Spontaneous intracranial hypotension following epidural anesthesia: a case report

Spontaneous intracranial hypotension following spinal anesthesia initially misdiagnosed as postdural puncture headache

Spontaneous intracranial hypotension (SIH) is not rare, but its diagnosis remains challenging. SIH tends to be misdiagnosed as postdural puncture headache when orthostatic headache develops subsequent to spinal anesthesia because both have similar symptoms. We report the case of a 35-year-old man with orthostatic headache following spinal anesthesia, who did not respond to conventional therapy for postdural puncture headache. SIH was confirmed after epidural fluid collection was identified at the thoracic spine level on magnetic resonance myelography. Physicians must consider SIH despite a history of neuraxial block. Diagnostic work-up is necessary to identify potential cerebrospinal fluid leakage in refractory cases.

Cerebrospinal fluid leaks secondary to dural tears: a review of etiology, clinical evaluation, and management

OBJECTIVE

Damage to the dura mater often occurs in trauma cases of the head and spine, surgical procedures, lumbar punctures, and meningeal diseases. The resulting damage from dural tears, or durotomy, causes cerebrospinal fluid (CSF) to leak out into the surrounding space. The CSF leak induces intracranial hypotension, which can clinically present with a range of symptoms not limited to positional headaches which can confound accurate diagnosis. Current methods of evaluation and management of dural tears are discussed herewith, as well as the present understanding of its etiology, which may be classified as related to surgery, procedure, trauma, or connective tissue disorder.

METHODS

We piloted a MEDLINE® database search of literature, with emphasis on the previous five years, combining keywords such as "cerebrospinal fluid leak," "surgery," "procedure," and "trauma" to yield original research articles and case reports for building a clinical profile.

RESULTS

Patients with suspected dural tears should be evaluated based on criteria set by the International Headache Society, radiological findings, and a differential diagnosis to accurately identify the tear and its potential secondary complications. Afflicted patients may be treated promptly with epidural blood patches, epidural infusions, epidural fibrin glue, or surgical repair. At this time, epidural blood patches are the first line of treatment. Dural tears can be prevented to an extent by utilizing minimally invasive techniques and certain positions for lumbar puncture. Surgical, trauma, lumbar puncture, and epidural injection patients should be observed very carefully for dural tears and CSF leaks as the presenting clinical manifestations can be highly individualized and misguiding.

CONCLUSION

Because studies have demonstrated a high frequency of dural tears, particularly in spinal surgery patients, there is a need for prospective studies so that clinicians can develop an elaborate prevention strategy and response to avoid serious, unseen complications.

The benefits of radiological imaging for postoperative orthostatic headache: a case report

Background

Traditionally, the diagnosis of post-dural puncture headache (PDPH) relied upon the patient’s history regarding dural puncture and symptoms, such as orthostatic headache. However, such evidence may not always be reliable or specific. We report an unexpected diagnosis with spontaneous intracranial hypotension (SIH), which was confirmed upon examination of Magnetic Resonance (MR) images in a patient who was initially suspected to have PDPH because he had recently undergone a uncertain dural puncture.

Case presentation

A 45-year-old man had undergone a thoracic epidural catheter insertion for perioperative analgesia prior to general anesthesia induction. Due to intermittent dripping of fluid while the epidural needle was being advanced, a dural puncture was suspected. The patient complained of an orthostatic headache after recovery from surgery, therefore a PDPH was suspected. MR images revealed signs of SIH: dural sinus engorgement, contrast enhancement along the neural sleeves of the left C6–7, bilateral C7-T1, T1–2, T2–3, T3–4, T4–5, and T5–6. Computed tomography-guided epidural blood patching (EBP) was performed the following day, with the patient experiencing immediate relief of the headache.

Conclusion

The benefits of radiological imaging in this case included confirming the correct diagnosis, guiding the accurate level and proper approach of EBP, distinguishing the epidural space from the intrathecal space, and ultimately increasing the likelihood of successful EBP.

Neuraxial Anesthesia in a Patient With a History of Spontaneous Intracranial Hypotension: A Case Report

One commonly cited complication of neuraxial techniques is postdural puncture headache. Patients with spontaneous intracranial hypotension may present with a similar constellation of symptoms in the absence of any neuraxial instrumentation. The underlying physiology of spontaneous intracranial hypotension is similar to postdural puncture headache, but cerebrospinal fluid leaks may develop spontaneously at multiple levels of the neuraxis due to a variety of proposed mechanisms. We present a patient with a history of spontaneous intracranial hypotension who underwent a total knee arthroplasty under spinal anesthesia without complication and discuss the pathophysiology, proposed etiologies and treatments, and safety of neuraxial anesthesia in spontaneous intracranial hypotension.

A clinical analysis on 40 cases of spontaneous intracranial hypotension syndrome

OBJECTIVE

To investigate clinical and imaging features of 40 patients with spontaneous intracranial hypotension (SIH).

METHODS

40 cases of spontaneous intracranial hypotension (SIH) diagnosed in our hospital from June 2013 to September 2017 were collected and retrospectively analyzed.

RESULTS

In our study, the male to female ratio was 2:3. The average age of onset was 43.0 ± 15.0 years. There were 12 (30.0%) patients with clear incentives, mostly catching cold. The average length of hospital stay was 11.2 ± 6.3 days. All the patients showed orthostatic headaches, 62.5% patients with nausea or vomiting, 40.0% patients with neck stiffness, 17.5% patients with dizziness and vertigo, 10.0% patients with numbness and weakness of limbs, 5% patients with neck discomfort, and 2.5% patients with visual symptoms (visual impairment, photophobia, diplopia). 24 patients underwent CT scans which showed no abnormalities in 20 cases (83.3%), subdural fluid accumulation in 3 cases (12.5%), and subdural haematoma in 1 case (2.5%). Cranial contrast-enhanced MR scans showed diffuse pachymeningeal enhancement (95.83%, 23/24), signs of pituitary hyperaemia in 5 cases (20.8%), subdural fluid accumulation and subdural hematoma in 4 cases (16.7%), sagging of the brain in 3 cases (12.5%), and engorgement of venous structures in 1 case (4.1%). Six patients underwent plain and contrast-enhanced spinal MR scans which showed varying degrees of dural thickening and enhanced performance in all the patients. 92.5% (37/40) of patients had cerebrospinal fluid pressure <60 mmH₂O on lumbar puncture. 97.5% of patients underwent conservative treatment with drugs and had a good outcome.

CONCLUSION

Orthostatic headache and cranial MRI diffuse pachymeningeal enhancement are characteristic features of SIH. Cranial contrast-enhanced MR scan is recognized as the first and non-invasive investigation in the diagnosis of SIH. Most patients had cerebrospinal fluid pressure <60 mmH₂O. The vast majority of patients improved with fluid replacement.

Vocal fold paralysis due to intracranial hypotension following spinal anesthesia

Cranial nerve palsy is a rare neurological complication of epidural and subarachnoid blocks. Most of these complications are attributed to secondary intracranial hypotension due to cerebrospinal fluid leakage following dural puncture. Vocal fold paralysis (VFP) seems more likely to be overlooked and underreported due to delayed onset of symptoms and lack of attribution of dysphonia to spinal anesthesia. Therefore, VFP can often be missed and described as idiopathic. This article describes a case of VFP due to vagus nerve injury following subarachnoid block.