Continuous epidural saline infusion combined with intranasal dexmedetomidine for severe post-dural puncture headache with intracranial hypotension: a case report

Background Post-dural puncture headache (PDPH) is a common complication of obstetric neuraxial anesthesia. Epidural blood patch (EBP) is the standard treatment for moderate-to-severe PDPH, but it may be deferred or relatively contraindicated when systemic infection is suspected. Current evidence on alternative treatments for PDPH has mainly focused on single interventions, and reports describing combined therapeutic strategies remain limited. Case presentation A 37-year-old parturient developed accidental dural puncture during epidural labor analgesia and subsequently experienced severe PDPH 2 h after delivery, with a sitting numerical rating scale (NRS) score of 10. Cranial magnetic resonance imaging (MRI) showed features consistent with intracranial hypotension, including narrowing of the suprasellar cistern and inferior displacement of the cerebellar tonsils. Because high fever (39.2 °C) and leukocytosis raised concern for possible systemic infection, EBP was considered high risk. Continuous epidural normal saline infusion was administered through the retained epidural catheter at 10 mL/h, together with empirical ceftriaxone, non-steroidal analgesia, bed rest, and fluid support. Intranasal dexmedetomidine 50 μg per dose twice daily was added at approximately 24 h postpartum because of persistent headache. Within 48 h, the patient's headache improved in a stepwise manner: the sitting NRS score was 10 at 24 h postpartum, 4 at 36 h postpartum, and 0 at 48 h postpartum. Follow-up MRI on postpartum day 5 showed marked improvement in the signs of intracranial hypotension. No recurrence occurred at 1- and 3-month follow-up. Conclusion In selected patients with severe PDPH for whom EBP is unsuitable or high risk, continuous epidural saline infusion combined with intranasal dexmedetomidine may be a feasible non-blood-patch alternative, although causality cannot be established from a single case because of concurrent interventions and possible spontaneous improvement. Larger studies are required to evaluate safety, efficacy, and optimal dosing.