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Pneumocephalus after an epidural steroid injection
Clinical Neurology and Neurosurgery 111 (2009) 309–311
Contents lists available at ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Letters to the Editor a r t i c l e
i n f o
Keywords: Pneumocephalus Epidural injection Headache Loss of consciousness
Pneumocephalus after an epidural steroid injection Dear Sir, Pneumocephalus is defined as the accumulation of intracranial air. It indicates a violation of the dural barrier or the presence of infection [1]. Trauma is the most frequent cause, accounting for 75% of the cases [2]. An 85-year-old woman with a history of low back pain, diabetes, high blood pressure, congestive heart failure and hypothyroidism was undergoing a procedure with epidural steroid and Marcaine injection. Immediately after the procedure she lost consciousness and collapsed. She regained consciousness after 1 min and started having severe global headache and nausea without vomiting. She was admitted to the hospital for observation. An initial head CT scan (Fig. 1) confirmed the presence of air located in the left temporal horn and the anterior horns without signs of hydrocephalus or brain displacement. Headache and
nausea progressively lessened. Twenty-four hours after the initial event, she was completely asymptomatic and was discharged home. She remained asymptomatic with a normal neurologic examination when seen 1 month later. Pneumocephalus has been reported to be secondary to multiple etiologies. It is defined as an intracranial air collection in the extradural, subdural, subarachnoid, intraventricular or intracerebral compartment. There are several reported cases of pneumocephalus after epidural injections, none of which reported loss of consciousness, as was seen in our case [3–6]. Cases have also been reported after lumbar puncture, lumbar catheterization, continuous epidural block, following an epidural blood patch, or as a complication of labor epidural anesthesia. The frequency of intracranial air after a lumbar epidural procedure is uncommon, with an average of one case report per year [7]. Pneumocephalus after a lumbar procedure, like the ones described above, may be caused by air entry in the meninges during the procedure, either by injection or by pressure differential
Fig. 1. Non-contrast axial CT scan demonstrating air (hypodensity) in left temporal horn and bilateral frontal horns of the lateral ventricles.
0303-8467/$ – see front matter © 2008 Elsevier B.V. All rights reserved.
310
Letters to the Editor / Clinical Neurology and Neurosurgery 111 (2009) 309–311
created between the spine and the unoccluded needle [7]. Subarachnoid pressure may easily decrease below the atmospheric pressure, which would permit a small quantity of air to enter. Pneumocephalus usually resolves spontaneously after several days of bed rest and symptomatic treatment. This is a rare potential complication of epidural steroid injection.
References [1] Yildiz A, Ozer C, Egilmez H, Duce MN, Apaydin FD, Yalcinoglu O. Iatrogenic intravascular pneumocephalus secondary to intravenous catheterization. Eur Radiol 2002;12(3):671–2. [2] Apostolakos D, Roistacher K. Pneumocephalus. Mayo Clin Proc 2007;82(11):1305. [3] Simopoulos T, Peeters-Asdourian C. Pneumocephalus after cervical epidural steroid injection. Anesth Analg 2001;92:1576–7. [4] Guarino AH, Wright NM. Pneumocephalus after a lumbar epidural steroid injection. Pain Physician 2005;8:239–41. [5] Nolan RB, Masneri DA, Pesce D. Pneumocephalus after epidural injections. Emerg Med J 2008;25:416. [6] Hawley JS, Ney JP, Swanberg MM. Subarachnoid pneumocephalus from epidural steroid injection. Headache 2005;45(3):247–8. [7] Scott DB. Identification of the epidural space: loss of resistance to air or saline? Reg Anesth 1997;22:1–2.
George J. Hutton ∗ Mirla Avila Gustavo A. Suarez Maxine Mesinger Multiple Sclerosis Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA ∗ Corresponding author at: Baylor College of Medicine, Department of Neurology, 6501 Fannin, NB-100, Houston, TX 77030, USA. Tel.: +1 713 798 8170; fax: +1 713 798 0115. E-mail address: [email protected] (G.J. Hutton)
3 September 2008 doi:10.1016/j.clineuro.2008.10.009
A rare cause of ventriculoatrial shunt malfunction Dear Editor, A 28-year old man with a known history of Dandy–Walker complex was admitted to our emergency room. He complained of headache, vomiting, and episodes of palpitations with onset within 1 day. There were multiple intraabdominal scars, eventually after peritonitis in the past. Five years previously a ventriculoatrial shunt (VAS) had been placed. The patient was mentally retarded. Physical examination revealed no further abnormalities. On computed tomographic (CT) scans hydrocephalus and mega cisterna magna were identified (not shown), that did not significantly differ from previous CT images. A plain radiograph of the neck demonstrated a fracture of the implanted shunt (Fig. 1) a distal fragment of which could be identified in the right ventricle on a chest radiograph (Fig. 2). During admission the patient suffered from cough attacks. A CT investigation of the thorax showed migration of the fractured shunt into the left pulmonary artery (Fig. 3). The embolized fragment was removed via an intravenous approach without complications. After placement of a new shunt, the patient was discharged from the hospital. The implantation of ventriculoperitoneal (VP) or of ventriculoatrial (VA) shunts is a standard therapy method for the management of hydrocephalus [1]. VP shunt is preferred because of the easier placement procedure [2]. VP or VA shunts can be complicated by malfunction due to obstruction, shunt disconnection or infection [1,3]. According to the literature, late complications occur more frequently with VA shunts [2]. VA shunts have a higher revision rate
Fig. 1. Radiograph of the neck demonstrating a fracture of the implanted shunt (arrow).
than VP shunts [1]. Furthermore, VP shunts have a longer shunt durability compared to VA shunts [1]. However, VP shunting can also be associated with serious complications, such as forming of abdominal cerebrospinal fluid (CSF) pseudocysts [4], bowel perforation [5], intraabdominal shunt migration [6], CSF ascites [7], bacterial peritonitis [8], and constipation [9]. In situations where VP shunts cannot be used, such as in intraabdominal infections and scarring, as in the presented case, VA shunts are an effective alternative to drain CSF. According to the literature, several complications can occur after VAS implantation, such as shunt thrombosis resulting in shunt malfunction, pulmonary thromboembolism, cor pulmonale, kinking of the distal catheter, and cardiac thrombus formation [10,11]. Shunt nephritis associated with chronically infected VA shunts has been reported [12]. VA shunt fracture and intravascular embolization is very rare [13]. It may be complicated, e.g. by heart failure or arrhythmia [10,11,13].
Contents lists available at ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Letters to the Editor a r t i c l e
i n f o
Keywords: Pneumocephalus Epidural injection Headache Loss of consciousness
Pneumocephalus after an epidural steroid injection Dear Sir, Pneumocephalus is defined as the accumulation of intracranial air. It indicates a violation of the dural barrier or the presence of infection [1]. Trauma is the most frequent cause, accounting for 75% of the cases [2]. An 85-year-old woman with a history of low back pain, diabetes, high blood pressure, congestive heart failure and hypothyroidism was undergoing a procedure with epidural steroid and Marcaine injection. Immediately after the procedure she lost consciousness and collapsed. She regained consciousness after 1 min and started having severe global headache and nausea without vomiting. She was admitted to the hospital for observation. An initial head CT scan (Fig. 1) confirmed the presence of air located in the left temporal horn and the anterior horns without signs of hydrocephalus or brain displacement. Headache and
nausea progressively lessened. Twenty-four hours after the initial event, she was completely asymptomatic and was discharged home. She remained asymptomatic with a normal neurologic examination when seen 1 month later. Pneumocephalus has been reported to be secondary to multiple etiologies. It is defined as an intracranial air collection in the extradural, subdural, subarachnoid, intraventricular or intracerebral compartment. There are several reported cases of pneumocephalus after epidural injections, none of which reported loss of consciousness, as was seen in our case [3–6]. Cases have also been reported after lumbar puncture, lumbar catheterization, continuous epidural block, following an epidural blood patch, or as a complication of labor epidural anesthesia. The frequency of intracranial air after a lumbar epidural procedure is uncommon, with an average of one case report per year [7]. Pneumocephalus after a lumbar procedure, like the ones described above, may be caused by air entry in the meninges during the procedure, either by injection or by pressure differential
Fig. 1. Non-contrast axial CT scan demonstrating air (hypodensity) in left temporal horn and bilateral frontal horns of the lateral ventricles.
0303-8467/$ – see front matter © 2008 Elsevier B.V. All rights reserved.
310
Letters to the Editor / Clinical Neurology and Neurosurgery 111 (2009) 309–311
created between the spine and the unoccluded needle [7]. Subarachnoid pressure may easily decrease below the atmospheric pressure, which would permit a small quantity of air to enter. Pneumocephalus usually resolves spontaneously after several days of bed rest and symptomatic treatment. This is a rare potential complication of epidural steroid injection.
References [1] Yildiz A, Ozer C, Egilmez H, Duce MN, Apaydin FD, Yalcinoglu O. Iatrogenic intravascular pneumocephalus secondary to intravenous catheterization. Eur Radiol 2002;12(3):671–2. [2] Apostolakos D, Roistacher K. Pneumocephalus. Mayo Clin Proc 2007;82(11):1305. [3] Simopoulos T, Peeters-Asdourian C. Pneumocephalus after cervical epidural steroid injection. Anesth Analg 2001;92:1576–7. [4] Guarino AH, Wright NM. Pneumocephalus after a lumbar epidural steroid injection. Pain Physician 2005;8:239–41. [5] Nolan RB, Masneri DA, Pesce D. Pneumocephalus after epidural injections. Emerg Med J 2008;25:416. [6] Hawley JS, Ney JP, Swanberg MM. Subarachnoid pneumocephalus from epidural steroid injection. Headache 2005;45(3):247–8. [7] Scott DB. Identification of the epidural space: loss of resistance to air or saline? Reg Anesth 1997;22:1–2.
George J. Hutton ∗ Mirla Avila Gustavo A. Suarez Maxine Mesinger Multiple Sclerosis Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA ∗ Corresponding author at: Baylor College of Medicine, Department of Neurology, 6501 Fannin, NB-100, Houston, TX 77030, USA. Tel.: +1 713 798 8170; fax: +1 713 798 0115. E-mail address: [email protected] (G.J. Hutton)
3 September 2008 doi:10.1016/j.clineuro.2008.10.009
A rare cause of ventriculoatrial shunt malfunction Dear Editor, A 28-year old man with a known history of Dandy–Walker complex was admitted to our emergency room. He complained of headache, vomiting, and episodes of palpitations with onset within 1 day. There were multiple intraabdominal scars, eventually after peritonitis in the past. Five years previously a ventriculoatrial shunt (VAS) had been placed. The patient was mentally retarded. Physical examination revealed no further abnormalities. On computed tomographic (CT) scans hydrocephalus and mega cisterna magna were identified (not shown), that did not significantly differ from previous CT images. A plain radiograph of the neck demonstrated a fracture of the implanted shunt (Fig. 1) a distal fragment of which could be identified in the right ventricle on a chest radiograph (Fig. 2). During admission the patient suffered from cough attacks. A CT investigation of the thorax showed migration of the fractured shunt into the left pulmonary artery (Fig. 3). The embolized fragment was removed via an intravenous approach without complications. After placement of a new shunt, the patient was discharged from the hospital. The implantation of ventriculoperitoneal (VP) or of ventriculoatrial (VA) shunts is a standard therapy method for the management of hydrocephalus [1]. VP shunt is preferred because of the easier placement procedure [2]. VP or VA shunts can be complicated by malfunction due to obstruction, shunt disconnection or infection [1,3]. According to the literature, late complications occur more frequently with VA shunts [2]. VA shunts have a higher revision rate
Fig. 1. Radiograph of the neck demonstrating a fracture of the implanted shunt (arrow).
than VP shunts [1]. Furthermore, VP shunts have a longer shunt durability compared to VA shunts [1]. However, VP shunting can also be associated with serious complications, such as forming of abdominal cerebrospinal fluid (CSF) pseudocysts [4], bowel perforation [5], intraabdominal shunt migration [6], CSF ascites [7], bacterial peritonitis [8], and constipation [9]. In situations where VP shunts cannot be used, such as in intraabdominal infections and scarring, as in the presented case, VA shunts are an effective alternative to drain CSF. According to the literature, several complications can occur after VAS implantation, such as shunt thrombosis resulting in shunt malfunction, pulmonary thromboembolism, cor pulmonale, kinking of the distal catheter, and cardiac thrombus formation [10,11]. Shunt nephritis associated with chronically infected VA shunts has been reported [12]. VA shunt fracture and intravascular embolization is very rare [13]. It may be complicated, e.g. by heart failure or arrhythmia [10,11,13].