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Wurm LM, Neuhaus L, Aspargur G, Angemair S, Laue D. Pseudohypoxic brain swelling following cerebrospinal fluid leakage: a case report on rapid identification and multidisciplinary management. J Surg Case Rep 2024; 2024:rjae520. [PMID: 39161424 PMCID: PMC11333088 DOI: 10.1093/jscr/rjae520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 08/05/2024] [Indexed: 08/21/2024] Open
Abstract
This report delineates the intricate diagnostic journey and therapeutic conundrum presented by a 61-year-old male who exhibited atypical neurological deterioration shortly after lumbar fusion surgery, manifesting clinical and radiological features suggestive of pseudohypoxic encephalopathy, an entity characterized by symptoms mimicking cerebral hypoxia in the absence of a discernible hypoxic insult. Following an initially unremarkable recovery from an elaborate spinal surgery, the patient's postoperative condition was confounded by a perplexing decline in consciousness, unresponsive to conventional therapeutic interventions and devoid of clear etiological indicators on standard neuroimaging. The subsequent diagnostic odyssey unraveled a cerebrospinal fluid leak as the putative reason, positing a nuanced clinical paradigm wherein the cerebrospinal fluid leak engendered a state mimicking pseudohypoxic brain swelling. This report underscores the clinical challenges and emphasizes the need for an astute diagnostic approach in postoperative patients with unexplained neurological symptoms advocating for a comprehensive evaluation to identify underlying cerebrospinal fluid leaks and mitigate potential morbidity.
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Affiliation(s)
- Lennard M Wurm
- Department of Traumatology and Reconstructive Surgery, Charité – Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany
| | - Lukas Neuhaus
- Department of Traumatology and Reconstructive Surgery, Charité – Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany
| | - Golschan Aspargur
- Department of Anesthesiology and Intensive Care Medicine, Charité – Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany
| | - Stefan Angemair
- Department of Anesthesiology and Intensive Care Medicine, Charité – Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany
| | - Dominik Laue
- Department of Traumatology and Reconstructive Surgery, Charité – Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany
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Miyaoka Y, Uehara M, Oba H, Kamanaka T, Ikegami S, Kuraishi S, Futatsugi T, Tsutsumimoto T, Kaneko T, Fujinaga Y, Nakao S, Kodaira M, Sekijima Y, Maruyama T, Hamano Y, Ichikawa M, Imamura H, Kuroiwa M, Horiuchi T, Tanaka S, Kawamata M, Takahashi J. Pseudohypoxic brain swelling and secondary hydrocephalus with pseudomeningocele after lumbar surgery: a case report. Br J Neurosurg 2024; 38:706-711. [PMID: 34553665 DOI: 10.1080/02688697.2021.1958157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/24/2021] [Accepted: 07/05/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Postoperative intracranial complications are rare in spine surgery not including cranial procedures. We describe an uncommon case of pseudohypoxic brain swelling (PHBS) and secondary hydrocephalus after transforaminal lumbar interbody fusion (TLIF) presenting as impaired consciousness and repeated seizures. CASE PRESENTATION A 65-year-old man underwent L4-5 TLIF for lumbar spondylolisthesis and began experiencing generalized seizures immediately postoperatively. Computed tomography (CT) revealed diffuse cerebral edema-like hypoxic ischemic encephalopathy. He was transported to our hospital, at which time epidural drainage was halted and anti-edema therapy was commenced. His impaired consciousness improved. However, he suffered secondary hydrocephalus due to continuous bleeding from a dural defect and spinal epidural fluid collection 3 months later. Following the completion of dural repair and insertion of a ventriculoperitoneal shunt, his neurologic symptoms and neuroimaging findings improved significantly. CONCLUSIONS PHBS can be considered in patients with unexpected neurological deterioration following lumbar spine surgery even with the absence of documented durotomy. This might be due to postoperative intracranial hypotension-associated venous congestion, and to be distinguished from the more common postoperative cerebral ischemic events-caused by arterial or venous occlusions-or anesthetics complications.
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Affiliation(s)
- Yoshinari Miyaoka
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Masashi Uehara
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Hiroki Oba
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Takayuki Kamanaka
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Shota Ikegami
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Shugo Kuraishi
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Nagano, Japan
| | | | | | - Tomoki Kaneko
- Department of Radiology, Shinshu University School of Medicine, Nagano, Japan
| | - Yasunari Fujinaga
- Department of Radiology, Shinshu University School of Medicine, Nagano, Japan
| | - Satoshi Nakao
- Department of Medicine, Neurology and Rheumatology, Shinshu University School of Medicine, Nagano, Japan
| | - Minori Kodaira
- Department of Medicine, Neurology and Rheumatology, Shinshu University School of Medicine, Nagano, Japan
| | - Yoshiki Sekijima
- Department of Medicine, Neurology and Rheumatology, Shinshu University School of Medicine, Nagano, Japan
| | - Takahiro Maruyama
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Yujiro Hamano
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Michitaro Ichikawa
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Hiroshi Imamura
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Masafumi Kuroiwa
- Department of Neurosurgery, Shinshu University School of Medicine, Nagano, Japan
| | - Tetsuyoshi Horiuchi
- Department of Neurosurgery, Shinshu University School of Medicine, Nagano, Japan
| | - Satoshi Tanaka
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, Nagano, Japan
| | - Mikito Kawamata
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, Nagano, Japan
| | - Jun Takahashi
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Nagano, Japan
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Maule G, Creamer C, Elsadek R, Abuassi M, Zajecka A, Obeidat O, Okonoboh P. Pseudohypoxic brain swelling following elective lumbar laminectomy: A rare case report and review of literature. Radiol Case Rep 2024; 19:1351-1355. [PMID: 38292785 PMCID: PMC10825922 DOI: 10.1016/j.radcr.2023.11.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 11/28/2023] [Accepted: 11/30/2023] [Indexed: 02/01/2024] Open
Abstract
Pseudohypoxic brain swelling, also known as postoperative intracranial hypotension-associated venous congestion, is an intriguing complication following routine neurosurgical interventions. We report a case of a 73-year-old female patient who exhibited this rare complication following an elective L4-L5 laminectomy, without evidence of intraoperative cerebrospinal fluid leakage. Initially presenting with clinical features suggestive of anoxic/hypoxic brain injury, the case deviated from typical pseudohypoxic ischemic venous hypertension (PIHV) patterns, leading to a challenging diagnostic process. The patient's remarkable recovery, contrary to the initial grim prognosis, emphasizes the critical need for considering PIHV in differential diagnoses when postoperative symptoms mimic anoxic/hypoxic brain injuries. This case contributes to the evolving understanding of PIHV, particularly in scenarios lacking conventional risk factors like cerebral spinal fluid (CSF) leakage, and underscores the importance of comprehensive postoperative surveillance and management. It also highlights the imperative for continued research into the pathophysiology and treatment strategies of PIHV to enhance patient outcomes in complex surgical contexts.
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Affiliation(s)
- Geran Maule
- University of Central Florida College of Medicine, Graduate Medical Education / HCA Florida North Florida Hospital, Internal Medicine Residency Program, 6500 W Newberry Rd, Gainesville, FL 32605 USA
| | - Carson Creamer
- University of Central Florida College of Medicine, Graduate Medical Education / HCA Florida North Florida Hospital, Internal Medicine Residency Program, 6500 W Newberry Rd, Gainesville, FL 32605 USA
| | - Rabab Elsadek
- University of Central Florida College of Medicine, Graduate Medical Education / HCA Florida North Florida Hospital, Internal Medicine Residency Program, 6500 W Newberry Rd, Gainesville, FL 32605 USA
| | - Mohammad Abuassi
- University of Central Florida College of Medicine, Graduate Medical Education / HCA Florida North Florida Hospital, Internal Medicine Residency Program, 6500 W Newberry Rd, Gainesville, FL 32605 USA
| | - Alexa Zajecka
- University of Central Florida College of Medicine, Graduate Medical Education / HCA Florida North Florida Hospital, Internal Medicine Residency Program, 6500 W Newberry Rd, Gainesville, FL 32605 USA
| | - Omar Obeidat
- University of Central Florida College of Medicine, Graduate Medical Education / HCA Florida North Florida Hospital, Internal Medicine Residency Program, 6500 W Newberry Rd, Gainesville, FL 32605 USA
| | - Peters Okonoboh
- University of Central Florida College of Medicine, Graduate Medical Education / HCA Florida North Florida Hospital, Internal Medicine Residency Program, 6500 W Newberry Rd, Gainesville, FL 32605 USA
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Kurzbuch AR, Bourlond B, García Martínez JJ, Bonjour T, Novaes NP, Tuleasca C, Millán DS. Postoperative Intracranial Hypotension-Associated Venous Congestion after Spinal Surgery Managed with Multiple Blood Patches: Case Report. J Neurol Surg A Cent Eur Neurosurg 2024; 85:112-115. [PMID: 36302518 DOI: 10.1055/s-0042-1757173] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Postoperative intracranial hypotension-associated venous congestion (PIHV) is a rare event. The authors report the case of a patient presenting with PIHV after spinal surgery following the sudden loss of cerebrospinal fluid (CSF) induced by suction drainage. METHODS A 69-year-old patient underwent uneventful revision surgery for wound dehiscence after lumbar surgery with placement of a subfascial suction drain. RESULTS Postoperatively, the patient presented with fluctuating consciousness and a generalized tonic-clonic seizure. Computed tomography (CT) and serial magnetic resonance imaging (MRI) were performed showing convexity subarachnoid hemorrhages (SAHs), diffuse swelling of the brain and thalami and striatum bilaterally without diffusion restriction, and signs of intracranial hypertension resulting in pseudohypoxic brain swelling in PIHV. A dural leak at L3-L4 was treated with several CT-guided patches combining autologous blood and fibrin glue injections. The patient recovered without neurologic deficit and follow-up MRI revealed progressive complete reversal of brain swelling, and re-expansion of CSF spaces. CONCLUSION PIHV is a rare but potentially fatal entity. Awareness of PIHV after cranial or spinal surgery leads to early treatment of CSF hypovolemia and possibly better clinical outcome. Following acute CSF volume loss, an acute elevation of cerebral blood volume overcoming autoregulatory mechanisms seems a likely explanation for diffuse cerebral vasogenic edema and SAH in PIHV.
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Affiliation(s)
- Arthur Robert Kurzbuch
- Department of Neurosurgery, Hôpital du Valais, Centre Hospitalier du Valais Romand (CHVR), Hôpital de Sion, Sion, Switzerland
| | - Baudouin Bourlond
- Department of Intensive Care Medicine, Hôpital du Valais, Centre Hospitalier du Valais Romand (CHVR), Hôpital de Sion, Sion, Switzerland
| | - Juan José García Martínez
- Department of Intensive Care Medicine, Hôpital du Valais, Centre Hospitalier du Valais Romand (CHVR), Hôpital de Sion, Sion, Switzerland
| | - Thierry Bonjour
- Department of Intensive Care Medicine, Hôpital du Valais, Centre Hospitalier du Valais Romand (CHVR), Hôpital de Sion, Sion, Switzerland
| | - Natalia P Novaes
- Department of Neurology, Hôpital du Valais, Centre Hospitalier du Valais Romand (CHVR), Hôpital de Sion, Sion, Switzerland
| | - Constantin Tuleasca
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne (Unil), Lausanne, Switzerland
- Signal Processing Laboratory (LTS 5), Ecole Polytechnique Fédérale de Lausanne, (EPFL), Lausanne, Switzerland
| | - Diego San Millán
- Unit of Neuroradiology, Service of Diagnostic and Intervention Radiology, Hôpital du Valais, Centre Hospitalier du Valais Romand (CHVR), Hôpital de Sion, Sion, Switzerland
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Frachet S, Girault S, François B, Magy L. Transient hemi-parkinsonism due to deep brain venous edema induced by severe intracranial hypotension, a case report. Rev Neurol (Paris) 2023; 179:1041-1044. [PMID: 37813769 DOI: 10.1016/j.neurol.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/13/2023] [Accepted: 07/18/2023] [Indexed: 10/11/2023]
Affiliation(s)
- S Frachet
- Department of Neurology, University Hospital of Limoges, 87000 Limoges, France
| | - S Girault
- Department of Clinical Haematology and Cell Therapy, University Hospital of Limoges, 87000 Limoges, France
| | - B François
- ICU Department, Inserm CIC-1435, UMR-1092, CRICS-TRIGGERSEP Network, University Hospital of Limoges, 87000 Limoges, France
| | - L Magy
- Department of Neurology, University Hospital of Limoges, 87000 Limoges, France.
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NAKAMURA H, SATO K, HIRAYAMA K, KITANOSONO H, HAYASHI Y, TOKUNAGA Y. Pseudohypoxic Brain Swelling after Unilateral Burr Hole Drainage: A Novel Case Report. NMC Case Rep J 2022; 9:135-138. [PMID: 35756191 PMCID: PMC9217157 DOI: 10.2176/jns-nmc.2021-0410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/31/2022] [Indexed: 11/20/2022] Open
Abstract
An 85-year-old man underwent emergency right trepanation and drainage for a symptomatic chronic subdural hematoma. Pseudohypoxic brain swelling (PHBS) was suspected because magnetic resonance imaging revealed diffuse brain swelling. Although cerebrospinal fluid (CSF) leakage was not obvious during or after surgery, most of the reported PHBS cases have leaked CSF during craniotomy or spine surgery. PHBS has not been previously reported in patients without obvious CSF leakage or after unilateral burr hole drainage. Herein, we report an extremely rare case with a literature review investigating its pathogenesis and clinical features.
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Affiliation(s)
- Hikaru NAKAMURA
- Department of Neurosurgery, Nagasaki Prefecture Shimabara Hospital
| | - Kei SATO
- Department of Neurosurgery, Nagasaki Prefecture Shimabara Hospital
| | - Kosuke HIRAYAMA
- Department of Neurosurgery, Nagasaki Prefecture Shimabara Hospital
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