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Uppal V, Russell R, Sondekoppam RV, Ansari J, Baber Z, Chen Y, DelPizzo K, Dirzu DS, Kalagara H, Kissoon NR, Kranz PG, Leffert L, Lim G, Lobo C, Lucas DN, Moka E, Rodriguez SE, Sehmbi H, Vallejo MC, Volk T, Narouze S. Evidence-based clinical practice guidelines on postdural puncture headache: a consensus report from a multisociety international working group. Reg Anesth Pain Med 2024; 49:471-501. [PMID: 37582578 DOI: 10.1136/rapm-2023-104817] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 07/25/2023] [Indexed: 08/17/2023]
Abstract
INTRODUCTION Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis or management of this condition is, however, currently lacking. This multisociety guidance aims to fill this void and provide practitioners with comprehensive information and patient-centric recommendations to prevent, diagnose and manage patients with PDPH. METHODS Based on input from committee members and stakeholders, the committee cochairs developed 10 review questions deemed important for the prevention, diagnosis and management of PDPH. A literature search for each question was performed in MEDLINE (Ovid) on 2 March 2022. The results from each search were imported into separate Covidence projects for deduplication and screening, followed by data extraction. Additional relevant clinical trials, systematic reviews and research studies published through March 2022 were also considered for the development of guidelines and shared with contributors. Each group submitted a structured narrative review along with recommendations graded according to the US Preventative Services Task Force grading of evidence. The interim draft was shared electronically, with each collaborator requested to vote anonymously on each recommendation using two rounds of a modified Delphi approach. RESULTS Based on contemporary evidence and consensus, the multidisciplinary panel generated 50 recommendations to provide guidance regarding risk factors, prevention, diagnosis and management of PDPH, along with their strength and certainty of evidence. After two rounds of voting, we achieved a high level of consensus for all statements and recommendations. Several recommendations had moderate-to-low certainty of evidence. CONCLUSIONS These clinical practice guidelines for PDPH provide a framework to improve identification, evaluation and delivery of evidence-based care by physicians performing neuraxial procedures to improve the quality of care and align with patients' interests. Uncertainty remains regarding best practice for the majority of management approaches for PDPH due to the paucity of evidence. Additionally, opportunities for future research are identified.
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Affiliation(s)
- Vishal Uppal
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Robin Russell
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rakesh V Sondekoppam
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Jessica Ansari
- Anesthesia Department, Stanford Health Care, Stanford, California, USA
| | - Zafeer Baber
- Department of Anesthesiology and Perioperative Medicine, Newton-Wellesley Hospital, Newton, Massachusetts, USA
| | - Yian Chen
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California, USA
| | - Kathryn DelPizzo
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Dan Sebastian Dirzu
- Anesthesia and Intensive Care, Emergency County Hospital Cluj-Napoca, Cluj-Napoca, Romania
| | - Hari Kalagara
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Narayan R Kissoon
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter G Kranz
- Depatement of Radiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Lisa Leffert
- Department of Anesthesiology, Yale New Haven Health System; Yale University School of Medicine, New Haven, Connecticut, USA
| | - Grace Lim
- Department of Anesthesiology & Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Obstetrics & Gynecology, Magee Womens Hospital of UPMC, Pittsburgh, Pennsylvania, USA
| | - Clara Lobo
- Anesthesiology Institute, Interventional Pain Medicine Department, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Dominique Nuala Lucas
- Department of Anaesthesia, London North West Healthcare NHS Trust, Harrow, London, UK
| | - Eleni Moka
- Department of Anaesthesiology, Creta Interclinic Hospital - Hellenic Healthcare Group (HHG), Heraklion, Crete, Greece
| | - Stephen E Rodriguez
- Department of Anesthesia, Walter Reed Army Medical Center, Bethesda, Maryland, USA
| | - Herman Sehmbi
- Department of Anesthesia, Western University, London, Ontario, Canada
| | - Manuel C Vallejo
- Departments of Medical Education, Anesthesiology, Obstetrics & Gynecology, West Virginia University, Morgantown, West Virginia, USA
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Samer Narouze
- Northeast Ohio Medical University, Rootstown, Ohio, USA
- Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, OH, USA
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Schievink WI, Maya MM, Taché RB, Walker CT. Pediatric post-dural puncture headache and paraplegia. Headache 2024; 64:865-868. [PMID: 38860510 DOI: 10.1111/head.14749] [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: 03/11/2024] [Revised: 05/01/2024] [Accepted: 05/06/2024] [Indexed: 06/12/2024]
Abstract
A cerebrospinal fluid (CSF) leak developed in a 14-year-old girl and a 12-year-old boy following a diagnostic lumbar puncture. Two days and sixteen years later, respectively, paraplegia developed due to a functional disorder. Imaging revealed an extensive extradural CSF collection in both patients and digital subtraction myelography was required to pinpoint the exact site of a ventral dural puncture hole where the lumbar spinal needle had gone "through and through" the dural sac. The CSF leak was complicated by cortical vein thrombosis in one patient. Both patients underwent uneventful surgical repair of the ventral dural puncture hole with prompt resolution of the paraplegia. Iatrogenic ventral CSF leaks may become exceptionally long standing and may be complicated by paraplegia on a functional basis both in the acute and chronic phases.
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Affiliation(s)
- Wouter I Schievink
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Marcel M Maya
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Rachelle B Taché
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Corey T Walker
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
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3
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Mierzwa AT, Aladamat N, Ali I, Kung L. Cerebral Venous Sinus Thrombosis Following Lumbar Puncture. Neurohospitalist 2024; 14:288-290. [PMID: 38895003 PMCID: PMC11181974 DOI: 10.1177/19418744241233796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024] Open
Abstract
Cerebral venous sinus thrombosis (CVST) is a rare and potentially fatal condition. It is believed to be one of the rare complications of lumbar puncture (LP), however other causes and risk factors should be considered and ruled out. Diagnosis can be challenging after an LP as it can mimic low pressure or post dural puncture. We present a 23-year-old patient diagnosed with CVST following a diagnostic lumbar puncture, in the absence of other risk factors. The patient presented with a persistent headache that was initially attributed to low CSF pressure, as well as a transient episode of right hemi-body paresthesia. Neuroimaging including contrasted MRI with venography confirmed the diagnosis. The patient had negative hypercoagulable evaluation and was placed on anticoagulation on discharge. Our report highlights the importance of considering CVST in refractory headaches after LP and the value of neuroimaging when indicated.
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Affiliation(s)
- Adam T. Mierzwa
- Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Nameer Aladamat
- Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Imran Ali
- Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Lisa Kung
- Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
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Wu JW, Wang SJ. Spontaneous Intracranial Hypotension: Clinical Presentation, Diagnosis, and Treatment Strategies. Neurol Clin 2024; 42:473-486. [PMID: 38575260 DOI: 10.1016/j.ncl.2024.02.002] [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: 04/06/2024]
Abstract
Spontaneous intracranial hypotension (SIH) typically presents as an acute orthostatic headache during an upright position, secondary to spinal cerebrospinal fluid leaks. New evidence indicates that a lumbar puncture may not be essential for diagnosing every patient with SIH. Spinal neuroimaging protocols used for diagnosing and localizing spinal cerebrospinal fluid leaks include brain/spinal MRI, computed tomography myelography, digital subtraction myelography, and radionuclide cisternography. Complications of SIH include subdural hematoma, cerebral venous thrombosis, and superficial siderosis. Treatment options encompass conservative management, epidural blood patches, and surgical interventions. The early application of epidural blood patches in all patients with SIH is suggested.
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Affiliation(s)
- Jr-Wei Wu
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Taipei, 11217, Taiwan; Center for Quality Management, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Taipei, 11217, Taiwan; College of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Shi-Pai Road, Taipei, 11217, Taiwan
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Taipei, 11217, Taiwan; College of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Shi-Pai Road, Taipei, 11217, Taiwan; Brain Research Center, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Shi-Pai Road, Taipei, 11217, Taiwan.
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5
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Lim RS, Chan EK, Das PP, Ibrahim T. Post-caesarean Section Headache: A Case Report of Post-dural Puncture Headache and Cerebral Venous Thrombosis Following Epidural Anaesthesia. Cureus 2024; 16:e60183. [PMID: 38868268 PMCID: PMC11167682 DOI: 10.7759/cureus.60183] [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: 05/13/2024] [Indexed: 06/14/2024] Open
Abstract
Post-dural puncture headache (PDPH) is a common complication of epidural and spinal anaesthesia in obstetric medicine. In rare cases, PDPH can be associated with complications such as cerebral venous thrombosis (CVT) as well. We discuss a recent case of a young female who developed PDPH and CVT concurrently after undergoing epidural anaesthesia for initially uncomplicated labour and delivered via an emergency caesarean section. She developed an orthostatic headache a few hours post administration of the epidural anaesthetic, which was initially treated as a suspected PDPH by giving simple analgesia and caffeine. Her symptoms did not improve and she underwent further neuroimaging, which revealed the development of a CVT. Despite the prompt administration of enoxaparin, the headache persisted and did not respond to increased doses of analgesia. After deliberation and inter-departmental discussion, an epidural blood patch was performed, leading to the prompt resolution of the headache. This report highlights a rare concurrence of PDPH and CVT, causing a diagnostic dilemma that resulted in treatment delays for the patient. Treating both conditions raises difficult practical questions, especially regarding the use of an epidural blood patch as opposed to anticoagulation. Given the risk of fatal complications such as venous cerebral infarction, seizures, and subdural hematoma, prompt treatment of both PDPH and CVT is strongly recommended. The multifactorial mechanism by which CVT develops with intracranial hypotension and PDPH also makes it essential for clinicians to keep an open mind when managing post-caesarean headaches, requiring inter-departmental cooperation to ensure optimal patient outcomes.
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Affiliation(s)
- Rachael S Lim
- Critical Care, Goulburn Valley Health, Shepparton, AUS
| | - Ethan K Chan
- General Medicine, Goulburn Valley Health, Shepparton, AUS
| | - Partha P Das
- General Medicine, Goulburn Valley Health, Shepparton, AUS
| | - Tunde Ibrahim
- General Medicine, Goulburn Valley Health, Shepparton, AUS
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6
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Preul C, Alijaj L, Neumann-Haefelin T, Kallenberg K. [Venous thrombectomy in extensive cerebral venous sinus thrombosis and cerebrospinal fluid leakage after cesarean sectio under peridural anesthesia]. DER NERVENARZT 2023; 94:956-959. [PMID: 37106148 DOI: 10.1007/s00115-023-01485-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/13/2023] [Indexed: 04/29/2023]
Affiliation(s)
- Christoph Preul
- Klinik für Neurologie, Klinikum Fulda gAG, Pacelliallee 4, 36043, Fulda, Deutschland.
| | - Lirim Alijaj
- Klinik für Neurologie, Klinikum Fulda gAG, Pacelliallee 4, 36043, Fulda, Deutschland
| | | | - Kai Kallenberg
- Klinik für Neuroradiologie, Klinikum Fulda gAG, Fulda, Deutschland
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7
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Lawrence H, Morton A. Postpartum complications following neuraxial anaesthesia for obstetric physicians. Obstet Med 2023; 16:142-150. [PMID: 37720002 PMCID: PMC10504890 DOI: 10.1177/1753495x221146329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 12/04/2022] [Indexed: 09/19/2023] Open
Abstract
Neuraxial analgesia and anaesthesia are widely accepted and well-tolerated modes of delivery analgesia, being employed in up to 76% of vaginal deliveries and 94% of caesarean deliveries in the United States.1 A cause of considerable concern for postpartum women, their family and caring health professionals is the occurrence of unexplained postpartum complications, not only for management in the index pregnancy, but the uncertain risk of recurrence in future pregnancies. Complications of neuraxial blocks may impact significantly on the ability of mothers to care for and bond with their newborn. The reported incidence of temporary neurological deficit following obstetric neuraxial blocks is 1 in 3900 procedures, and the risk of permanent neurological harm estimated to be between 1 in 80,000 and 1 in 320,425 procedures.2 Obstetric physicians may be asked to review women with postpartum complications following neuraxial blocks. This article reviews complications that may be seen following neuraxial blocks for delivery.
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Affiliation(s)
- Heather Lawrence
- Obstetrics Department, Mater Health, Raymond Terrace, South Brisbane, Australia
| | - Adam Morton
- Obstetric Medicine, Mater Health, Raymond Terrace, South Brisbane, Australia
- Department of Medicine, University of Queensland, Herston, Australia
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8
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M O, JK CG, I G, NR K, CM C, W B. Prevalence of cerebral vein thrombosis among patients with spontaneous intracranial hypotension. Interv Neuroradiol 2022; 28:719-725. [PMID: 34904470 PMCID: PMC9706257 DOI: 10.1177/15910199211065912] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 11/17/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND AND PURPOSE Cerebral venous sinus thrombosis (CVST) is a rare condition but an important complication of spontaneous intracranial hypotension (SIH). We reviewed our experience of patients with SIH and assessed for the presence of CVST. METHODS We reviewed the medical records and imaging studies from our tertiary referral institution, assessing patients with clinically suspected SIH as well as imaging findings of intracranial hypotension. All relevant brain MRIs were reviewed for the presence of brain sag, pachymeningeal enhancement, and CVST. RESULTS Among 563 patients with a clinical diagnosis of SIH, 431 (76%) demonstrated brain sag. In the overall patient cohort, a total of 5 patients had CVST (0.9%) and all 5 of these patients demonstrated findings of brain sag. Of the patients with CVST, 3 had significant complications, including dural arteriovenous fistulas (2 patients) and lobar hemorrhage with seizure (1 patient). CONCLUSION SIH is a risk factor for the development of CVST. In our review of 563 patients with clinical and/or imaging findings of SIH, 0.9% of patients were diagnosed with CVST and 3 of these patients (60%) had additional severe complications.
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Affiliation(s)
- Oien M
- Departments of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Garza I
- Departments of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Kissoon NR
- Neurology, Mayo Clinic, Rochester, MN, USA
| | - Carr CM
- Departments of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Brinjikji W
- Departments of Radiology, Mayo Clinic, Rochester, MN, USA
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9
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Ferro JM, de Sousa DA, Canhão P. Cerebral Venous Thrombosis. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00045-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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10
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Chang YJ, Hung KC, Chen IW, Kuo CL, Teng IC, Lin MC, Yew M, Liao SW, Wu CY, Yu CH, Lan KM, Sun CK. Efficacy of greater occipital nerve block for pain relief in patients with postdural puncture headache: A meta-analysis. Medicine (Baltimore) 2021; 100:e28438. [PMID: 34941197 PMCID: PMC8701447 DOI: 10.1097/md.0000000000028438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 11/18/2021] [Accepted: 12/06/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND This study aimed at assessing the therapeutic effectiveness of greater occipital nerve block (GONB) against postdural puncture headache (PDPH). METHODS Studies investigating analgesic effects of GONB against PDPH in adults were retrieved from the MEDLINE, EMBASE, Google scholar, and Cochrane central databases from their inception dates to May, 2021. Pain score at postprocedural 24 hours was the primary endpoint, while secondary endpoints were pain score at postprocedural 1 hour and 12 hours as well as the risk of intervention failure. RESULTS Of the 7 studies (randomized controlled trials [RCTs], n = 4; non-RCTs, n = 3) that recruited 275 patients, 2 investigated female patients undergoing cesarean section and the other 5 were conducted in both obstetric and nonobstetric settings. Pooled results showed a lower mean pain score at 24 hours (i.e., primary outcome) (mean difference [MD] = -2.66, 95%: CI: -3.98 to -1.33, P < .001; I2 = 97%, 6 studies), 1 hour (MD = -4.23, 95% confidence interval [CI]: -5.08 to -3.37, P < .00001; I2 = 86%, 5 studies), and 6 hours (MD = -2.78, 95% CI: -4.99 to -0.57, P = .01; I2 = 98%, 4 studies) in patients with GONB compared to those without. Trial sequential analysis supported the robustness of evidence at postprocedural 24 hours. The use of GONB also decreased the risk of intervention failure (relative ratio [RR] = 0.4, 95% CI: 0.19 to 0.82, P = .01; I2 = 96%, 6 studies, 277 patients). CONCLUSION Our results suggested a therapeutic effect of greater occipital nerve block against postdural puncture headache up to postprocedural 24 hours. Further large-scale studies are warranted to evaluate its therapeutic benefit beyond the acute stage.
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Affiliation(s)
- Ying-Jen Chang
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
- Department of Recreation and Health-Care Management, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, Tainan City, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Chi-Lin Kuo
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - I-Chia Teng
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Ming-Chung Lin
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Ming Yew
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Shu-Wei Liao
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Chung-Yi Wu
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Chia-Hung Yu
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Kuo-Mao Lan
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Cheuk-Kwan Sun
- Department of Emergency Medicine, E-Da Hospital, Kaohsiung City, Taiwan
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung City, Taiwan
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Kannarkat GT, Moghekar A. Before and after: lumbar puncture complicated by cerebral venous sinus thrombosis. Neurol Sci 2021; 43:1469-1470. [PMID: 34817730 DOI: 10.1007/s10072-021-05773-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 11/19/2021] [Indexed: 11/25/2022]
Affiliation(s)
- George T Kannarkat
- Department of Neurology, Johns Hopkins Hospital, 1800 Orleans St, Baltimore, MD, 21287, USA.
| | - Abhay Moghekar
- Department of Neurology, Johns Hopkins Hospital, 1800 Orleans St, Baltimore, MD, 21287, USA
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12
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Chambers DJ, Bhatia K, Columb M. Postpartum cerebral venous sinus thrombosis following obstetric neuraxial blockade: a literature review with analysis of 58 case reports. Int J Obstet Anesth 2021; 49:103218. [PMID: 34598860 DOI: 10.1016/j.ijoa.2021.103218] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 07/17/2021] [Accepted: 09/06/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Cerebral venous sinus thrombosis (CVST) is a rare complication of pregnancy. It usually presents with a headache and may mimic a post-dural puncture headache (PDPH) in women who receive a neuraxial block. METHODS Medline, CINAHL and EMBASE databases were searched to identify postpartum cases of CVST following neuraxial block. The aim was to delineate the characteristics, presentation, investigations, and outcomes of postpartum women who presented with CVST. RESULTS Forty-nine articles with 58 case reports were identified. Forty-two women (72.4%) had an epidural attempted whilst 16 women (27.6%) received a spinal anaesthetic. Accidental dural puncture (ADP) was reported in 17 women (40.5%). Headache was the presenting symptom in 57 women (98.3%); 26 women (44.8%) also experienced seizures. Post-dural puncture headache was reported in 46 (79.3%) and an epidural blood patch was performed in 26 women (44.8%). Superior sagittal sinus, transverse sinus, and cortical veins were the most common sites of thrombosis. The median time to diagnosis was 6.5 days from delivery. Magnetic resonance imaging was the most common diagnostic neuro-imaging modality. Full neurological recovery was reported in 48 (82.8%), whilst neurological deficits were reported in six (10.3%) women. DISCUSSION The diagnosis of CVST may be overlooked in women who present with headache following neuraxial block. A change in character of headache with loss of postural element, and focal neurological signs are the key clinical features that could help anaesthetists differentiate headache of CVST from PDPH. The high reported rates of ADP and PDPH lend support to their possible association with CVST.
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Affiliation(s)
| | - K Bhatia
- Saint Mary's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester, UK.
| | - M Columb
- Wythenshawe Hospital, Manchester University Hospital NHS Foundation Trust, Manchester, UK
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13
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de Valck L, Defelippe VM, Bouwman NAMG. Cerebral venous sinus thrombosis: a complication of nitrous oxide abuse. BMJ Case Rep 2021; 14:e244478. [PMID: 34400432 PMCID: PMC8370558 DOI: 10.1136/bcr-2021-244478] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2021] [Indexed: 11/04/2022] Open
Abstract
Nitrous oxide (NO) is an inhalant that has become increasingly popular as a recreational drug. While it is presumed to be harmless, a number of adverse effects of NO have been described. We discuss the case of a 24-year-old man with no medical history, who initially presented to the emergency department with progressive polyneuropathy caused by vitamin B12 deficiency after NO abuse. Two days after being discharged with hydroxocobalamin supplementation, the patient returned with a severe headache, blurry vision and slurred speech. Imaging revealed cerebral venous sinus thrombosis. Hypercoagulability workup showed slightly elevated homocysteine and normalised vitamin B12 after supplementation. Genetic testing showed a heterozygous prothrombin G20210A mutation. He was treated with low-molecular-weight heparin followed by dabigatran. We hypothesise that NO use may increase the risk of developing cerebral venous thrombosis, especially in patients with multiple risk factors and elevated homocysteine levels.
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Affiliation(s)
- Laura de Valck
- Neurology, Zuyderland Medisch Centrum Sittard-Geleen, Sittard-Geleen, The Netherlands
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14
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Daqqaq TS, Naqshabandi AA, Rajih ES. Superior sagittal sinus thrombosis after spinal anesthesia. ACTA ACUST UNITED AC 2021; 25:210-213. [PMID: 32683402 PMCID: PMC8015483 DOI: 10.17712/nsj.2020.3.20200003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Superior sagittal sinus thrombosis is an uncommon phenomenon that could occur in patients with a risk for thrombosis. It has been reported after spinal anesthesia with persistent cerebrospinal fluid leak. The current case is a young 29-year-old man who was complaining of persistent headache after spinal anesthesia for varicocelectomy and a new onset of blurred vision with a sign of papilledema. The diagnosis was confirmed with magnetic resonance imaging and proved to be superior sagittal sinus thrombosis. He was started on anticoagulant therapy and showed gradual improvement. No previous case has been reported in the literature in a patient without prothrombotic status risk. Received 8th January 2020. Accepted 26th March 2020.
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Affiliation(s)
- Tareef S Daqqaq
- Department of Radiology, College of Medicine, Taibah University, Madinah Al-Munawarah, Kingdom of Saudi Arabia
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15
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Ng S, Poulen G, Lonjon N, Boetto J, Le Corre M. Cerebral venous sinus thrombosis following post-neurosurgical intracranial hypotension: A case report and systematic review of the literature. Neurochirurgie 2021; 68:117-122. [PMID: 33667532 DOI: 10.1016/j.neuchi.2021.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 02/02/2021] [Accepted: 02/14/2021] [Indexed: 10/22/2022]
Abstract
Cerebral venous sinus thrombosis (CVST) following brain surgery is a feared complication, commonly described after direct injury to the sinus. However, distant CVST occurring away from the operative area are unexpected. Yet, there is a strong physio-pathological rational supporting the role of intracranial hypotension as a risk factor of CVST. Here, we report the case of a frontal arachnoid cyst depletion followed by an extensive contralateral CVST. Given the major prognostic consequences observed in this clinical illustration, we further investigated the hypothesis of intracranial hypotension as an etiology of CVST by carrying out a systematic review of the literature.
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Affiliation(s)
- S Ng
- Department of Neurosurgery, Montpellier University Medical Center, Montpellier, France.
| | - G Poulen
- Department of Neurosurgery, Montpellier University Medical Center, Montpellier, France
| | - N Lonjon
- Department of Neurosurgery, Montpellier University Medical Center, Montpellier, France
| | - J Boetto
- Department of Neurosurgery, Montpellier University Medical Center, Montpellier, France
| | - M Le Corre
- Department of Neurosurgery, Montpellier University Medical Center, Montpellier, France
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Zheng YY, Weng XP, Fu FW, Cao YG, Li Y, Zheng GQ, Chen W. Cerebrospinal Fluid Hypovolemia and Posterior Reversible Encephalopathy Syndrome. Front Neurol 2020; 11:591. [PMID: 32655488 PMCID: PMC7324723 DOI: 10.3389/fneur.2020.00591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 05/22/2020] [Indexed: 12/23/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a reversible neuroradiological syndrome characterized by reversible vasogenic edema. The pathophysiological mechanism is still unclear, but PRES may be triggered by various etiologies. To date, only a few PRES cases linked to cerebrospinal fluid (CSF) hypovolemia were reported. The association between PRES and CSF hypovolemia needs to be explored. We presented a case of PRES with CSF hypovolemia as a result of an inadvertent dural puncture and reviewed the literature to identify the clinical characterization and pathophysiological mechanism of PRES following CSF hypovolemia. A total of 31 cases of PRES-CSF hypovolemia was included for analysis. The median age was 33 years, with a notable female predominance (87.1%). Fifteen patients (48.4%) didn't have either a history of hypertension nor an episode of hypertension. The most common cause of CSF hypovolemia was epidural or lumbar puncture (n = 21), followed by CSF shunt (n = 6). The median interval between the procedure leading to CSF hypovolemia and PRES was 4 days. Seizure, altered mental state, and headache were the most frequent presenting symptom. The parietooccipital pattern was most frequent (71.0%). Conservative management remains the mainstay of treatment with excellent outcomes. Three patients had a second episode of PRES. CSF hypovolemia is a plausible cause of PRES via a unique pathophysiologic mechanism including arterial hyperperfusion and venous dysfunction. Patients with CSF hypovolemia is more susceptible to PRES, which is potentially life-threatening. Given that CSF hypovolemia is a common complication of anesthetic, neurological, and neurosurgical procedures, PRES should be early considered for prompt diagnosis and appropriate management.
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Affiliation(s)
- Yuan-Yuan Zheng
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiong-Peng Weng
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Fang-Wang Fu
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yun-Gang Cao
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yan Li
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Guo-Qing Zheng
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Wei Chen
- Department of Radiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
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Estol CJ. We Dropped the Reflex Hammer on Hypertension 20 Years Ago. JAMA Neurol 2020; 77:526. [PMID: 32119064 DOI: 10.1001/jamaneurol.2020.0070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Niazi AK, Minko P, Elliott KK, Ghaly TR, Ayad S. Cerebral Venous Thrombosis After a Possible Inadvertent Dural Puncture for Labor Epidural Analgesia. Cureus 2019; 11:e4822. [PMID: 31404378 PMCID: PMC6682386 DOI: 10.7759/cureus.4822] [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] [Indexed: 12/04/2022] Open
Abstract
Pregnancy is a hypercoagulable state that increases the risk of thrombotic complications. A 32-year-old gravida 4 para 3 (G4P3) had a dural puncture during epidural catheter placement for labor analgesia. A positional headache started after delivery and continued for several days. A week after the delivery, she developed non-positional headaches along with seizures. Magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) lead to the diagnosis of cerebral venous thrombosis (CVT). A factor V Leiden mutation was also found; that was suspected to contribute to the development of CVT along with dural puncture and pregnancy. CVT can present with non-positional headaches a week after the dural puncture.
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Affiliation(s)
| | - Paul Minko
- Anesthesiology, Cleveland Clinic Fairview Hospital, Cleveland, USA
| | | | - Tamer R Ghaly
- Anesthesiology, Cleveland Clinic Fairview Hospital, Cleveland, USA
| | - Sabry Ayad
- Anesthesiology, Cleveland Clinic Fairview Hospital, Cleveland, USA
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Zhang D, Wang J, Zhang Q, He F, Hu X. Cerebral Venous Thrombosis in Spontaneous Intracranial Hypotension: A Report on 4 Cases and a Review of the Literature. Headache 2018; 58:1244-1255. [PMID: 30238694 DOI: 10.1111/head.13413] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 06/30/2018] [Accepted: 07/01/2018] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Spontaneous intracranial hypotension is a risk factor for cerebral venous thrombosis. The occurrence of cerebral venous thrombosis in patients with spontaneous intracranial hypotension raises difficult practical questions regarding the management of the 2 conditions. We reviewed our experience and the relevant literature to evaluate these related questions. METHODS We retrospectively studied the medical records and imaging studies of patients with spontaneous intracranial hypotension at a tertiary center from January 2007 through January 2017. The main search strategy was a literature review of journal articles in PubMed (1966 to January 2017). RESULTS Among 374 patients with spontaneous intracranial hypotension, 4 were also diagnosed with cerebral venous thrombosis. A literature review yielded an additional 31 cases, including 21 men and 14 women with a mean age of 40.6 years. Of the 35 patients, 8 (22.8%) patients received anticoagulation therapy and epidural blood patch. Nineteen (54.3%) patients were given anticoagulant only. Seven (20%) patients were treated with epidural blood patch only. One (2.9%) patient did not receive epidural blood patch or anticoagulation therapy. There is no difference in terms of age, sex, diagnosis interval, association with other complications, and prognosis between the first 3 groups. Of the 19 patients who received anticoagulation therapy, 4 patients (21.1%) had intracranial hemorrhage or hematoma enlargement after anticoagulation, and one of these 4 patients died following further intracranial hemorrhage. Of the 8 patients who received both anticoagulation and epidural blood patch, 1 patient (12.5%, P = 0.528) developed subdural hematoma after anticoagulation. Of the 5 cases had intracranial hemorrhage aggravation after anticoagulation, 4 were subdural hematoma occurrence or enlargement. CONCLUSION Cerebral venous thrombosis is a rare but important complication of spontaneous intracranial hypotension. The primary focus of treatment should be the treatment of intracranial hypotension. It could be possible that anticoagulation might increase the risk of intracranial hemorrhage in patients with spontaneous intracranial hypotension, although a firm conclusion could not be drawn based on the limited number of patients currently available. The use of anticoagulation therapy should be prudent and should be monitored carefully if initiated.
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Affiliation(s)
- Dan Zhang
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, PR. China
| | - Jin Wang
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, PR. China
| | - Qiaowei Zhang
- Department of Radiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, PR. China
| | - Feifang He
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, PR. China
| | - Xingyue Hu
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, PR. China
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Perry A, Graffeo CS, Brinjikji W, Copeland WR, Rabinstein AA, Link MJ. Spontaneous occult intracranial hypotension precipitating life-threatening cerebral venous thrombosis: case report. J Neurosurg Spine 2018; 28:669-678. [PMID: 29600909 DOI: 10.3171/2017.10.spine17806] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Spontaneous intracranial hypotension (SIH) is an uncommon headache etiology, typically attributable to an unprovoked occult spinal CSF leak. Although frequently benign, serious complications may occur, including cerebral venous thrombosis (CVT). The objective of this study was to examine a highly complicated case of CVT attributable to SIH as a lens for understanding the heterogeneous literature on this rare complication, and to provide useful, evidence-based, preliminary clinical recommendations. A 43-year-old man presented with 1 week of headache, dizziness, and nausea, which precipitously evolved to hemiplegia. CT venography confirmed CVT, and therapeutic heparin was initiated. He suffered a generalized seizure due to left parietal hemorrhage, which subsequently expanded. He developed signs of mass effect and herniation, heparin was discontinued, and he was taken to the operating room for clot evacuation and external ventricular drain placement. Intraoperatively, the dura was deflated, suggesting underlying SIH. Ventral T-1 CSF leak was identified, which failed multiple epidural blood patches and required primary repair. The patient ultimately made a complete recovery. Systematic review identified 29 publications describing 36 cases of SIH-associated CVT. Among 31 patients for whom long-term neurological outcome was reported, 25 (81%) recovered completely. Underlying coagulopathy/risk factors were identified in 11 patients (31%). CVT is a rare and potentially lethal sequela occurring in 2% of SIH cases. Awareness of the condition is poor, risking morbid complications. Evaluation and treatment should be directed toward identification and treatment of occult CSF leaks. Encouragingly, good neurological outcomes can be achieved through vigilant multidisciplinary neurosurgical and neurocritical care.
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Affiliation(s)
| | | | | | - William R Copeland
- 3Division of Neurosurgery, Department of Surgery, Tenwek Hospital, Bomet, Kenya
| | | | - Michael J Link
- Departments of1Neurologic Surgery.,5Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota; and
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Bijral N, Qureshi I, Hameed A. A rare cause of postpartum headache. BMJ Case Rep 2018; 2018:bcr-2017-223048. [PMID: 29592984 PMCID: PMC5878351 DOI: 10.1136/bcr-2017-223048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2018] [Indexed: 11/04/2022] Open
Abstract
Postpartum women can develop headache, and their assessment requires a thorough and multidisciplinary approach. If the headache is unresponsive to treatment and accompanied by neurological deficit, neuroimaging needs to be undertaken to rule out other life-threatening causes. 1 We present a case of 35-year-old woman with pre-eclampsia and diet-controlled gestational diabetes mellitus, who had normal vaginal delivery at 40 weeks. She had an epidural analgesia for pain relief during labour, but had inadvertent dural puncture during the procedure and developed headache 24 hours after delivery. The headache was managed conservatively and she was discharged home, but was readmitted 8 days later with worsening headache. The headache was postural on admission but became continuous, developed neurological symptoms in the form of ataxic hemiparesis and convulsions. After neuroimaging, she was found to have cerebral venous sinus thrombosis. She was commenced on anticoagulants and anticonvulsants and made a complete recovery.
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Affiliation(s)
- Nayantara Bijral
- Obstetrics and Gynaecology, Princess Royal University Hospital, Orpington, UK
| | - Imran Qureshi
- Department of Radiology, Princess Royal University Hospital, Orpington, UK
| | - Aisha Hameed
- Obstetrics and Gynaecology, Princess Royal University Hospital, Orpington, UK
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De Pietri L, Clima B, Reggiani A, Valzania F, Danelli FG. Sinus venous thrombosis following central neuraxial block: A difficult and often late differential diagnosis of postpartum headache. J Clin Anesth 2018; 47:52-53. [PMID: 29574287 DOI: 10.1016/j.jclinane.2018.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/04/2018] [Accepted: 03/08/2018] [Indexed: 02/01/2023]
Affiliation(s)
- Lesley De Pietri
- Division of Anaesthesiology and Intensive Care Unit, Department of General Surgery, AUSL Reggio Emilia-IRCCS, 42100 Reggio Emilia, Italy.
| | - Barbara Clima
- Division of Anaesthesiology and Intensive Care Unit, Department of General Surgery, AUSL Reggio Emilia-IRCCS, 42100 Reggio Emilia, Italy.
| | - Alexia Reggiani
- Division of Anaesthesiology and Intensive Care Unit, Department of General Surgery, AUSL Reggio Emilia-IRCCS, 42100 Reggio Emilia, Italy.
| | - Franco Valzania
- Neurology, Neuromotory And Rehabilitative Department, AUSL Reggio Emilia-IRCCS -IRCCS, 42100 Reggio Emilia, Italy.
| | - Francesco Giorgio Danelli
- Division of Anaesthesiology and Intensive Care Unit, Department of General Surgery, AUSL Reggio Emilia-IRCCS, 42100 Reggio Emilia, Italy.
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Elkoundi A, Tahri A, Meziane M, Bensghir M, Lalaoui SJ. Sildenafil related cerebral venous thrombosis following spinal anesthesia. J Clin Anesth 2017; 42:47-48. [PMID: 28803125 DOI: 10.1016/j.jclinane.2017.08.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 08/04/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Abdelghafour Elkoundi
- Department of Anesthesiology and Intensive Care, Military Hospital Mohammed V of Rabat, Morocco; Faculty of Medicine and Pharmacy of Rabat, University Mohammed V, Rabat, Morocco.
| | - Achraf Tahri
- Department of Anesthesiology and Intensive Care, Military Hospital Mohammed V of Rabat, Morocco; Faculty of Medicine and Pharmacy of Rabat, University Mohammed V, Rabat, Morocco
| | - Mohammed Meziane
- Department of Anesthesiology and Intensive Care, Military Hospital Mohammed V of Rabat, Morocco; Faculty of Medicine and Pharmacy of Rabat, University Mohammed V, Rabat, Morocco
| | - Mustapha Bensghir
- Department of Anesthesiology and Intensive Care, Military Hospital Mohammed V of Rabat, Morocco; Faculty of Medicine and Pharmacy of Rabat, University Mohammed V, Rabat, Morocco
| | - Salim Jaafar Lalaoui
- Department of Anesthesiology and Intensive Care, Military Hospital Mohammed V of Rabat, Morocco; Faculty of Medicine and Pharmacy of Rabat, University Mohammed V, Rabat, Morocco
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Idiopathic Intracranial Hypertension Progressing to Venous Sinus Thrombosis, Subarachnoid Hemorrhage, and Stroke. J Neuroophthalmol 2017; 38:60-64. [PMID: 28742639 DOI: 10.1097/wno.0000000000000540] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Idiopathic intracranial hypertension (IIH) is a syndrome characterized by increased intracranial pressure (ICP), the absence of structural lesions on neuroimaging, and normal cerebrospinal fluid composition. Cerebral venous sinus thrombosis (CVST) is a common cause of increased ICP and can be differentiated from IIH with magnetic resonance venography. We describe a young woman with typical IIH who underwent lumbar puncture and was treated with a short course of high-dose corticosteroids followed by acetazolamide. She subsequently developed CVST, subarachnoid hemorrhage, and stroke. Risk factors that may have resulted in CVST are discussed.
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Katz D, Beilin Y. Review of the Alternatives to Epidural Blood Patch for Treatment of Postdural Puncture Headache in the Parturient. Anesth Analg 2017; 124:1219-1228. [DOI: 10.1213/ane.0000000000001840] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Barami K. Cerebral venous overdrainage: an under-recognized complication of cerebrospinal fluid diversion. Neurosurg Focus 2016; 41:E9. [DOI: 10.3171/2016.6.focus16172] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Understanding the altered physiology following cerebrospinal fluid (CSF) diversion in the setting of adult hydrocephalus is important for optimizing patient care and avoiding complications. There is mounting evidence that the cerebral venous system plays a major role in intracranial pressure (ICP) dynamics especially when one takes into account the effects of postural changes, atmospheric pressure, and gravity on the craniospinal axis as a whole. An evolved mechanism acting at the cortical bridging veins, known as the “Starling resistor,” prevents overdrainage of cranial venous blood with upright positioning. This protective mechanism can become nonfunctional after CSF diversion, which can result in posture-related cerebral venous overdrainage through the cranial venous outflow tracts, leading to pathological states. This review article summarizes the relevant anatomical and physiological bases of the relationship between the craniospinal venous and CSF compartments and surveys complications that may be explained by the cerebral venous overdrainage phenomenon. It is hoped that this article adds a new dimension to our therapeutic methods, stimulates further research into this field, and ultimately improves our care of these patients.
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Iatrogenic intracranial hypotension and cerebral venous thrombosis. J Neurol Sci 2016; 366:191-194. [DOI: 10.1016/j.jns.2016.05.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 04/10/2016] [Accepted: 05/04/2016] [Indexed: 01/03/2023]
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Sherfudeen KM, Ramasamy G, Kaliannan SK, Dammalapati PK. Differentiating the headache of cerebral venous thrombosis from post-dural puncture: A headache for anaesthesiologists. Indian J Anaesth 2016; 60:352-4. [PMID: 27212724 PMCID: PMC4870950 DOI: 10.4103/0019-5049.181609] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Cerebral venous thrombosis (CVT) is a rare complication of lumbar puncture. Occasionally, the clinical picture of CVT may mimic post-dural puncture headache (PDPH) resulting in delayed diagnosis. A case of PDPH progressing to CVT is presented and the pathophysiology, diagnostic challenges and management options discussed in this article.
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Affiliation(s)
| | - Gurumoorthi Ramasamy
- Department of Anaesthesiology and Critical Care, Kauvery Hospitals, Trichy, Tamil Nadu, India
| | - Senthil Kumar Kaliannan
- Department of Anaesthesiology and Critical Care, Kauvery Hospitals, Trichy, Tamil Nadu, India
| | - Pavan Kumar Dammalapati
- Department of Anaesthesiology and Critical Care, Kauvery Hospitals, Trichy, Tamil Nadu, India
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Price M, Günther A, Kwan JSK. Antiepileptic drugs for the primary and secondary prevention of seizures after intracranial venous thrombosis. Cochrane Database Syst Rev 2016; 4:CD005501. [PMID: 27098266 PMCID: PMC7265129 DOI: 10.1002/14651858.cd005501.pub4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Intracranial venous thrombosis (ICVT) commonly presents with seizures in the acute period, and some people may develop recurrent seizures in the long term. The prophylactic use of antiepileptic drugs (AEDs) for the management of post-ICVT seizures is controversial, and there is currently no consensus on the optimal management of post-ICVT seizures. This is an updated version of the Cochrane review first published in theCochrane Database of Systematic Reviews 2006, Issue 3. OBJECTIVES To assess the effects of AEDs for the primary and secondary prevention of seizures related to ICVT.(1) For the question of primary prevention, we aimed to examine whether AEDs reduce the likelihood of seizures in people who have had an ICVT but have not had a seizure.(2) For the question of secondary prevention, we aimed to examine whether AEDs reduce the likelihood of further seizures in people who have had an ICVT and at least one seizure. SEARCH METHODS For the latest update, we searched the Cochrane Epilepsy Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online (CRSO), and MEDLINE (Ovid 1946 onwards) to 20 April 2015, and we checked the reference lists of articles retrieved from the searches. SELECTION CRITERIA We planned to include all randomised and quasi-randomised controlled trials in which participants with a diagnosis of ICVT were assigned to a treatment group (that is, receiving at least one AED) or control group (receiving placebo or no drug). DATA COLLECTION AND ANALYSIS Both review authors independently screened and assessed the methodological quality of the studies. If studies had been included in the review, one review author would have extracted the data and another would have checked the extracted data. MAIN RESULTS No relevant studies were found. AUTHORS' CONCLUSIONS There is no evidence to support or refute the use of antiepileptic drugs for the primary or secondary prevention of seizures related to intracranial venous thrombosis. Well-designed randomised controlled trials are urgently needed to inform practice. Since the last version of this review no new studies have been found.
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Affiliation(s)
| | - Albrecht Günther
- Jena University HospitalDepartment of NeurologyErlanger Allee 101JenaGermany07747
| | - Joseph SK Kwan
- The University of Hong Kong, Queen Mary HospitalDepartment of Medicine102 Pok Fu Lam RoadHong KongChina
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Meseeha MG, Attia M. Throbbing headache is not always migraine; it can be serious. J Community Hosp Intern Med Perspect 2016; 6:32361. [PMID: 27802851 PMCID: PMC5087259 DOI: 10.3402/jchimp.v6.32361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 08/19/2016] [Accepted: 08/25/2016] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Maximos Attia
- Department of Family MedicineGuthrie Clinic, Sayre, PA, USA
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Prashanth A, Chakravarthy M. Post-spinal headache in a parturient - look beyond post-dural puncture headache. Indian J Anaesth 2016; 60:782-783. [PMID: 27761049 PMCID: PMC5064710 DOI: 10.4103/0019-5049.191708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Anitha Prashanth
- Department of Anaesthesia, Fortis Hospitals, Bengaluru, Karnataka, India
| | - Murali Chakravarthy
- Department of Anaesthesia, Critical Care and Pain Relief, Central Infection Prevention and Control Committee, Fortis Hospitals, Bengaluru, Karnataka, India
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35
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Paulson D, Page J, Moisi MD, Oskouian RJ. Commentary on: "Remote Cerebellar Hemorrhage after Revision Lumbar Spine Surgery". Global Spine J 2015; 5:538. [PMID: 26682109 PMCID: PMC4671894 DOI: 10.1055/s-0035-1567837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- David Paulson
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, Washington, United States
| | - Jeni Page
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, Washington, United States
| | - Marc D. Moisi
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, Washington, United States,Address for correspondence Marc D. Moisi, MD Department of Neurosurgery, Swedish Neuroscience Institute550 17th Avenue, Seattle, WA 98122United States
| | - Rod J. Oskouian
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, Washington, United States
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Zuurbier SM, Lauw MN, Coutinho JM, Majoie CBLM, van der Holt B, Cornelissen JJ, Middeldorp S, Biemond BJ, Stam J. Clinical Course of Cerebral Venous Thrombosis in Adult Acute Lymphoblastic Leukemia. J Stroke Cerebrovasc Dis 2015; 24:1679-84. [PMID: 25934140 DOI: 10.1016/j.jstrokecerebrovasdis.2015.03.041] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 03/23/2015] [Accepted: 03/27/2015] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a frequent complication in patients with acute lymphoblastic leukemia (ALL). A significant proportion of patients develop cerebral venous thrombosis (CVT). METHODS To investigate risk factors for and the clinical course of CVT in ALL patients, we describe all cases of CVT which occurred in a well-defined cohort of 240 adults, treated for newly diagnosed ALL in the HOVON (Dutch-Belgian Hemato-Oncology Cooperative Group)-37 study. We conducted a nested case-control study to explore the relevance of early symptoms and risk factors for CVT in ALL patients. RESULTS Nine of 240 patients developed CVT (4%). CVT occurred during or shortly after L-asparaginase therapy (in 8 cases) and shortly after intrathecal methotrexate injections (in all cases) during cycle I of remission induction treatment. CVT was associated with prior headache and seizures. In 5 of 9 patients with CVT, headache before the diagnosis of CVT occurred within 3 days after lumbar puncture and initially had a postural character. CONCLUSIONS CVT is relatively common in adult ALL patients. Our data suggest that CVT in adult ALL patients results from the additive effects of multiple risk factors, with a particular role for asparaginase and the effects of lumbar punctures for intrathecal therapy.
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Affiliation(s)
- Susanna M Zuurbier
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - Mandy N Lauw
- Department of Hematology, Academic Medical Center, Amsterdam, The Netherlands; Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands.
| | | | - Bronno van der Holt
- HOVON Data Centre, Erasmus MC Cancer Institute-Clinical Trial Centre, Rotterdam, The Netherlands
| | - Jan J Cornelissen
- Department of Hematology, Erasmus MC-Daniel den Hoed, Rotterdam, The Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Bart J Biemond
- Department of Hematology, Academic Medical Center, Amsterdam, The Netherlands
| | - Jan Stam
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
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Bisinotto FMB, Dezena RA, Abud TMV, Martins LB. [Cerebral venous thrombosis after spinal anesthesia: case report]. Rev Bras Anestesiol 2015; 67:305-310. [PMID: 25840468 DOI: 10.1016/j.bjan.2014.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 09/10/2014] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Cerebral venous thrombosis (CVT) is a rare, but serious complication after spinal anesthesia. It is often related to the presence of predisposing factors, such as pregnancy, puerperium, oral contraceptive use, and malignancies. Headache is the most common symptom. We describe a case of a patient who underwent spinal anesthesia who had postoperative headache complicated with CVT. CASE REPORT Male patient, 30 years old, ASA 1, who underwent uneventful arthroscopic knee surgery under spinal anesthesia. Forty-eight hours after the procedure, the patient showed frontal, orthostatic headache that improved when positioned supine. Diagnosis of sinusitis was made in the general emergency room, and he received symptomatic medication. In subsequent days, the headache worsened with holocranial location and with little improvement in the supine position. The patient presented with left hemiplegia followed by tonic-clonic seizures. He underwent magnetic resonance venography; diagnosed with CVT. Analysis of procoagulant factors identified the presence of lupus anticoagulant antibody. The patient received anticonvulsants and anticoagulants and was discharged eight days without sequelae. DISCUSSION Any patient presenting with postural headache after spinal anesthesia, which intensifies after a plateau, loses its orthostatic characteristic or become too long, should undergo imaging tests to rule out more serious complications, such as CVT. The loss of cerebrospinal fluid leads to dilation and venous stasis that, coupled with the traction caused by the upright position, can lead to TVC in some patients with prothrombotic conditions.
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Affiliation(s)
- Flora Margarida Barra Bisinotto
- Universidade Federal do Triângulo Mineiro, Disciplina de Anestesiologia, Uberaba, MG, Brasil; Universidade Federal do Triângulo Mineiro, Hospital de Clínicas, Uberaba, MG, Brasil.
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Dural puncture: an overlooked cause of cerebral venous thrombosis. Acta Neurol Belg 2015; 115:53-7. [PMID: 24838384 DOI: 10.1007/s13760-014-0305-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 04/30/2014] [Indexed: 10/25/2022]
Abstract
Cerebral venous thrombosis (CVT) accounts for 0.5-1 % of all strokes. Although dural puncture is proposed as one of the rare risk factors, this association has only been mentioned in anecdotal reports. Headache, i.e., usually the first and the most frequent clinical symptom on admission, is often attributed to the dural puncture itself. We investigated the frequency of CVT following a recent dural puncture in our stroke database, together with the other risk factors. The computerized medical records of patients (n = 10,740) registered in our tertiary-care neurology clinic stroke database were reviewed retrospectively. Patients diagnosed with CVT were reanalyzed. Patients who had a dural puncture in the preceding 7 days were included in the study. A total of 46 patients were diagnosed with CVT. Nine patients (19.6 %) had a recent dural puncture before the onset of the symptoms. Patients were younger than 45 years and had at least one more predisposing condition for thromboembolism other than the dural puncture. All patients have received either spinal anesthesia or intrathecal chemotherapy. Dural puncture seems to trigger CVT particularly in patients with predisposing disorders. Although reported as an extremely rare complication, our data indicate a much higher association. This case series emphasize the importance of reevaluation of patients with persistent/progressive headache following dural puncture. The effect of change in the biochemical composition of CSF due to intrathecal drug administration in pathogenesis is not known. Larger controlled trials are warranted to clarify the causal relationship between lumbar puncture and/or intrathecal drug administration and CVT.
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Nishida H, Wakida K, Sakurai T. Cerebral venous thrombosis as a complication of neuropsychiatric systemic lupus erythematosus. Intern Med 2015; 54:837-41. [PMID: 25832953 DOI: 10.2169/internalmedicine.54.3079] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 51-year-old woman undergoing steroid treatment for systemic lupus erythematosus (SLE) was admitted to our hospital after developing a fever, consciousness disturbance and seizures, leading to a diagnosis of SLE-induced meningoencephalitis. Although steroid therapy improved her symptoms, she complained of post-lumbar puncture thunderclap headaches during follow-up, and cerebral venous thrombosis (CVT) was subsequently diagnosed on magnetic resonance venography and cerebral angiography. This is a rare case of neuropsychiatric SLE complicated by CVT during treatment for aseptic meningoencephalitis. The onset of aseptic meningoencephalitis and administration of the lumbar puncture and steroid therapy may have induced the development of the patient's CVT symptoms.
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Affiliation(s)
- Hiroshi Nishida
- Department of Neurology, Gifu Prefectural General Medical Center, Japan
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Humbertjean L, Ducrocq X, Lacour JC, Mione G, Richard S. Incidental Diagnosis of Cerebral Cortical Venous Thrombosis in Postdural Puncture Headache on Brain Computed Tomography. J Neuroimaging 2014; 25:665-7. [PMID: 25510263 DOI: 10.1111/jon.12203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 08/20/2014] [Accepted: 09/13/2014] [Indexed: 11/30/2022] Open
Affiliation(s)
- Lisa Humbertjean
- Department of Neurology; University Hospital of Nancy; Nancy France
| | - Xavier Ducrocq
- Department of Neurology; University Hospital of Nancy; Nancy France
| | | | - Gioia Mione
- Department of Neurology; University Hospital of Nancy; Nancy France
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Cerebral venous thrombosis in two patients with spontaneous intracranial hypotension. Case Rep Neurol Med 2014; 2014:528268. [PMID: 25525533 PMCID: PMC4265689 DOI: 10.1155/2014/528268] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 10/28/2014] [Indexed: 01/03/2023] Open
Abstract
Although few patients with spontaneous intracranial hypotension develop cerebral venous thrombosis, the association between these two entities seems too common to be simply a coincidental finding. We describe two cases of spontaneous intracranial hypotension associated with cerebral venous thrombosis. In one case, extensive cerebral venous thrombosis involved the superior sagittal sinus and multiple cortical cerebral veins. In the other case, only a right frontoparietal cortical vein was involved. Several mechanisms could contribute to the development of cerebral venous thrombosis in spontaneous intracranial hypotension. When spontaneous intracranial hypotension and cerebral venous thrombosis occur together, it raises difficult practical questions about the treatment of these two conditions. In most reported cases, spontaneous intracranial hypotension was treated conservatively and cerebral venous thrombosis was treated with anticoagulation. However, we advocate aggressive treatment of the underlying cerebrospinal fluid leak.
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Mullane D, Tan T. Three cerebral venous sinus thromboses following inadvertent dural puncture: a case series over an eight-year period. Can J Anaesth 2014; 61:1134-5. [DOI: 10.1007/s12630-014-0234-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Accepted: 08/28/2014] [Indexed: 10/24/2022] Open
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Price M, Günther A, Kwan JSK. Antiepileptic drugs for the primary and secondary prevention of seizures after intracranial venous thrombosis. Cochrane Database Syst Rev 2014:CD005501. [PMID: 25086250 DOI: 10.1002/14651858.cd005501.pub3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Intracranial venous thrombosis (ICVT) commonly presents with seizures in the acute period, and some people may develop recurrent seizures in the long term. The prophylactic use of antiepileptic drugs (AEDs) for the management of post-ICVT seizures is controversial, and there is currently no consensus on the optimal management of post-ICVT seizures. This is an updated version of the original Cochrane review published in The Cochrane Library 2006, Issue 3. OBJECTIVES To assess the effects of AEDs for the primary and secondary prevention of seizures related to ICVT.(1) For the question of primary prevention, we aimed to examine whether AEDs reduce the likelihood of seizures in people who have had an ICVT but have not had a seizure.(2) For the question of secondary prevention, we aimed to examine whether AEDs reduce the likelihood of further seizures in people who have had an ICVT and at least one seizure. SEARCH METHODS We aimed to identify relevant studies in the Cochrane Epilepsy Group and Cochrane Stroke Group Specialised Registers. We also undertook specialised searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2013, Issue 7) and MEDLINE (Ovid 1946 to 22 August 2013) and checked the reference lists of articles retrieved from the searches. SELECTION CRITERIA We considered all randomised and quasi-randomised controlled trials in which participants were assigned to a treatment group (that is, receiving at least one AED) or control group (receiving placebo or no drug). DATA COLLECTION AND ANALYSIS Both review authors independently screened and assessed the methodological quality of the studies. If studies had been included in the review, then one review author would have extracted the data and the other would have checked the extracted data. MAIN RESULTS No relevant studies were found. AUTHORS' CONCLUSIONS There is no evidence to support or refute the use of antiepileptic drugs for the primary or secondary prevention of seizures related to intracranial venous thrombosis. Well-designed randomised controlled trials are urgently needed to inform practice. Since the last version of this review no new studies have been found.
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Sillero Sánchez M, Rodriguez Fernandez N, Sánchez Vera L, Gómez González B, Asencio Marchante J. Cerebral venous thrombosis after lumbar puncture and treatment with high-dose corticosteroids. NEUROLOGÍA (ENGLISH EDITION) 2014. [DOI: 10.1016/j.nrleng.2012.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Ilkhchoui Y, Szabo EE, Gerstein NS, Jaime F. Cerebral venous thrombosis complicating severe preeclampsia in the postpartum period: a diagnostic challenge. J Clin Anesth 2014; 26:143-6. [PMID: 24561108 DOI: 10.1016/j.jclinane.2013.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 10/30/2013] [Accepted: 11/05/2013] [Indexed: 10/25/2022]
Abstract
A 26 year old primigravida with preeclampsia was diagnosed with a cerebral venous thrombosis 6 days following Cesarean section. The diagnosis was initially challenging due to the patient's history of migraines, the preeclampsia, multiple attempts at spinal anesthesia for Cesarean section, and a dural puncture while performing epidural blood patch.
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Affiliation(s)
- Yashar Ilkhchoui
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico, School of Medicine, Albuquerque, NM 87106, USA.
| | - Eva E Szabo
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico, School of Medicine, Albuquerque, NM 87106, USA
| | - Neal S Gerstein
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico, School of Medicine, Albuquerque, NM 87106, USA
| | - Francisco Jaime
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico, School of Medicine, Albuquerque, NM 87106, USA
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Kate MP, Thomas B, Sylaja PN. Cerebral venous thrombosis in post-lumbar puncture intracranial hypotension: case report and review of literature. F1000Res 2014; 3:41. [PMID: 24627803 PMCID: PMC3945949 DOI: 10.12688/f1000research.3-41.v1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2014] [Indexed: 11/20/2022] Open
Abstract
The spectrum of presentation of intracranial hypotension is clinically perplexing. We report a case of 31-year-old post-partum woman who underwent an uneventful caesarean section under spinal anesthesia. From the second day of surgery she developed postural headache, the headache lost its postural character after few days. She then developed seizures and ataxic hemiparesis. Magnetic resonance imaging showed features of severe intracranial hypotension in the brain and the spinal cord, and magnetic resonance venography showed cortical vein and partial superior sagittal sinus thrombosis. Prothrombotic (etiological) work-up showed Protein C and S deficiency. She responded to anticoagulation therapy and recovered completely. On review of literature two distinct groups could be identified obstetric and non-obstetric. The non-obstetric group included patients who underwent diagnostic lumbar puncture, intrathecal injection of medications and epidural anesthesia for non-obstetric surgeries. Poor outcome and mortality was noted in non-obstetric group, while obstetric group had an excellent recovery.
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Affiliation(s)
- Mahesh P Kate
- Department of Medicine, University of Alberta, Edmonton, T6G0T1, Canada
| | - Bejoy Thomas
- Department of Imaging Sciences & Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Medical College Campus, Medical College, Thiruvananthapuram, Kerala, 695011, India
| | - P N Sylaja
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Medical College Campus, Medical College, Thiruvananthapuram, Kerala, 695011, India
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MATSUBARA T, AYUZAWA S, AOKI T, IKEDA G, SHIIGAI M, MATSUMURA A. Cerebral Venous Thrombosis after Ventriculoperitoneal Shunting: A Case Report. Neurol Med Chir (Tokyo) 2014; 54:554-7. [DOI: 10.2176/nmc.cr2012-0312] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Teppei MATSUBARA
- Department of Neurosurgery, Graduate School of Comprehensive Human Sciences, University of Tsukuba
| | - Satoshi AYUZAWA
- Department of Neurosurgery, Graduate School of Comprehensive Human Sciences, University of Tsukuba
| | - Tsukasa AOKI
- Department of Neurosurgery, Ryugasaki Saiseikai Hospital
| | - Go IKEDA
- Department of Neurosurgery, Graduate School of Comprehensive Human Sciences, University of Tsukuba
| | - Masanari SHIIGAI
- Department of Radiology, Graduate School of Comprehensive Human Sciences, University of Tsukuba
| | - Akira MATSUMURA
- Department of Neurosurgery, Graduate School of Comprehensive Human Sciences, University of Tsukuba
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Cerebral venous thrombosis: an unexpected complication from spinal surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2013; 23 Suppl 2:253-6. [DOI: 10.1007/s00586-013-3147-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 12/15/2013] [Accepted: 12/19/2013] [Indexed: 10/25/2022]
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Gonen KA, Taskapilioglu O, Dusak A, Hakyemez B. Persistent headache in a postpartum patient: the investigation and management. BMJ Case Rep 2013; 2013:bcr-2013-009931. [PMID: 23813512 DOI: 10.1136/bcr-2013-009931] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Postdural puncture headache (PDPH) is the most common complication of obstetric regional anaesthesia and the most likely cause of headache in a woman who underwent epidural anaesthesia during delivery. Cerebral venous sinus thrombosis (CVST) is an uncommon cause of postpartum headache. Anaesthesia in obstetrics may lead to long-lasting intracranial hypotension resulting in CVST. CVST is a serious pathology with high mortality if misdiagnosed, but its correct and rapid diagnosis offers the opportunity for early treatment. Cranial magnetic resonance imaging (MRI) is an important modality in the diagnosis of both CVST and intracranial hypotension. The latter condition may be treated either by an epidural blood patch or bed rest and hydration. We report a case of a 36-year-old woman who developed CVST and multiple venous infarcts after an attempted epidural procedure during delivery. She was treated conservatively with bed rest, hydration and low-molecular-weight heparin and the patient recovered completely.
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Affiliation(s)
- Korcan Aysun Gonen
- Department of Radiology, Namik Kemal University, School of Medicine, Tekirdag, Turkey.
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Presicci A, Garofoli V, Simone M, Campa MG, Lamanna AL, Margari L. Cerebral venous thrombosis after lumbar puncture and intravenous high dose corticosteroids: a case report of a childhood multiple sclerosis. Brain Dev 2013; 35:602-5. [PMID: 23044052 DOI: 10.1016/j.braindev.2012.09.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Revised: 09/05/2012] [Accepted: 09/06/2012] [Indexed: 11/28/2022]
Abstract
The association between cerebral venous thrombosis (CVT) and multiple sclerosis (MS) has already been reported in several adult patients with clinically definite MS, in a suspected relation to i.v. corticosteroids or previously performed lumbar puncture (LP). We are reporting a case, which is, to our knowledge, the first one concerning a child patient with a MS, who developed multiple CVT after LP and during high-dose i.v. corticosteroid. Our conclusions are that the sequence LP followed by high dose corticosteroids may be a contributory factor for the development of CVT when associated with other risk factors.
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Affiliation(s)
- Anna Presicci
- Child Neuropsychiatry Unit, Department of Neurological Science and Sense Organs, University Aldo Moro of Bari, Italy
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