Cranial nerve palsy and intracranial subdural hematoma following implantation of intrathecal drug delivery device

BACKGROUND AND OBJECTIVES: Complications related to cerebrospinal fluid (CSF) leak and low CSF pressure can occur following placement of an intrathecal drug delivery device. METHODS: A 58-year-old man with chronic, intractable lower back pain underwent implantation of an intrathecal drug delivery device. On the fourth postoperative day, he developed a postural headache and diplopia with findings compatible with left sixth cranial nerve palsy. The headache subsequently became constant and nonpostural. Cranial magnetic resonance imaging was obtained that showed the presence of a posterior subdural intracranial hematoma. Conservative treatment for postdural puncture headache did not improve the symptomatology. Therefore, an epidural blood patch was performed that produced rapid improvement and eventual resolution of symptoms. CONCLUSIONS: Intrathecal catheter implantation can result in CSF loss that might not resolve promptly with conservative therapy. In this case, epidural blood patch proved to be a safe and effective form of treatment.     

Intracranial hypotension caused by leakage of cerebrospinal fluid from the thecal sac after lumboperitoneal shunt placement. Case report

The authors describe a newly recognized complication of lumboperitoneal (LP) shunt placement, namely, intracranial hypotension from leakage of cerebrospinal fluid (CSF) through a defect in the lumbar dura created by the shunt catheter. They report on a 47-year-old obese woman with idiopathic intracranial hypertension who underwent routine placement of an LP shunt. Following surgery, her headache became worse. Two radionuclide shunt studies showed no anterograde tracer flow, suggesting either obstruction or a leak. After shunt reservoir manometry indicated low pressure, spinal magnetic resonance (MR) imaging was performed. The MR images revealed a CSF leak from the lumbar thecal sac. A computed tomography (CT) myelogram, performed by injection into the shunt reservoir, confirmed the presence of a leak by showing extravasation of contrast agent into the epidural space. The patient was treated by application of a CT-guided blood patch at the leak site. Catheter-associated CSF leak is an unusual cause of intracranial hypotension that can occur following LP shunt placement. This case report outlines the clinical features of this condition, documents the neuroradiological findings, and demonstrates successful treatment with a blood patch.     

Postpartum workup of postdural puncture headache leads to diagnosis and surgical treatment of thoracic pseudomeningocele: a case report

Purpose

Postdural puncture headache is a well-known complication of neuraxial anesthesia in childbirth. There are, however, many other causes of postpartum headache, some of which may present like postdural puncture headache and confuse the diagnosis. We report a case of postpartum headache due to pseudomeningocele.

Clinical features

A 31-yr-old primigravida presented at 35 weeks gestation for induction of labour. A pre-pregnancy history of migraines was suspicious for low cerebrospinal fluid headache, but this had been ruled out by normal brain magnetic resonance imaging (MRI), and the headaches had resolved with pregnancy. A labour epidural was easily placed at L3/4. On postpartum day one the patient complained of mild headache, and the severe pre-pregnancy headache returned within weeks. The pounding occipital/hemispheric headache was associated with nausea and vomiting; it worsened over the day, and improved when the patient was supine. A repeat brain MRI showed evidence of intracranial hypotension, and an epidural blood patch was performed at L3/L4 with no improvement. A second blood patch was performed ten days later, still with no improvement. A subsequent brain MRI showed unchanged intracranial hypotension, and a spine MRI revealed a pseudomeningocele at T7. A computed tomography myelogram confirmed a T7/8 pseudomeningocele. The patient underwent direct microsurgical exploration and repair four months later, which was followed by re-operation ten months later. The patient’s condition has since remained significantly improved.

Discussion

This case highlights the importance of maintaining a wide differential in the workup of postpartum headache after regional anesthesia, particularly in cases refractory to blood patch. This case also reveals a T7 pseudomeningocele causing spontaneous intracranial hypotension that otherwise may not have been detected and corrected.     

Case report: Epidural blood patch in the treatment of abducens palsy after a dural puncture

PURPOSE: To describe a case of iatrogenically induced abducens nerve palsy following a diagnostic lumbar puncture, and to review the evidence for blood patching in the management of sixth cranial nerve palsy after dural puncture. CLINICAL FEATURES: A 45-yr-old woman developed post-dural puncture headache with bilateral abducens palsy following a diagnostic lumbar puncture. Magnetic resonance imaging showed findings compatible with intracranial hypotension. An epidural blood patch was performed five days after the onset of diplopia and ten days following the dural puncture. After blood patching, the patient reported relief of the headache, but still complained of diplopia. The palsies recovered spontaneously 21 months after the dural puncture. CONCLUSION: Experience from this case as well as other case report evidence suggest that an epidural blood patch performed more than 24 hr after the onset of a sixth cranial nerve palsy consistently fails to relieve diplopia. An epidural blood patch executed within 24 hr from the onset of diplopia could possibly lead to partial improvement and/or earlier resolution of symptoms.     

Successful epidural blood patch in a patient with headache for 6 months after lumbar root decompression

Prolonged headache following dural puncture is an uncommon problem that may occur after a spinal tap, often as a complication of epidural anaesthesia. This problem has also been described after long-term epidural or spinal anaesthesia, myelography or spinal surgery. A case of prolonged postdural puncture headache following lumbar nerve root decompression is described in a healthy young man. No other cause could be found either clinically or with the aid of scanning by computerized tomography or magnetic resonance imaging techniques at the spinal level involved. The symptoms were successfully treated with an epidural blood patch performed seven months following the original surgical operation.     

A case of spontaneous intracranial hypotension effectively treated with cervical epidural blood patch

We report a case of cervical spontaneous intracranial hypotension (SIH). The patient is a 46-year-old woman with hard of hearing, dizziness and postural headache. Radionuclide cisternography (RNC) demonstrated a cerebrospinal fluid (CSF) leak at the low cervical region. Resolution of headache was obtained by conservative therapies of bed rest and intravenous (i.v.) drip infusion, but the dizziness remained. We performed epidural blood patch (EBP) with 8 ml of autologous blood at the C 6-7 interspace. Her dizziness disappeared after several days of EBP. SIH is an uncommon disease caused by CSF leakage. SIH is often self-limiting, responding to bed rest and/or i.v. drip infusion. However, if the symptoms of SIH do not show a complete recovery by conservative therapies, EBP or continuous epidural infusion of saline has reportedly been used for the management of these cases. Most of the reported cases of EBP are in the thoracic and lumbar spinal regions. We have performed cervical EBP without complications, and the 6 month-follow-up MRI and RNC demonstrated that the abnormal findings had disappeared.     

Cranial subdural hematoma with intracranial hypotension related to epidural anesthesia and Trendelenburg position: a case report

We report a case of cranial subdural hematoma with intracranial hypotension. A 34-year-old woman had laparoscopic ovarial cysterectomy under general anesthesia combined with epidural anesthesia. Two days later, she developed a severe headache and nausea. She underwent cranial magnetic resonance imaging (MRI) scanning, and was diagnosed with cranial subdural hematoma with intracranial hypotension. The patient had had no anticoagulant therapy before the surgery. She was managed conservatively with bed rest and additional intravenous infusion. Her symptoms gradually improved except a slight headache, and she was discharged on the 38th postoperative day. Intracranial hypotension is a syndrome characterized by orthostatic headaches and hypovolemia of cerebrospinal fluid (CSF). There were typical findings on MRI, which include linear enhancement of the pachymeninges, pituitary hyperemia and subdural hemorrhage. We thought that these were due to epidural anesthesia first, but there was no evidence of dural puncture. It was also considered that it is influenced by change in CSF pressure, and intracranial venous engorgement may be due to Trendelenburg position for several hours. Because cranial subdural hematoma is a life-threatening complication, it is necessary to reconsider application of epidural anesthesia for laparoscopic surgery with Trendelenburg position.     

Epidural blood patch in a patient with an arachnoid cyst

Arachnoid cysts are relatively common occurrences, with the majority being asymptomatic. The safety of an epidural blood patch in a patient with an arachnoid cyst has not been reported. Our patient had a known thoracic arachnoid cyst and required epidural blood patch for a postdural puncture headache. Magnetic resonance imaging obtained following the epidural blood patch demonstrated no alterations of the cyst or spinal cord compression.     

Spontaneous intracranial hypotension: a recent indication for epidural blood patch

Editor—We report the efficacy of a single lumbar bloodpatch, in spontaneous intracranial hypotension (SIH). SIH ischaracterized by intense headache leading to neurological referral.Diagnosis is mainly clinical, but magnetic resonance imaging(MRI) shows specific features. If the usual therapy fails, treatmentwith an epidural blood patch can be effective. Three     

Epidural dextran-40 and paramethasone injection for treatment of spontaneous intracranial hypotension

PURPOSE: This report describes treatment with epidural dextran-40 and paramethasone injection of postural headache resulting from spontaneous intracranial hypotension in a pregnant patient. CLINICAL FEATURES: A 39-yr-old pregnant woman consulted the pain clinic for the assessment of a debilitating postural headache which was non-responsive to conventional analgesic treatment. Clinical findings and cranial magnetic resonance imaging indicated the diagnosis of spontaneous intracranial hypotension syndrome. Treatment with an epidural blood patch was not undertaken for several reasons. A lumbar epidural injection with dextran-40 and paramethasone led to a significant improvement in the symptoms and allowed a progressive discontinuation of adjuvant treatment with oral steroids, with complete resolution of symptoms. CONCLUSION: We report a case of spontaneous intracranial hypotension in a pregnant patient successfully treated by epidural injection of dextran-40 and paramethasone, with adjuvant oral steroid therapy. Clinical trials are warranted to establish the efficacy of this treatment as an alternative to the epidural blood patch administration.     

Antenatal blood patch in a pregnant woman with spontaneous intracranial hypotension

Spontaneous intracranial hypotension is a condition that presents with postural headaches similar to those caused by accidental dural puncture. The diagnosis is based on clinical presentation, cerebrospinal fluid evaluation and magnetic resonance imaging scanning. We present a case of spontaneous intracranial hypotension with typical clinical and magnetic resonance imaging findings in a pregnant patient who was treated with an epidural blood patch. The blood patch, performed at 32 weeks of gestation, produced transient improvement in symptoms but failed to completely cure the headache, which worsened over the next few days. Symptoms resolved over the subsequent three weeks with conservative therapy.     

Spinal subdural haematoma as a complication of immediate epidural blood patch

Purpose

The authors report a case of a patient who developed spinal subdural haematoma after a series of epidural blood patches to alert anaesthetists to this rare complication.

Clinical Features

The patient was a 35-yr-old woman without coagulopathy and was initially treated elsewhere for chronic pain by repetitive epidural phenol injections. When the dura was inadvertently punctured during subsequent attempts to inject phenol, immediate epidural blood patch was performed to treat or prevent headache. The patient developed cauda equina syndrome after six epidural blood patches. The clinical diagnosis was confirmed by magnetic resonance imaging and the intradural haematoma was evacuated surgically. The patient made a complete recovery.

Conclusions

Epidural blood patch is not without complications. Transient backache and/or radiculopathy may occur in up to one-third of patients receiving a blood patch. If signs and symptoms continue or worsen, a spinal subarachnoid and/or subdural haematoma should be suspected and neurosurgical opinion sought. The technique used to identify the epidural space is important in preventing subdural injection of blood. The needle should be withdrawn after durai puncture and the epidural space identified at a different level. Blood patches may carry a higher risk of serious complications after multiple epidural phenol injections because of fibrosis and obliteration of the epidural space. Magnetic resonance scans reliably demonstrate the extent of the pathology. If diagnosed and treated before irreversible changes occur, spinal intradural haematoma can result in complete recovery.     

Intrathecal hematoma and arachnoiditis mimicking bacterial meningitis after an epidural blood patch

We present a case of arachnoiditis and an intrathecal hematoma after an epidural blood patch. A 24-year-old parturient underwent an epidural blood patch three days after an accidental dural puncture during epidural labor analgesia. Four days later, the patient developed severe lower back pain, bilateral leg pain, persistent headache and fever. Bacterial meningitis was initially suspected and antibiotics started. Lumbar magnetic resonance imaging was performed and showed an intrathecal hematoma, with no blood in the epidural space. This report briefly reviews the few cases in the literature of arachnoiditis caused by an intrathecal hematoma and discusses the mechanism which resulted in blood in the subarachnoid space.     

Intracranial hypotension syndrome treated with an epidural blood patch

A 41-year-old woman was admitted to the internal medicine department to assess incapacitating postural headache. Clinical findings suggested the need for computed tomography and nuclear magnetic resonance scanning of the head, which led to a diagnosis of spontaneous intracranial hypotension syndrome. Later, isotopic cysternography and nuclear magnetic resonance imaging of the spine were used unsuccessfully to try to locate the cerebrospinal fluid leak that caused the syndrome. When conservative treatment proved ineffective, the pain clinic was called in to perform an epidural blood patch procedure. The patch led to an improvement in symptoms and the syndrome resolved completely after a second lumbar blood patch was used.     

Epidural blood patch for the treatment of intracranial hypotension due to cerebrospinal fluid leakage after thoracic spine surgery

We report a case of a 44-year-old woman successfully treated by an epidural blood patch for intracranial hypotension due to cerebrospinal fluid (CSF) leakage into the thoracic cavity after thoracic spine surgery. The patient was admitted to our hospital with the complaint of postural headaches. She had received anterior thoracic instrumentation for thoracic disc herniation four months earlier. Lumbar puncture demonstrated low CSF pressure, and Gd-enhanced MR images displayed diffuse dural enhancement. Accordingly, she was diagnosed as having intracranial hypotension. 111In-DTPA cisternography revealed a CSF leakage into the left thoracic cavity, possibly caused by dural laceration during thoracic spine surgery. To avoid the risk of direct surgery, we performed epidural blood patch; 3 ml of autologous blood was injected into the epidural cavity. Postoperatively postural headaches immediately disappeared. MRI taken one year later revealed disappearance of diffuse dural enhancement, and 111In-DTPA cisternography revealed no CSF fluid leaks. Epidural blood patch seems to be a choice of treatment for CSF leak after spinal surgery.     

Chronic adhesive arachnoiditis after repeat epidural blood patch

Epidural blood patching is an effective treatment for postdural puncture headache but has potential risks. Arachnoiditis is a very rare disabling condition and few cases have been described following an epidural blood patch. We present a case of chronic adhesive arachnoiditis in a parturient treated with a repeat epidural blood patch. A healthy 29-year-old woman had an accidental dural puncture following epidural insertion during labour. Initial treatment of postdural puncture headache with an epidural blood patch was ineffective and was therefore repeated. She gradually developed severe neurological symptoms consistent with arachnoiditis confirmed with magnetic resonance imaging. Despite intensive multimodal treatment with analgesics and physiotherapy, her neurological condition remains unresolved two years later. This serious but rare complication should encourage caution when treating parturients with postdural puncture headache with a repeat epidural blood patch.     

Broadening the clinical spectrum: unusual presentation of spontaneous cerebrospinal fluid hypovolemia. Case report

The syndrome of spontaneous intracranial hypotension is characterized by orthostatic headaches in conjunction with reduced cerebrospinal fluid (CSF) pressure or CSF volume, and characteristic magnetic resonance (MR) imaging findings. A 50-year-old man presented with a 1-year history of paroxysmal ataxia of gait and short attacks of blurred vision when he stood up from a recumbent position and began to walk. Orthostatic headache was not a feature of his clinical presentation. Magnetic resonance images of the brain revealed diffuse enhancement of the dura mater and hygromas over both cerebral convexities. Magnetic resonance images of the spine demonstrated dilated cervical epidural veins and dilation of the perimedullary veins. Radionuclide cisternography identified a CSF leakage that was localized to the T12-L1 level on subsequent myelograms and on computerized tomography scans obtained after the myelograms. An epidural blood patch was administered and visualized with tungsten powder. The patient's clinical symptoms and sites of disease on imaging completely resolved. The unusual clinical presentation in this case--paroxysmal ataxia of gait, lack of orthostatic headaches, and dilated epidural and perimedullary venous plexus--supports a recently noted broadening of both the clinical and imaging characteristics of spontaneous intracranial hypovolemia.     

Thoracic epidural hemangiopericytoma. Case report

Hemangiopericytoma is an uncommon mesenchymal neoplasm that rarely affects the spinal canal. We report a case of thoracic epidural hemangiopericytoma in a 39-year-old man with symptoms of spinal cord compression studied by myelo-computed tomography (CT) and magnetic resonance imaging (MRI). Total resection was followed by complete recovery. Postoperative radiotherapy was performed. The clinical, radiological, and histological findings of epidural spinal hemangiopericytoma are reviewed in the light of relevant literature     

A New Mechanism of Cerebrospinal Fluid Leakage after Lumboperitoneal Shunt: A Theory of Shunt Side Hole—Case Report

Cerebrospinal fluid (CSF) overdrainage after lumboperitoneal (LP) shunt placement for the patients with idiopathic normal pressure hydrocephalus (iNPH) is mainly caused by insufficient management of pressure settings of the shunt valve and/or siphon effect of shunt systems induced by the patient''s postural changes. We here report a unique case of intracranial hypotension (IH) due to CSF leakage after LP shunt placement in which another mechanism leads to the CSF leakage. A 67-year-old man suffered from persistent headache worsening with postural change 2 months after LP shunt reconstruction for iNPH. Brain computed tomography scan showed bilateral chronic subdural hematomas (CSDH). Lumbar images including shuntography and magnetic resonance imaging showed the tip of the lumbar catheter was spontaneously pulled out close to the dura mater with expansion of the epidural space due to CSF leakage from a shunt side hole of the lumbar catheter to the epidural space. Shunt removal and subsequent irrigation of CSDH improved his headache. CSF leakage in our case differs from those in previous reports, because early and enormous CSF leakage into the epidural space can be explained only by a different mechanism through a side hole just located in the epidural space in our case. We must pay attention to the possibility of this rare cause of IH due to CSF leakage in patients suffering from postural headache after LP shunt placement.