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Riga M, Koursoumi E, Kostopanagiotou GG, Matsota P. Unusual Presentation of Pneumocephalus With Late Onset During Labour Epidural Analgesia. Cureus 2023; 15:e39888. [PMID: 37404401 PMCID: PMC10315179 DOI: 10.7759/cureus.39888] [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] [Accepted: 05/31/2023] [Indexed: 07/06/2023] Open
Abstract
A 36-year-old woman with no significant medical history was in active labour and requested labour analgesia. While the epidural technique was performed at the L4-L5 interspace, using the loss of resistance to air technique (LORA), inadvertent dural puncture occurred. Since the patient reported no headache or discomfort, the same procedure was repeated at the L3-L4 interspace successfully. Loss of resistance was reported at 3 cm and the epidural catheter was advanced uneventfully at 8 cm. Aspiration was negative for blood or cerebrospinal fluid (CSF) and a test dose of 2 ml lidocaine 2% was administered epidurally. Within five minutes the patient exhibited a mild hypotensive episode successfully treated with 2.5 mg ephedrine IV, a sensory blockade up to T6 level, and a motor blockade up to T10 level. Both the woman's and the baby's vital signs remained stable, no further drugs were administered epidurally and labour progressed painlessly and uncomplicated for 90 minutes with subsequent vaginal delivery of a healthy newborn. During the episiotomy incision repair, the patient complained of light dizziness and nausea. Her vital signs and the arterial blood gases (ABGs) ordered were within normal range, but the neurological examination revealed an isolated Babinski on the right foot. The head CT scan requested indicated a considerable quantity of air within the subarachnoid region. The patient was treated conservatively; symptoms showed steady improvement with total resolution on the sixth day, and the woman was discharged. This case reemphasizes the possibility of pneumocephalus, which may, in reality, occur more frequently than is commonly recognized without a CT confirmation.
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Affiliation(s)
- Maria Riga
- 2nd Department of Anesthesiology, Attikon University Hospital, Athens, GRC
- School of Medicine, National and Kapodistrian University of Athens, Athens, GRC
| | - Evgenia Koursoumi
- 2nd Department of Anesthesiology, Attikon University Hospital, Athens, GRC
| | | | - Paraskevi Matsota
- 2nd Department of Anesthesiology, Attikon University Hospital, Athens, GRC
- School of Medicine, National and Kapodistrian University of Athens, Athens, GRC
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Pneumocephalus Following an Accidental Dural Puncture, Treated Using Hyperbaric Oxygen Therapy. A Case Report. J Crit Care Med (Targu Mures) 2021; 7:237-240. [PMID: 34722927 PMCID: PMC8519381 DOI: 10.2478/jccm-2021-0017] [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: 12/11/2020] [Accepted: 05/25/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction Neuraxial techniques, including epidural anaesthesia, are often used for perioperative pain control and are generally safe. However, both transient, mild and even severe, life-threatening neurologic complications can occur. Case presentation A seventy-eight-year-old man was admitted to the hospital for a radical nephrectomy plus transurethral resection due to kidney and bladder cancer. During the epidural exploration, an accidental dural puncture was noted. This was followed by the patient complaining of an intense headache. The epidural catheter was placed in a different location, and surgery was performed uneventfully. The patient presented with confusion, agitation, vertical nystagmus, vision loss, and paraparesis about two hours later. The epidural levobupivacaine and morphine infusion were stopped, followed by motor block resolution. A computerized head-tomography scan showed extra-axial multiple air spots involving the frontal and temporal lobes. Emergent hyperbaric oxygen therapy was commenced. After a single session, there was complete resolution of all symptoms and a marked reduction in the number and volume of the extra-axial air visible on the CT scan. Conclusions Although rare, pneumocephalus is a well-recognized complication of a dural puncture. Its rapid recognition in a patient with new-onset neurological symptoms and early treatment with hyperbaric oxygen therapy allows rapid clinical and imaging resolution and an improved prognosis.
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Galanou P, Tsoleridis T, Tsoleridis S. Epidural Blood Patch Performed Immediately After Dural Puncture and Epidural Drug Administration. Cureus 2021; 13:e16634. [PMID: 34462675 PMCID: PMC8386135 DOI: 10.7759/cureus.16634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2021] [Indexed: 11/18/2022] Open
Abstract
The epidural blood patch (EBP) is a solution for persistent headaches following an accidental dural puncture. We report three cases where EBP was performed immediately after dural puncture combined with drug administration for lumbago. To the best of our knowledge, no similar cases have been reported in the literature. The patients provided their informed consent, and all standard protocols were followed. At the moment of the dural puncture, all the patients manifested severe headaches, nausea, vomiting, and profuse sweating. A second epidural puncture was performed at a higher intervertebral space, followed by drug administration and 20 mL of autologous blood. All the patients improved gradually, while their headaches vanished after 30-35 minutes. The patients were kept in for monitoring and released the following day with specific instructions and daily phone contact for a week without any complications. Their lumbago symptoms regressed. The possibility of pneumocephalus was excluded because of the patients’ symptomatology. The risk of high or total spinal anesthesia due to local anesthetic leakage subarachnoidally was countered with close monitoring of the patients. EBP complications include failure, postdural-puncture headache worsening by an accidental additional dural tear(s), back pain, and infection. All patients were instructed to report any symptoms immediately. EBP executed immediately after dural puncture seems to relieve headache fast and does not appear to impede epidural analgesia.
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Affiliation(s)
- Polymnia Galanou
- Anesthesia and Pain Treatment Unit, General Hospital of Rhodes, Greece, Rhodes, GRC
| | - Theofilos Tsoleridis
- Anesthesia and Pain Treatment Unit, General Hospital of Rhodes, Greece, Rhodes, GRC
| | - Savvas Tsoleridis
- Anesthesia and Pain Treatment Unit, General Hospital of Rhodes, Greece, Rhodes, GRC
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Pneumocephalus in thoracoabdominal aortic aneurysm repair after lumbar drain removal and blood patch. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2021; 7:478-480. [PMID: 34278087 PMCID: PMC8267490 DOI: 10.1016/j.jvscit.2021.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 04/20/2021] [Indexed: 11/20/2022]
Abstract
Lumbar spinal drain use during thoracic and thoracoabdominal aortic aneurysm repair has reduced the incidence of ischemic spinal cord injury with relatively low risk. We report a case of pneumocephalus in a 55-year-old woman who had undergone open repair of a 6.7-cm type IV thoracoabdominal aortic aneurysm. After lumbar spinal drain removal, she developed a postdural headache, which was subsequently treated with blood patch placement. After discharge, she had presented with transient headaches, perioral numbness, and left-hand weakness. Computed tomography revealed intraventricular gas within the lateral ventricles. Pneumocephalus is an exceedingly rare and potentially dangerous complication of lumbar spinal drains and blood patch placement.
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Shaginyan GG, Gedygushev IA, Gorshkov AN, Nagornov MN, Kochoyan AL. [Pneumocephaly: an expert assessment in determining the severity of harm to health]. Sud Med Ekspert 2020; 63:53-56. [PMID: 32686392 DOI: 10.17116/sudmed20206304153] [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] [Indexed: 06/11/2023]
Abstract
The purpose of the work is the analysis of etiology and pathogenesis of pneumocephaly in various injuries, diseases and pathological conditions for the reasonable determination of the severity of health damage during forensic medical examinations. The analysis of literature data on the causes and mechanisms of pneumocephaly is given. Attention is paid to the assessment of pneumocephaly in determining the health damage in patients with traumatic brain injury or if it is suspected. It is proposed to consider pneumocephaly as an indirect sign of a skull fracture. In case of pneumocephaly, a radiologically confirmed fracture is necessary to justify serious health damage. The medical documents of the victim should be examined to exclude concomitant diseases and pathological conditions that can lead to pneumocephaly.
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Affiliation(s)
- G G Shaginyan
- Russian Medical Academy of Continuing Professional Education of the Ministry of Health of Russia, Moscow, Russia
| | - I A Gedygushev
- Russian Center for Forensic Medicine of the Ministry of Health of Russia, Moscow, Russia
| | - A N Gorshkov
- N.A. Semashko Central Clinical Hospital No. 2 of Russian Railways LLC, Moscow, Russia
| | - M N Nagornov
- I.M. Sechenov First Moscow State Medical University (Sechenov University) of the Ministry of Health of Russia, Moscow, Russia
| | - A L Kochoyan
- Russian Center for Forensic Medicine of the Ministry of Health of Russia, Moscow, Russia
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Anesthetic and Obstetric Neurologic Complications of Pregnancy. CURRENT ANESTHESIOLOGY REPORTS 2017. [DOI: 10.1007/s40140-017-0202-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Kwak KH. Postdural puncture headache. Korean J Anesthesiol 2017; 70:136-143. [PMID: 28367283 PMCID: PMC5370299 DOI: 10.4097/kjae.2017.70.2.136] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 11/24/2016] [Accepted: 12/19/2016] [Indexed: 12/18/2022] Open
Abstract
Postdural puncture headache (PDPH) is a common complication after inadvertent dural puncture. Risks factors include female sex, young age, pregnancy, vaginal delivery, low body mass index, and being a non-smoker. Needle size, design, and the technique used also affect the risk. Because PDPH can be incapacitating, prompt diagnosis and treatment are mandatory. A diagnostic hallmark of PDPH is a postural headache that worsens with sitting or standing, and improves with lying down. Conservative therapies such as bed rest, hydration, and caffeine are commonly used as prophylaxis and treatment for this condition; however, no substantial evidence supports routine bed rest and aggressive hydration. An epidural blood patch is the most effective treatment option for patients with unsuccessful conservative management. Various other prophylactic and treatment interventions have been suggested. However, due to a lack of conclusive evidence supporting their use, the potential benefits of such interventions should be weighed carefully against the risks. This article reviews the current literature on the diagnosis, risk factors, pathophysiology, prevention, and treatment of PDPH.
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Affiliation(s)
- Kyung-Hwa Kwak
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
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Orbach-Zinger S, Ashwal E, Hazan L, Bracco D, Ioscovich A, Hiersch L, Khinchuck A, Aviram A, Eidelman LA. Risk Factors for Unintended Dural Puncture in Obstetric Patients: A Retrospective Cohort Study. Anesth Analg 2016; 123:972-6. [PMID: 27537928 DOI: 10.1213/ane.0000000000001510] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Unintended dural puncture (UDP) is one of the main risks of epidural analgesia, with a reported incidence of approximately 1.5% among the obstetric population. UDP is associated with maternal adverse outcomes, with the most frequent adverse outcome being postdural puncture headache (PDPH). Our retrospective cohort study objective was to identify demographic and obstetric risk factors that increase the risk of unintentional dural puncture as well as describing the obstetric outcome once a dural puncture has occurred. METHODS We retrospectively reviewed all cases of UDPs during attempted vaginal delivery between the years 2004 and 2013 in a single Israeli hospital. Each UDP case was matched with the 2 parturients who received epidural analgesia before and 2 parturients after performed by the same anesthesiologist (control group). Demographic, anesthetic, and obstetric variables were compared between the UDP and control groups. RESULTS Out of 46,668 epidural procedures, 177 cases of UDPs were documented (0.4%). One hundred seven women (60.5%) developed PDPH, and 38 (35.5%) required an epidural blood patch. In multivariate logistic regression, the degree of cervical dilation in centimeters at the time of epidural insertion was associated with an increased rate of UDP (P < .001). Multiparity was associated with PDPH after UDP (P = .004). Women with UDP had longer length of hospital stay than those without UDP (P < .001). CONCLUSIONS UDP, an uncommon complication, is associated with obstetric factors. Nevertheless, it does not seem to be associated with adverse obstetric outcomes except for prolonged duration of hospital stay.
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Affiliation(s)
- Sharon Orbach-Zinger
- From the Departments of *Anesthesia and †Obstetrics and Gynecology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel; and ‡Department of Anesthesia, Shaare Zedek Medical Center, Jerusalem, Israel
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Jagia M, Kapoor M, Panjiar P. Pneumocephalus after epidural analgesia: Should loss of resistance with air be blown out? J Anaesthesiol Clin Pharmacol 2016; 32:272-3. [PMID: 27275068 PMCID: PMC4874093 DOI: 10.4103/0970-9185.173399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
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Limaye K, Mahuwala Z, Lee RW. Not everything that worsens on standing is intracranial hypotension! Acta Neurol Belg 2015; 115:481-3. [PMID: 25287820 DOI: 10.1007/s13760-014-0371-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 09/24/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Kaustubh Limaye
- University of Arkansas for Medical Sciences, 4301 W.Markham, #500, Little Rock, AR, 72202, USA,
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Hsieh XX, Hsieh SW, Lu CH, Wu ZF, Ju DT, Huh B, Wang JC, Kuo CY. A rare case of pneumocephalus and pneumorrhachis after epidural anesthesia. ACTA ACUST UNITED AC 2015; 53:47-9. [DOI: 10.1016/j.aat.2015.01.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 01/16/2015] [Indexed: 10/24/2022]
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Verdun AV, Cohen SP, Williams BS, Hurley RW. Pneumocephalus after lumbar epidural steroid injection: a case report and review of the literature. ACTA ACUST UNITED AC 2015; 3:9-13. [PMID: 25612267 DOI: 10.1213/xaa.0000000000000055] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Pneumocephalus may occur after inadvertent injection of air into the subarachnoid space while performing epidural anesthesia using a loss-of-resistance technique with air in the syringe. We report a case of pneumocephalus after an interlaminar epidural steroid injection using the loss-of-resistance to air technique. In this report, we examine the etiology, the expected course of symptoms, and resolution, as well as treatment, of pneumocephalus following a systematic literature review.
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Affiliation(s)
- Aubrey V Verdun
- From the *Department of Pain Medicine, Walter Reed National Military Medical Center, Bethesda; †Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, Baltimore; ‡Department of Anesthesiology, Kaiser Permanente, Gaithersburg, Maryland; and §Department of Anesthesiology, University of Florida, Gainesville, Florida
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Abstract
Lumbar epidural anesthesia is commonly used for labor analgesia. The 'loss-of- resistance' to air technique (LORA) is generally employed for recognition of the epidural space. One of the rare complications of this technique is pneumocephalus (PC). Here we describe the case of a parturient who developed a frontal headache when locating the epidural space using LORA. On the second day after epidural injection, the patient exhibited occipital headaches with gradual worsening. Computed tomography scans of the brain indicated PC. Following symptomatic treatment, our patient was discharged on the 13th day. We concluded that the amount of air used to identify the epidural space in LORA should be minimized, LORA should not be used after dural puncture and the use of saline avoids PC complications.
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Affiliation(s)
- Beatriz Nistal-Nuño
- Department of Anaesthesiology and Perioperative Medicine, Complexo Hospitalario Universitario A Coruña (CHUAC), A Coruña, 15006, Spain
| | - Manuel Ángel Gómez-Ríos
- Department of Anaesthesiology and Perioperative Medicine, Complexo Hospitalario Universitario A Coruña (CHUAC), A Coruña, 15006, Spain
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Ferrante E, Rubino F, Porrinis L. Pneumocephalus: A Rare Complication of Epidural Catheter Placement During Epidural Blood Patch. Headache 2013; 54:539-40. [DOI: 10.1111/head.12235] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Enrico Ferrante
- Department of Neurosciences; Headache Centre; Ospedale Niguarda Cà Granda; Milano Italy
| | - Fabio Rubino
- Department of Anaesthesiology; Ospedale Niguarda Cà Granda; Milano Italy
| | - Lara Porrinis
- Department of Anaesthesiology; Ospedale Niguarda Cà Granda; Milano Italy
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