Acta Neurol Belg DOI 10.1007/s13760-014-0371-2

LETTER TO THE EDITOR

Not everything that worsens on standing is intracranial hypotension! Kaustubh Limaye • Zabeen Mahuwala Ricky W. Lee



Received: 18 August 2014 / Accepted: 24 September 2014 Ó Belgian Neurological Society 2014

Complications from epidural steroid injection occur mostly when the dura has been accidentally punctured. Most headaches occurring after an epidural procedure are the result of cerebrospinal fluid (CSF) leakage. A less common and under-recognized cause of post-epidural headache is pneumocephalus. The technique used to identify the epidural space during the epidural steroid injection is either loss of resistance to saline (LORS) or loss of resistance to air (LORA). LORA is more commonly associated with pneumocephalus than LORS [1, 2]. We describe an interesting case of pneumocephalus in a patient with orthostatic headache as a presenting chief compliant.

completely alleviate the presumed post-dural puncture headache (PDPH). Brain imaging was obtained. A computed tomography (CT) of head revealed pneumocephalus in the frontal and temporal part of the right lateral ventricle (Fig. 1a). In the view of unexpected pneumocephalus on CT head, magnetic resonance imaging (MRI) of brain with contrast was pursued (Figs. 2, 3). MRI brain again showed pneumocephalus. However, MRI brain did not reveal any abnormal leptomeningeal enhancement or subdural hygroma to suggest the presence of intracranial hypotension (Fig. 2). His headache was further improved with high-flow oxygen therapy. Repeat head CT at 1 week post-discharge showed resolution of pneumocephalus (Fig. 1b) and complete resolution of symptoms.

Case report

Discussion

A 24-year-old man received his first epidural steroid injection for his chronic low back pain. Immediately after the procedure, he complained of bilateral frontal headache that was worse on standing and better in supine position. He presented to our emergency department when his headache was not relieved by over-the-counter pain medications. He was subsequently admitted to the hospital for pain control. IV fluids, caffeine and blood patch did not

Our patient presented with orthostatic headache, which is a prototypical manifestation of post-dural puncture headache (PDPH). The lack of MRI brain findings for intracranial hypotension was unexpected, but not surprising as studies have shown up to 20–30 % of patients with intracranial hypotension would have a normal cranial MRI [3]. The incomplete resolution of his headache after the blood patch raises the possibility of additional pathology causing his headache. Cranial imaging revealed the presence of unexpected pneumocephalus. The further improvement of his symptoms with high-flow oxygen therapy would suggest this patient had mixed headaches of PDPH and pneumocephalus. Pneumocephalus is a rare complication from epidural steroid injection. Headache due to pneumocephalus is characterized by early onset and lack of relief by lying down [4]. However, our case shows that in patients with

Introduction

K. Limaye (&)  Z. Mahuwala  R. W. Lee University of Arkansas for Medical Sciences, 4301 W.Markham, #500, Little Rock, AR 72202, USA e-mail: [email protected] R. W. Lee Central Arkansas Veterans Healthcare System, Little Rock, AR, USA

123

Acta Neurol Belg Fig. 1 a Initial head CT and b repeat head CT post-hospital discharge

Fig. 3 Sagittal MRI brain with gadolinium without evidence of intracranial hypotension

refractory to conventional therapy, so appropriate therapy can be pursued. Fig. 2 Axial MRI brain with gadolinium showing pneumocephalus without evidence of intracranial hypotension

coexisting PDPH, improvement of headache after lying down cannot reliably rule out the possibility of pneumocephalus. Pneumocephalus responds well to the oxygen therapy by facilitating denitrogenation and quicker air absorption [1, 5, 6], while PDPH secondary to CSF leak is managed by administering a blood patch. Here we report, to our knowledge, a rare case of a patient with coexisting PDPH and pneumocephalus after accidental dural puncture during an epidural steroid injection procedure. We believe early brain imaging might be indicated in patients with orthostatic headache that is

123

Conflict of interest Kaustubh Limaye, Zabeen Mahuwala and Ricky W. Lee report no disclosures relevant to the manuscript.

References ´ , Ferna´ndez-Goti MC (2013) Pneumocephalus 1. Go´mez-Rı´os MA after inadvertent dural puncture during epidural anesthesia. Anesthesiology 118(2):444 2. Kang XH, Bao FP, Xiong XX, Li M, Jin TT, Shao J, Zhu SM (2014) Major complications of epidural anesthesia: a prospective study of 5083 cases at a single hospital. Acta Anaesthesiol Scand. 2014 Jun 24 3. Schievink WI (2006) Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA 295:2286–2295

Acta Neurol Belg 4. Katz JA, Lukin R, Bridenbaugh PO, Gunzenhauser L (1991) Subdural intracranial air: an unusual cause of headache after epidural steroid injection. Anesthesiology 74:615–618 5. Fournet-Fayard A, Malinovsky JM (2013) Post-dural puncture headache and blood-patch: theoretical and practical approach. Ann Fr Anesth Reanim 32(5):325–338

6. Bezov D, Ashina S, Lipton R (2010) Post-dural puncture headache: part II—prevention, management, and prognosis. Headache 50(9):1482–1498

123

Not everything that worsens on standing is intracranial hypotension!

Not everything that worsens on standing is intracranial hypotension! - PDF Download Free
400KB Sizes 2 Downloads 8 Views