of organic diagnoses, and frequency of PPH. The MMPI disclosed no statistically significant differences between PPH patients and controls regarding personality traits.

Adult↗

Self-sealing, large bore arterial punctures: a counterintuitive new phenomenon.

The human femoral artery can bleed dangerously following the removal of a catheter uring cardiac catheterization. In this study, a modified technique of needle insertion, simply inserting the needle bevel-down instead of the standard bevel-up approach, was tested as a means to reduce bleeding after catheter removal. Large bore needle punctures were made in surgically exposed arteries of anesthetized pigs using either a standard technique (45 degree approach, bevel up) or a modified technique (25 degree approach, bevel down). For half the punctures, topical phenylephrine solution (1 mg/ml) was applied to the adventitia of the artery to cause constriction. Median bleeding rates were reduced from 81 to less than 1 ml/min/100 mmHg intraluminal pressure by the modified technique with application of phenylephrine. In most cases zero bleeding, that is self-sealing, of the arteries occurred. It is postulated that a flap-valve of tissue created by the modified technique produced this self-sealing behavior. Sophisticated modeling studies are needed to fully understand this new phenomenon.

Animals↗

Nuclear factor-kappaB decoy oligodeoxynucleotides prevent acute lung injury in mice with cecal ligation and puncture-induced sepsis.

The transcription factor nuclear factor-kappaB (NF-kappaB) plays a key role in expression of many inflammatory genes responsible for the pathophysiology of sepsis-induced acute lung injury. We investigated whether the introduction of synthetic double-stranded oligodeoxynucleotides (ODNs) with consensus NF-kappaB sequence as transcription factor decoy can prevent acute lung injury with suppression of pulmonary expression of multiple genes involved in its pathological process in a cecal ligation and puncture septic mouse model. NF-kappaB decoy ODNs were introduced with the aid of the hemagglutinating virus of Japan-envelope vector method. Northern blot analysis indicated that transfection of NF-kappaB decoy ODN, but not of its scrambled form, resulted in a significant inhibition of sepsis-induced gene overexpression of inducible nitric-oxide synthase (iNOS), cyclooxygenase-2, histamine H(1)-receptor, platelet-activating factor receptor, and bradykinin B(1) and B(2) receptors in lung Histological damage in lungs tissues. (wall thickening, inflammatory infiltrate, and hemorrhage), increased pulmonary vascular permeability, and blood gas exchange impairment were clearly documented in mice after cecal ligation and puncture. These changes were strongly eliminated by the introduction of NF-kappaB decoy but not of scrambled ODN. The effects of the iNOS inhibitor FR260330 on these histological and functional derangements compared unfavorably with those of NF-kappaB decoy ODN transfection. Our results suggest that ODN decoy, acting as in vivo competitor for the transcription factor's ability to bind to cognate recognition sequence, may represent an effective strategy in the treatment of septic acute lung injury.

Animals↗

Mortality and bacteriology of sepsis following cecal ligation and puncture in aged mice.

Epidemiologic data suggest that elderly adults are more susceptible to invasive bacterial infection by indigenous gut flora than are younger adults. The purpose of this investigation was to characterize a murine model of clinically encountered peritonitis in the aged. We subjected three different age groups (young, 16 weeks; mature, 12 months; senescent, 24 months) of C57BL/6NNia mice to surgically induced peritonitis by the cecal ligation and puncture procedure. Senescent mice died in a significantly shorter time following surgery than mature mice (median time to death, 24.4 versus 38.5 h, respectively; P less than or equal to 0.001). Blood, liver, spleen and occasionally, ceca were obtained at 2 and 12 h after the cecal ligation and puncture procedure and immediately following death, to characterize the bacterial kinetics of the model. Qualitative and quantitative aerobic, anaerobic, and coliform cultures were performed. No age-related differences were found in the types of bacteria isolated throughout the time course of progressive sepsis. In mice in the mature and senescent age groups, at 2 and 12 h postsurgery, gram-negative anaerobes and gram-positive aerobes predominated in all tissues that were cultured. At the time of death, however, blood and tissue isolates consisted predominantly of coliform bacteria. The shift from mixed infection during sepsis to predominantly gram-negative bacterial infection reflected a similar progressive shift in bacterial types found in the cecum. At death, senescent mice had 100-fold fewer coliform bacteria in the bloodstream than those found in mature mice (2.5 x 10(9) versus 4.6 x 10(11), respectively). The increased sensitivity of aged mice to invasive bacterial infection documented in this series of experiments accords well with human epidemiologic experience and demonstrates the appropriateness of the model for continued investigations of sepsis in the aged.

Aging↗

Repeat lumbar puncture in the diagnosis of meningitis.

Meningitis may be difficult to diagnose. If it is suspected clinically and a first lumbar puncture is normal, a second cerebrospinal fluid (CSF) sample may be required within a few hours to confirm the diagnosis. A child is presented in whom CSF was normal 14 hours after the onset of illness, but who 14 hours later showed the characteristic changes of purulent meningitis. This case differs from those previously cited in the literature, in that the blood cultures taken at the time of the first lumbar puncture were also negative.

Humans↗

Epidermoid spinal cord tumour after lumbar puncture.

A 5 year old boy developed an implantation dermoid tumour after a lumbar puncture in infancy. A survey of senior paediatricians has shown it to be common practice to use an unstiletted needle for lumbar puncture in small children. A stiletted needle is recommended for all such procedures.

Dermoid Cyst↗

Lumbar puncture in the presence of raised intracranial pressure.

Study of 30 patients with raised intracranial pressure whose condition worsened after lumbar puncture emphasizes the danger of carrying this out in the presence of raised intracranial pressure. In half the cases deterioration was immediate and dramatic, and in the other half it occurred within 12 hours. Probably a tentorial or cerebellar pressure cone, or both, had formed before lumbar puncture, and the procedure made this worse and caused the clinical deterioration.A history of progressive headache associated with mental changes, and the development and progression of localizing neurological signs were the two features suggestive of varied intracranial pressure found most constantly in this series. A good quality plain x-ray film is important in the diagnosis of this condition.

Brain Abscess↗

The clinical effect of lumbar puncture in normal pressure hydrocephalus.

Owing to all the difficulties involved in selecting patients with normal pressure hydrocephalus for shunt-operation, a cerebrospinal fluid-tap-test (CSF-TT) is introduced. Psychometric and motor capacities of the patients are measured before and after lumbar puncture and removal of 40-50 ml CSF. Patients fulfilling criteria for normal pressure hydrocephalus were compared to patients with dementia and atrophy shown by computed tomography. Normal pressure hydrocephalus patients showed temporary improvement after lumbar puncture. The extent of the temporary improvement appeared to be well correlated with the improvement after shunt operation. Accordingly, the CSF-TT seems to be of value when selecting those patients who will probably benefit from a shunt operation.

Adult↗

Outcome of shunt operation on urinary incontinence in normal pressure hydrocephalus predicted by lumbar puncture.

Bladder function in four patients with normal pressure hydrocephalus, one with dementia of Alzheimer type and five patients with multi-infarct dementia was studied by history and urodynamic tests (cystometry and Bor's ice water test). The bladder hyperactivity could be temporarily improved by a lumbar puncture and removal of 50 ml CSF and later abolished by a shunt operation in patients with normal pressure hydrocephalus while no changes occurred in the other patients. Urodynamic testing in connection with a lumbar puncture may be a reliable way to predict the outcome of a shunt operation in cases of normal pressure hydrocephalus.

Aged↗

Detection of subarachnoid haemorrhage on early CT: is lumbar puncture still needed after a negative scan?

Computed tomography may be normal in up to 5% of patients who are investigated within one or two days after subarachnoid haemorrhage. This study investigated the need for further diagnostic evaluation after a normal CT scan was found very early (within 12 hours) in patients suspected of subarachnoid haemorrhage. A consecutive series of 175 patients with sudden headache and a normal neurological examination who had first CT within 12 hours after the onset of headache were investigated. The patients with normal CT underwent lumbar puncture, but not earlier than 12 hours after the event. Computed tomography showed subarachnoid blood in 117 patients, and was normal in 58. Spectrophotometric analysis of CSF gave evidence for a subarachnoid haemorrhage in two of these 58 patients (3%; 95% confidence interval (95% CI) 0.4-12%); a ruptured aneurysm was found in both. Thus CT was normal in two of 119 patients with a definite subarachnoid haemorrhage (2%; 95% CI 0.2-6%). It is concluded that in patients with sudden headache but normal CT a deferred lumbar puncture is necessary to rule out subarachnoid haemorrhage, even if CT is performed within 12 hours after the onset of symptoms.

Acute Disease↗

Post lumbar puncture discitis and vertebral collapse.

Discitis and vertebral collapse are rare but serious complications of lumbar puncture. Clinical profile, management and course of post lumbar puncture discitis in five patients is presented. Such a complication should be kept in mind whenever any invasive procedure is carried out on the spine.

Adult↗

Fluoroscopic guidance in femoral artery puncture.

Analysis of 100 femoral arteriograms demonstrated a consistent relationship between the course of the femoral artery and the femoral head. Fluoroscopic guidance can be of value in femoral puncture when the arterial pulse is diminished or obscured, for training purposes, and for analysis and correction of missed punctures.

Adult↗

Percutaneous vascular and nonvascular puncture under US guidance: role of color Doppler imaging.

Although ultrasound guidance is extensively used in percutaneous interventional procedures, the limitations of B-mode, gray-scale sonographic guidance can restrict clinical use. Little attention has been paid to the use of color Doppler sonography during such procedures. There are several ways in which color Doppler sonography can facilitate percutaneous procedures that involve insertion of a needle or catheter. The advantages of color Doppler sonography include the following: (a) better visualization of the shaft and tip of the needle, especially in solid, echogenic lesions, when the needle is moving, or when the beam-needle angle is narrow; (b) improved targeting of either vessels or non-vascular structures (ie, biliary ducts) to be punctured; (c) avoidance of interposed vascular structures and highly vascular areas during puncture of lesions; (d) improved visualization of poorly echogenic catheters, allowing proper placement; and (e) prompt detection of complications, including active bleeding, after withdrawal of the needle.

Biopsy, Needle↗