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RESPONSE OF AUTHOR TO COMMENTS
Year : 2016  |  Volume : 60  |  Issue : 3  |  Page : 229-230  

New approach to treat an old problem: Mannitol for post-dural puncture headache


1 Department of Anaesthesiology, TS Mishra Medical College, Lucknow, Uttar Pradesh, India
2 Department of Anaesthesiology, Narayan Medical College and Hospital, Sararam, Bihar, India

Date of Web Publication2-Mar-2016

Correspondence Address:
Mohammed Meesam Rizvi
MIG 15 Napier Road Colony Part II, Thakurganj, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5049.177878

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How to cite this article:
Rizvi MM, Singh RB, Tripathi R. New approach to treat an old problem: Mannitol for post-dural puncture headache. Indian J Anaesth 2016;60:229-30

How to cite this URL:
Rizvi MM, Singh RB, Tripathi R. New approach to treat an old problem: Mannitol for post-dural puncture headache. Indian J Anaesth [serial online] 2016 [cited 2020 Aug 11];60:229-30. Available from: http://www.ijaweb.org/text.asp?2016/60/3/229/177878

Sir,

In their comments on our article,[1],[2] the readers are correct on the theories regarding the causation of post-dural puncture headache (PDPH, a low-pressure headache), either due to traction on pain-sensitive parietal duramater or veno-dilatation in keeping with the Monroe-Kellie doctrine. Their observations and arguments are essentially sound and astute; however, we offer the following clarifications regarding the relief of PDPH.

Mannitol acts by the following means: 'Acute increases in blood osmolality → decrease brain water content (occurs mainly in healthy brain tissue with intact blood brain barrier) → decreased brain bulk, intracranial pressure, increased intracranial compliance'.[3] It is this decreased brain bulk, the authors believe, cause the brain to re-float in a contracted cerebrospinal fluid (CSF) volume, the end result of continuous CSF leakage [Figure 1] and [Figure 2]. We believe that re-floatation is an important factor that helps mannitol alleviate PDPH along with other factors, which are quoted in the following text. 'Blood rheology is also improved because of decreased endothelial oedema and decreased erythrocyte oedema and increased erythrocyte deformability with augmentation of perfusion, especially through the microvasculature'.[3] Ergo, the effects of mannitol on brain circulation are beneficial and contributory to re-floatation, leading to mitigation of PDPH.[4]
Figure 1: Brain floatation

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Figure 2: Re-floatation principle

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The rebound phenomena as pointed out by the readers, is also a true entity. But in a patient who underwent spinal anaesthesia or inadvertent dural puncture with a Tuohy needle, the disruption to the blood-brain barrier is extremely minimal and will not cause entry of sufficient mannitol into the brain parenchyma to cause a rebound effect. Rebound phenomena also effects the CSF pressure, making it higher and maybe beneficial in a low-pressure headache.[5]

The arguments regarding dyselectrolytemia and dehydration are true as well, but as we all know, mannitol is a time-tested drug in the fields of neurology and neurosurgery (and in other clinical situations, where indicated).[6] However, it should be carefully used, like any other drug, keeping in mind the hydration and electrolyte status of the patient, as not to defeat its very purpose.

Although mannitol has never been traditionally indicated to treat PDPH, the authors have used it successfully in numerous instances with rapid clinical gains. Our colleagues at the Department of Anaesthesia, at CMC Vellore, support these benefits of mannitol on PDPH. That's why the authors only suggest that a clinical trial may be taken up to establish this fact. Instead of just reassuring the patient that PDPH is self-limiting and will subside in a couple days, and giving hydration and analgesics, if there is a way to 'fix the problem', why not embrace it?

The authors do not claim this as an established approach, but it is a step in the right direction and may be subjected to modifications and analysis, after the necessary clinical trials: Risk-benefit ratio needs to be analysed in depth.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Dhansura T, Shaikh T, Shaikh MA. Comments: New approach to treat an old problem: Mannitol for postdural puncture headache. Indian J Anaesth 2015;59:762  Back to cited text no. 1
    
2.
Rizvi MM, Singh RB, Tripathi RK, Immaculate S. New approach to treat an old problem: Mannitol for post dural puncture headache! Indian J Anaesth 2015;59:260-1.  Back to cited text no. 2
    
3.
Newfield P, Cottrell JE. Handbook of Neuroanesthesia. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2012. p. 121-2.  Back to cited text no. 3
    
4.
Shawkat H, Westwood MM, Mortimer A. Mannitol: A review of its clinical uses. Contin Edu Anaesth Crit Care Pain 2012;2:82-5.  Back to cited text no. 4
    
5.
Kalita J, Ranjan P, Misra UK. Current status of osmotherapy in intracerebral hemorrhage. Neurol India 2003;51:104-9.  Back to cited text no. 5
[PUBMED]  Medknow Journal  
6.
Demaerschalk BM, Wingerchuk DM. Evidence Based Neurology: Management of Neurological Disorders. 2nd ed. Oxford: Wiley-Blackwell; 2015. p. 92.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]


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