Patients with chronic post-dural puncture headache do not have typical imaging features of intracranial hypotension:...

This study evaluated cranial magnetic resonance imaging (MRI) signs in patients with post-dural puncture headache (PDPH) using an established assessment score developed for spontaneous intracranial hypotension (Bern score). We hypothesize that patients with chronic PDPH do not have typical imaging features of intracranial hypotension.

PDPH is a well-known complication following an intentional or unintentional lumbar dural puncture with positional headache, neck stiffness, and hearing disturbances usually resolving within 14 days. However, the chronic course of PDPH is poorly represented in the third version of the International Classification of Headache Disorders (ICHD-3). Moreover, data on the role of cranial MRI in this cohort are lacking, but could facilitate care and management of chronic PDPH.

In this post hoc retrospective case series based on a chart review, we identified 86 consecutive patients from a tertiary medical care center in Freiburg, Germany between 01/2018 and 10/2024 with chronic PDPH, defined as persisting symptoms for >14 days post puncture and/or persisting after one or more epidural blood patches (EBP). Inclusion criteria were history of lumbar puncture (LP) or unintended dural puncture (UDP) and contrast enhanced cranial MRI for assessment of Bern score in all patients. Presence of epidural lumbar fluid was evaluated using heavily T2-weighted MRI or computed tomography (CT) myelography, whenever available (83/86 patients). Data were reviewed independently and blinded by two radiologists.

Eighty-six patients with chronic PDPH (66 females; mean age of 38.8 ± 11.2 SD years) were included with LP as primary cause in 72% (n=62) and UDP while peridural (synonymous epidural) anesthesia (PDA) in 28% (n = 24). Median symptom duration was 220.0 (interquartile range [IQR] 94.0-474.0) days. Overall median Bern score was 2.0 (IQR 1.0-3.0) with no significant differences between LP versus PDA (p = 0.379). Local epidural fluid was present in 9/83 (11%) cases with adequate imaging and accompanied by higher median Bern scores (5.0 vs. 2.0; p = 0.026). Prior EBP was linked to lower median Bern scores (1.0 vs. 3.5; p < 0.001).

Patients with chronic PDPH predominantly present a low Bern score and rarely exhibit spinal epidural fluid. If present, spinal epidural fluid is accompanied by higher Bern score. Our findings highlight the unreliability of current MRI diagnostics to detect patients with chronic PDPH, which must not lead to a mitigation of the diagnosis or a refusal of treatment. Further research on MRI markers is needed here.