Sometimes I say, “Good, I’m good. How are you?”
Rebound intracranial hypertension (RIH) is a potential complication of epidural blood patching characterized by a postprocedural elevation of CSF pressure . . . . The mechanism underlying this phenomenon remains unknown and the onset of symptoms has been reported over a wide timeframe, ranging from days to years after [epidural blood patch]. Despite the small number of reported cases in the literature, our experience has been that this phenomenon is not uncommon. It is likely, in our opinion, that RIH often goes unrecognized.
The primary clinical manifestation of RIH is headache, which may be accompanied by nausea, emesis, and blurred vision. Because patients with [spontaneous intracranial hypotension] typically also have headache as their primary complaint, and because experience with treating these patients is limited at many centers, the headaches associated with RIH might be mistakenly attributed to refractory [spontaneous intracranial hypotension]. As a consequence, treatment aimed at increasing CSF pressure, such as repeat [epidural blood patches], will be unhelpful for patients with RIH and could even exacerbate the condition. Awareness of this complication is therefore important.
—P.G. Kranz, T.J. Amrhein, and L. Gray, “Rebound Intracranial Hypertension: A Complication of Epidural Blood Patching for Intracranial Hypotension,” American Journal of Neuroradiology, June 2014
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February 2016
Rebound, like spontaneous, is a funny word. There is an energy to it, a buoyancy, a lightness that seems to imply a temporary state, the moment just after you spring off a trampoline and hover, nearly weightless, in the air, and just before you land again, sinking down into the elastic place that launches you ever upwards. Rebound makes me think of relationships, the fling you have to get over the guy who broke your heart, and in that sense it carries with it a feeling of propulsion, of abandon, an almost predatory or at least pointed and specific kind of freedom. It makes me think of flying, after having been on the ground. Potential energy suddenly made potent.
But my rebound high pressure is neither high-flying nor short-lived. It is a constant thing, my leap from the depths of those leaking days a launch into slow-motion suspension, a tense floating that seems to defy gravity as I pause mid-flight, high, my head tight with fluid.
Imagine you are on an airplane, and imagine that you have a cold, or a sinus infection, and imagine that during the plane’s descent the pilot is required to circle for a bit before landing, and imagine that that altitude where the plane kills time is precisely the level of altitude that makes your sinus pressure unbearable. Your face hurts, your head hurts, it feels as though the front of your face is encased in pain. Perhaps you feel nauseated from it, perhaps the other passengers notice you crying. You can’t pop your ears to release the pressure, in fact there is no release, until finally, thankfully, the pilot announces the plane has been cleared to make its final descent, and moves down, down, closer to the ground, away from the altitude level that held your head in a vise.
That’s what rebound high pressure is like, here on the ground, at sea level, in my house, in my room, in my bed. Caffeine makes it worse, salt makes it worse, sitting makes it worse, lying flat makes it worse. Afternoons make it worse, because that’s when cerebrospinal fluid production bottoms out, and the middle of the night makes it worse, because that’s when cerebrospinal fluid production surges again. My choroid plexus has been producing cerebrospinal fluid, circulating it and swelling it and creating a high tide in the dead of night and a low tide in the late afternoon, since before I even had a brain. And yet until now I’ve never noticed, never been sensitive to the high tides of the ocean in my head.
When it’s bad, when I forget and have caffeine or a salty food, or lie down in my bed without the wedge pillow to prop me up, or even when I’ve done nothing to provoke it except be alive with a brain now sensitive to the ebb and flow of fluid, I feel not only the tightness in my head, the headache in the front of my head, behind my eyes, on the top of my forehead, I feel a heaviness and burning along my spine, just between my shoulder blades, where it’s theorized the leak likely was. I lean on ice packs, long and cold against my spine. Will this surge pry open the wound? Will the rising tide of fluid seep into the edges of the patched-up tear, like the rain that finds its way into my house sometimes, trickling through the brick, inexorably flowing toward a weak, leaky spot?
Little is understood about rebound intracranial hypertension, even by neurologists and other doctors who work with headache patients. It’s generally noted as a new headache that develops after blood patching—which is confusing, since most people who receive blood patches are being treated for headaches in the first place. The rebound headache often has a different quality than the leak headache, though—frontal instead of occipital, worse instead of better when lying down, sometimes accompanied by nausea and vomiting and blurry vision—and while it generally develops within hours or days after patching, sometimes it can be weeks or even months until the headache reveals itself. The severity of these rebound
