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Subdural hematoma after lumbar puncture: two case reports and review of the literature
Subdural hematoma after lumbar puncture: two case reports and review of the literature P.E. Vos* * * * *, W.A. de Boer* *, J.A.L. Wurzer* * *, and J. van Gijn* * * *
Introduction Summary
Post lumbar puncture headache (PLPH) is a common problem (30-40%) following lumbar puncture (LP), myelography or spinal anesthesia. PLPH may be accompanied by several other symptoms: nausea and vomiting, stiff neck, vertigo, tinnitus or even hearing loss, diplopia, and blurred visior&*. These symptoms are caused by cerebrospinal fluid (CSF) hypotension and characteristically are posture dependent. They arise when the patient is upright and immediately disappear when the patient lies down. Intracranial subdural hematoma (SDH) is a rare complication of lumbar puncture (see table 1 & 2), but it should be considered in all patients who complain of persistent headache after lumbar puncture. SDH has been described after inadvertent dural puncture in epidural anesthesia, after lumbar myelography, and after spinal anesthesia. The following two case reports describe the occurrence of SDH after cervical myelography, via the lumbar route and after lumbar puncture performed for laboratory analysis only. Case reports
Case l- A 54-year old man underwent myelography * ** *** ****
for evaluation
of a recurrent
cervical cervi-
Two cases of intracranial subdural hematoma following lumbar puncture are presented. A review of all previously reported cases shows that subdural hematoma after lumbar puncture is a rare but serious complication. The pathogenesis of subdural hematoma after lumbar puncture is probably related to that of post lumbar puncture headache. Application of an epidural blood patch may therefore be a safe way not only to treat typical post lumbar puncture headache but also to prevent subdural hematoma after lumbar puncture. Key words: myelography; subdural hematoma; epidural blood patch; lumbar puncture; spinal anesthesia.
cal root syndrome.
Four years before he had been operated upon for removal of a C5-C6 intervertebral prolapse on the left side. Fifteen ml Iopamiro@ 300 fluid was injected through a single lumbar puncture at the L4-L5 level. A 22 Gauge needle was used. During myelography the patient was tilted in prone, head down posi-
tion. Apart from a small ventral indentation of the contrast column no abnormalities were seen. After the puncture he complained of postural headache for several days, which was treated with bed rest. The symptoms gradually disap-
Rudolf Magnus Institute for Pharmacology, Utrecht, The Netherlands. Department of Internal Medicine, Academic Medical Centre, Amsterdam, The Netherlands Department of Neurosurgery, Westeinde Hospital, Den Haag, The Netherlands. University Department of Neurology, Utrecht, The Netherlands.
Address for correspondence and reprint requests: Pieter E. Vos, University Department of Neurology, 3584 CX Utrecht, The Netherlands
Heidelberglaan
100,
Accepted 12.10.90 Clin Nemo1 Neurosurg 1991. Vol. 93-2
127
peared and he was discharged 3 days later. Twenty days after cervical myelography the patient still suffered from headache, an EEG was made which was normal. Thirty-five days after cervical myelography he was readmitted to another hospital because of intractable headaches. There was no history of trauma or of alcohol abuse. The headache was initially attributed to persistent leakage of CSF through the puncture hole, and he was treated with bed rest. Because the symptoms persisted, he was treated with an epidural blood patch (EBP) 38 days after cervical myelography. Despite this treatment, no improvement occurred. From the 44th day onwards, the headache was located unilaterally, on the left side, instead of bifrontally, and it did not disappear on lying down. He became more severely ill, with dizziness, nausea and vomiting. There were no focal neurological signs. Haematologic screening and coagulation tests were normal. The EEG showed slow activity over the left hemisphere. CT-scanning finally showed a left-sided isodense subdural hematoma. On the 46th day after cervical myelography, burr hole exploration was carried out and a chronic subdural hematoma was evacuated. Following surgery the patient made a gradual and complete recovery and he was discharged 10 days postoperatively.
ing showed no biochemical or coagulation disorders. CT scanning showed a border zone infarct between the territories of the left middle and posterior cerebra1 arteries. A diagnostic lumbar puncture, one day after CT-scanning. gave a normal pressure, and analysis of the cerebrospinal fluid showed no abnormalities. An ECG showed evidence of an apical infarct which was not present on an ECG performed several months before. It was assumed that the cerebral infarct had developed as a result of hypotension after myocardial infarction. Five hours after the LP the patient started complaining of throbbing headache with a postural character. This headache persisted on the first and second day after LP. On the second day he suddenly became more unwell, with increased headache, nausea and vomiting. A right-sided central facial palsy and a right hemiplegia were diagnosed. A CT scan showed a subdural hematoma over the left hemisphere. Burr hole exploration was performed, and the SDH was evacuated. Postoperatively the signs and symptoms disappeared within two months. Eight months after operation, neurological examination showed only the minimal left sided weakness that existed before the LP.
Case 2- A 61-year old man was admitted to the hospital because of memory disorders and loss of dexterity. He had been well until 3 months earlier when he suffered one evening from dyspnoea, sweating and chest pain. From that time on he had difficulties in writing and in remembering phone numbers. He experienced no weakness but was yet unable to open and close doors and to manipulate faucets. His past medical history included essential hypertension for which he was treated with labetalol and dipyridamol. General physical examination was normal. On neurological examination, speech was fluent and speech comprehension was normal. On reading, however, he showed perseveration, and on writing there were disphasic errors of spelling. There was also constructional apraxia and a disturbance of visual orientation, but no finger agnosia. In the limbs, a minima1 left-sided hemiparesis was found. Haematological screen-
After LP the spinal needle leaves a small hole in the dura mater, through which CSF can leak to the epidural space. If leakage of CSF exceeds the production of CSF, the CSF volume will decrease. PLPH is caused by CSF hypotension. The volume depletion is partially compensated by (painful) venous dilatation and by an increase of brain vo1ume2. The brain, normally kept afloat by the CSF, will be displaced downwards when the patient assumes a vertical position, with stretching of the pain-sensitive veins and meninges. This explains the typical postural character of PLPH’x*,“. The same pathogenesis as that for PLPH can be invoked to explain the occurrence of SDH after LP. Congestion of bridging veins, in combination with traction by downward displacement of the brain, may cause tearing of these veins in the subdural space, and unilateral or bilateral SDH will develop. Other causes of SDH associated with reduced counter pressure
128
Discussion
Table
1. Review
Study
of cases of SDH following
lumbar
puncture
for anesthetic
Age --
Procedure
Sex
Indication
0
spinal anesthesia
Gerlach
purposes
Diagnosis
PLPH
Therapy
Outcome
? 10d
RSDH
+
none
CR
Interval
Welch
69/M 421F
spinal anesthesia spinal anesthesia
22 7w ? 5m
Bil. SDH LSDH
+ f
surgery surgery
: CR
Arseni
2.7130 46/49 58162 M 42/F
spinal anesthesia
?
LSDH
?
surgery
CR
IF
accidental LP Iabour accidental LP labour accidental LP labour spinal anesthesia rectal abcess accidental LP labour spinal anesthesia
Ganz McDonald Jack
29/F
Pavlin
23iF 37/M
Edelman
22lF
Reinhold
36/F
Reynolds
22/F
Mantia
27iF
l-4m
ref
PI
(4) Bil. SDH accidental
LP
?
llw
(2) SDH
+
surgery
CR
?
?
RSDH
+
surgery
CR
?
28d
Bil. SDH
+
surgery
CR
18 8d
Bil. SDH
+
surgery
CR
22 6d
RSDH
+
surgery
PR
16 4od
Bil. SDH
i-
non
t
1171
18 18d
LSDH
+
surgery
CR
1231
25 35h
LSDH
-
surgery
PR
1241
26 Sd
RSDH
+
CR
1251
25 Ild
RSDH
+
?
1261
18 4w
Bil. SDH
-
conservative conservative surgery
PR
1271
22 13d
LSDH
-
surgery
-t
21 26d
LSDH
+
surgery
CR
I91
22 2Od
RSDH
+
surgery
CR
1281
24 13d
LSDH
-
surgery
CR
1291
22 21d
Bil. SDH
+
surgery
CR
I301
22 Jm
LSDH
+
surgery
CR
1311
?
3od
LSDH
+
surgery
CR
1321
?
16d
SDH
-
surgery
CR
I331
25 21d
LSDH
-
surgery
CR
1341
?
Bil. SDH
?
surgery
CR
1351
Jonsson
63/M
Personne
70/M
Kiersz
79/M
Giamundo
SO/M
Ruutiainen
69/M
Blake
67/M
Lam-My
3.5/M
accidental LP labour spinal anesthesia labour spinal anesthesia urological operation accidental LP labour spinal anesthesia inguinal hernio~haphy spinal anesthesia cesarean section spinal anesthesia inguinal hemiorrhaphy spinal anesthesia inguinal hemiorrhaphy spinal anesthesia hydrocele spinal anesthesia spermatocele spinal anesthesia inguinal terniorrhaphy spinal anesthesia urological operation spinal anesthesia urotogical operation accidental LP
Kunz
70/M
spinal anesthesia
25 43d
LSDH
?
surgery
CR
[361
Brinquin
47/M
spinat anesthesia
?
3w
RSDH
+
surgery
CR
1371
Degiaire
70/M
accidentai
17 30h
RSDH
?
surgery
*
I381
BCal
67/M
spinal anesthesia
22 6d
I.. SDH
+
surgery
PR
1391
61/M
diagnostic
?
LSDH
+
surgery
CR
Eernla Newrick
29/F 67iM
Miyazaki
33/F
Rudehi
LP
LP
6Od
12d
Abbreviations: M = mate; F = female; LP = lumbar puncture; 8 = needle diameter (Gauge); h = hours; d = days; w = weeks; m = months; L = left; R = right; Bil. = bilateral; SDH = subdural hematoma; PLPH = post lumbar puncture headache; CR = complete recovery; PR = partial recovery; : = died; ref = reference.
129
Table 2. Review of cases of SDH following
lumbar
puncture
for lumbar
myelopraphy
_-_ ..- -_.. ._ Age
Iel
Study
SCX
Indication
0
Interval
Diagnosis
PLPH
Therapy
Gabriele
58/M
low back pain
”
id
RSDH
+
none
Alemohammed
40/M
low back pain
IX hw
Bil. SDH
t
surgery
CR
Von E. Heiss
60/M
low back pain
‘!
Sd
LSDH
+
surgery
CR
Dohrmann
65/M
low back pain
9
Zld
RSDH
surgery
CR
50/M
low back pain
?
Xd
RSDH
-
surgery
:
Benzon
58/F
sciatica
?
5d
LSDH
-
none
t
1161
Gupta
62/M
lumbar stenosis
‘?
2w
LSDH
?
none
CR
1441
Dan
31/F
sciatica
7
26d
R SDH
‘?
surgery
CR
1451
Megele
50/F
low back pain
20 16d
RSDH
?
surgery
CR
1461
Lam-My
52/F
low back pain
?
RSDH
surgery
CR
I351
Llewellyn
40/M
low back pain
20 4d
LSDH
+
surgery
CR
I471
vos
54/M
cervical root syndrome
22 44d
LSDH
+
surgery
CR
60d
Gutcomc
Abbreviations: M = male; F = female; LP = lumbar puncture; 0 = needle diameter (Gauge); h = hours; d = days; w = weeks; m = months; L = left; R = right; BiI. = bilateral; SDH = subdural hematoma; PLPH = post lumbar puncture headache; CR = complete recovery; PR = partial recovery; t = died; ref = reference.
of the brain, are cerebral atrophy, brain shrinkage from alcoholism and operative shunting of the ventricular system4s5*6.SDH also complicated an operation on a tumor of the cauda equina with withdrawal of large amounts of CSF7. Another theory for the development of acute or chronic SDH was proposed by ArakiB and later by Miyazaki et aP. They hypothesized that acute SDH results from laceration of the superior sagittal sinus. If only the arachnoid granulation in the parasagittal subdural region ruptures and the sinus itself remains intact, leakage of CSF will only cause a chronic hygroma. The incidence of SDI-I after LP is not known. We expect that a patient with severe PLPH, and therefore probably with a greater displacement of the brain, is at more risk of developing SDH than a patient with minor PLPH complaints. All 35 reported cases of SDH in relation to spinal or epidural anesthesia have been summa130
rized in table 1. In table 2 we listed all 12 reported cases of SDH after LP for myelographic procedures. All cases were clearly related to the lumbar puncture, without a history of trauma or other predisposing factors. In 25 of the 47 reviewed cases a clear history of PLPH preceded the demonstration of SDH, in 10 cases it was recorded absent and in 12 cases it could not be distilled from the text. This association gives support to the role of CSF hypotension in the development of SDH. The tables make clear that the use of a small bore needle does not absolutely protect against SDH. Use of a 26G needle, however, diminishes the incidence of PLPH’O and therefore will probably also diminish the chance of developing SDH after LP. Only one case has been reported with this needle size. In the elderly patient, cerebral atrophy and vulnerability of the venous wall may increase the risk of SDH”.
Our review also shows that SDH is a potentially serious complication; of the 47 reported patients 8 died and 4 were left with serious neurological deficits. PLPH can be easily differentiated from other forms of headache by its postural character. Other rare causes of headache are lumbar puncture induced meningitis and, in case of a preexistent brain shift, tentorial or tonsillar herniation. SDH should be suspected if PLPH lasts for longer than a week, if it loses its typical postural character, or when it returns after an initial disappearance. Cases with small SDH’s may be missed, if these spontaneously resolve’2*13. Treatment of PLPH may also prevent development of SDH. A safe and successful therapy for PLPH is E13P1~*2~‘4. By means of an epidural needle 10 cc autologous blood is introduced in the epidural space. A clot will form over and in the dural rent, thus stopping further leakage of CSFi2. In patients with chronic PLPH, the success rate of this procedure is very high (859.5%)s*‘4.1*.In the cases reviewed by us SDH developed as early as 30 hours and as late as 5 months after LP. The average interval was 25 days. Apparently, intracranial hypotension usually exists for a long time before SDH develops. If patients with severe and prolonged postural headache would be treated with EBP not only the symptoms would disappear, but so might the risk of SDH16.“. References DE BOER WA. Hoofdpijn na lumbale punctie. Ned Tijdschr Geneeskd 1987; 131:2(X%12. HILTON JONES D. What is post lumbar puncture headache and is it avoidable? In Wharlow C, Garfield T, eds. Dilemmas in the management of the neurological patient. Edinburgh: Churchill Livingstone, 1984; 144-57. ARSENI C,IONESCUS,L~NU M. Intracranialhypotension, an etiologic factor of subdural hematoma (chronic subdural hematoma following spinal subarachnoid block anesthesia). Rev Roum de Nemo1 1970; 7~283-6. MARKWALDER T-M. Chronic subdural hematomas: a review. J Neurosurgery 1981; 54637-45. SAMUELSON S,LONGDM,SHOU SN. Subduralhematoma as a complication of shunting procedures for normal pressure hydrocephalus. J Neurosurg 1972; 37548-51. WHITTIER JR. Deaths related to pneumoencephalography during a six year period. Arch Neural Psychiat 1951; 65:463-71. COONEY JF,BAKER GS. Subdural hematoma following an operation on the spinal cord Report of acase. Proc. Staff Meet. Mayo Clin. 1953; 28~364-7. ARAKI C. Pathology of chronic subdural hematoma and
hygroma. Proceedings of the 5th International Congress of Neurological Surgery. Tokyo, Amsterdam; Extra Medica Press, 1973. MIYAZAKI s, FLJKUSHIMA H,KAMATA K,ISHII s. Chronic subdural hematoma after lumbar-subarachnoid analgesia for a cesarian section. Surgical Neuroll983; 19:45960. TOIJRTELOTT'E WW,
HENDERSON
LANDO,WALKERJE,KOKMAN
WG, TUCKER
RP, GIL-
E. Arandomizeddouble
blind clinical trial comparing the 22 versus the 26 gauge needle in the production of the post lumbar puncture syndrome in normal individuafs. Headache 1972; 12:73-8. ARONSON SM, OKAZAKI H. A study of some factors modifying response of cerebral tissue to subdural hematoma. J Neurosurg 1962; 20:89-93. DIGIOVANNI AJ, GALBERT MW, WAHLE MW. Epiduralinjections of autologous blood for post lumbar puncture headache. Anest Anaig 1972; 51:226-32. GANNONWE,COOKAW,BROWDERE~. Resoivingsubdural collections. J Neurosurg 1962; 19:865-9. ABOULEISH E. Epidural blood patch for the treatment of chronic post lumbar puncture cephalgia. Anesthesiology 1978; 49:291-2. VAN
CREVEL
H, MUIZELAAR
JP, VAN
OUWERKERK
RC.
Behandeling van langdurig post punctionele hoofdpijn. Ned Tijdschr Geneeskd 1987; 131:2003-S. BENZON HT. Intracerebral hemorrhage after dural puncture and epidural blood patch: non-~stural and noncontinuous headache. Anesthesiology 1984; 6&258-g. EDELMAN JD, WINGARD DW. SubduraI hematomas after lumbar dural puncture. Anesthesiology 1980; 52:166-7. GERLACH I.Subduraihamatom und erniedrigter Schadelinnend~ck. Dtsch Zeits Ne~enheiik 1949; 160:387. WELCH K. Subdural hematoma following spinal anesthesia. A.M.A. Arch Surg 1959; 79:49-51. JACK TM. Postpartum intracranial subdural hematoma. Anaesthesia 1979; 34: 176-8. MCDONALD MD. Subdural hematoma: an unusual post lumbar epidural, post puncture CompIication. Abs Scien Pap ASA Ann Meet. Anesthesiology 1977 suppl; 455-6. PAVLIN DJ, MCDONALD JS, CHILD B, RUSCH v. Acute subdural hematoma: an unusuai sequeta to lumbarpuncture. AnesthesioIogy 1979; 51:338-40. REINHOLD P,LINDAU 8, B&M. Chroni~hessu~uraies Hamatom nach peridural Ankthesie. Anasth Intensivther Notfallmed 1980; 15428-31. REYNOLDS AF, SLAVIN L. Postpartum acute subdural hematoma; a probable complication of saddle block analgesia. Neurosurgery 1980; 7:398-9. MANTIA AM. Clinical report of the occurrence of an intracerebral hemorrhage following post-lumbar puncture headache. Anesthesiology 1981; .55:684-5. EEROLA M, KAUKINEN L, KAUKINEN s. Fatal brain lesion following spinal anesthesia. Acta Anaesth Stand 1981; 25:115-6. NEWRICK P, READ D. Subdural hematoma as a complication of spinal anaesthetic. Br Med J 1982; 285:341-2. RUDEHILL A,GORDON E,RAWN T. Subdural hematoma. A rare but life threatening complication after spinal anaesthesia. Acta Anaesthesiol Stand 1983; 27:376-7. IONSSON LO,EINARSSON P,OI_SSONGL. Subduralhaematoma and spinal anaesthesia. Anaesthesia 1983; 38: 144-6. PERSONNE M. Intrakraniellt subduraihematom~vaniig komplikation till spinalanestesi. L~ka~idningen 1983; 80:333. KIERSZ R, LINDSKOG G. Intrakraniell blodning efter lum-
131
balpunktion. Lakartidningen ”
GIAMUNDO
A, BENVENUTI
1985; H2:2795
v, LAVANO
A, V'ANVREA
F.
Chronic subdural hematoma after spinal anaesthesia. J Neurosurg Sci 1985; 29:153-5. ” RUUTIANEN J, MARTILLA R. Subduraalhematooma spinaalianestesian salkavala komplikaatio. Duodecim 19%; 102:376-7. y BLAKE DW.DON~AN G,JENSEN D. Intracrani~ subdural hematoma after spinal anaesthesia. Anaesth Intensive Care 1987; 15:341-2. 3s LAM-MYS,ARLAUVJ,GRISOLIF,LEHMANG. Hematomes sous duraux intracrlniens subaigus apres ponction lombaire. La Presse Medicale 1987; 161979-80. 36 KUNZ LJ,PANNING B, STOLKE n. Chronisches Subduralhematom nach einer Spinalanaesthesie. RegionalAnaesthesia 1989; 12~34-37. ” BRINQUIN L,BONSIGNOURJP,BlRON R,DEBuEIF,HORF, DIRAISON Y, BUFFAT JJ.Hematome sous-durai intra-cranien dans les suites d’une rachianesth~sie 198x; Cah. Anesthesiol.; 36:379-X0. ‘* DEGLAIRE 8,VUVERGER P,MUCKENSTuRM B,MAISSINF, DESBORVES JM. HCmatome sous-dural aigu intra-cranien apres brtche dure-merienne accidentelle lors dune anesthesie peridurale 1988; Ann Fr Anesth RCanim 7: 156-8. sg BEAL IL, ROYER JM, FREYSZ M, POLI L, WILKENING M.
132
” ”
”
J3
U
45 uI 37
Hematome sous-dural aigu mtracramen d origme drtcrielle apres rachianesthesie 19R9; Ann Fr Aricsth RCanim 8: 143-S. GABKIELE OF. Subdural hematoma and lumbar diskography. JAMA 1969; 207: 1%. ALEMOHAMMED s, BOUZARTH WF. intracranial subdural hematoma following lumbar myelography. J Neurosurg 1980; 52256-K VON HEISS E. NEUBAUER u. Akutes subdurales hematom nach lumbaler Myelography. Fortschr Rontgonstr 1981: 135:735-6. DOHRMANN PJ,ELRICK WL, SIU KH. Intracranial sudural hematoma after lumbar myelography. Neurosurgery 1983; 12:694-6. GUPTA SK, NAHEEDY MH, RUBINO FA. Cranial subdural hematoma following lumbar myelography. Comput Radiof 1985; 9:129-31. DAN NG. Intracranial subdural haematoma after metrizamide myelo~aphy. Med J Austr 1984; 140:289-90. MEGELE R. Kraniales Subduraihamatom nach Myelography. Dtsch Med Wochenschr 1986; 111:1820-2. LLEWELLYN CG,CAMPBELL VR,QUAR-rEY GRc:.Case report: Intracranial subdural hematoma complicating metrizamide myelography. J Can Assoc Radio1 1988; 39:230-l.
Introduction Summary
Post lumbar puncture headache (PLPH) is a common problem (30-40%) following lumbar puncture (LP), myelography or spinal anesthesia. PLPH may be accompanied by several other symptoms: nausea and vomiting, stiff neck, vertigo, tinnitus or even hearing loss, diplopia, and blurred visior&*. These symptoms are caused by cerebrospinal fluid (CSF) hypotension and characteristically are posture dependent. They arise when the patient is upright and immediately disappear when the patient lies down. Intracranial subdural hematoma (SDH) is a rare complication of lumbar puncture (see table 1 & 2), but it should be considered in all patients who complain of persistent headache after lumbar puncture. SDH has been described after inadvertent dural puncture in epidural anesthesia, after lumbar myelography, and after spinal anesthesia. The following two case reports describe the occurrence of SDH after cervical myelography, via the lumbar route and after lumbar puncture performed for laboratory analysis only. Case reports
Case l- A 54-year old man underwent myelography * ** *** ****
for evaluation
of a recurrent
cervical cervi-
Two cases of intracranial subdural hematoma following lumbar puncture are presented. A review of all previously reported cases shows that subdural hematoma after lumbar puncture is a rare but serious complication. The pathogenesis of subdural hematoma after lumbar puncture is probably related to that of post lumbar puncture headache. Application of an epidural blood patch may therefore be a safe way not only to treat typical post lumbar puncture headache but also to prevent subdural hematoma after lumbar puncture. Key words: myelography; subdural hematoma; epidural blood patch; lumbar puncture; spinal anesthesia.
cal root syndrome.
Four years before he had been operated upon for removal of a C5-C6 intervertebral prolapse on the left side. Fifteen ml Iopamiro@ 300 fluid was injected through a single lumbar puncture at the L4-L5 level. A 22 Gauge needle was used. During myelography the patient was tilted in prone, head down posi-
tion. Apart from a small ventral indentation of the contrast column no abnormalities were seen. After the puncture he complained of postural headache for several days, which was treated with bed rest. The symptoms gradually disap-
Rudolf Magnus Institute for Pharmacology, Utrecht, The Netherlands. Department of Internal Medicine, Academic Medical Centre, Amsterdam, The Netherlands Department of Neurosurgery, Westeinde Hospital, Den Haag, The Netherlands. University Department of Neurology, Utrecht, The Netherlands.
Address for correspondence and reprint requests: Pieter E. Vos, University Department of Neurology, 3584 CX Utrecht, The Netherlands
Heidelberglaan
100,
Accepted 12.10.90 Clin Nemo1 Neurosurg 1991. Vol. 93-2
127
peared and he was discharged 3 days later. Twenty days after cervical myelography the patient still suffered from headache, an EEG was made which was normal. Thirty-five days after cervical myelography he was readmitted to another hospital because of intractable headaches. There was no history of trauma or of alcohol abuse. The headache was initially attributed to persistent leakage of CSF through the puncture hole, and he was treated with bed rest. Because the symptoms persisted, he was treated with an epidural blood patch (EBP) 38 days after cervical myelography. Despite this treatment, no improvement occurred. From the 44th day onwards, the headache was located unilaterally, on the left side, instead of bifrontally, and it did not disappear on lying down. He became more severely ill, with dizziness, nausea and vomiting. There were no focal neurological signs. Haematologic screening and coagulation tests were normal. The EEG showed slow activity over the left hemisphere. CT-scanning finally showed a left-sided isodense subdural hematoma. On the 46th day after cervical myelography, burr hole exploration was carried out and a chronic subdural hematoma was evacuated. Following surgery the patient made a gradual and complete recovery and he was discharged 10 days postoperatively.
ing showed no biochemical or coagulation disorders. CT scanning showed a border zone infarct between the territories of the left middle and posterior cerebra1 arteries. A diagnostic lumbar puncture, one day after CT-scanning. gave a normal pressure, and analysis of the cerebrospinal fluid showed no abnormalities. An ECG showed evidence of an apical infarct which was not present on an ECG performed several months before. It was assumed that the cerebral infarct had developed as a result of hypotension after myocardial infarction. Five hours after the LP the patient started complaining of throbbing headache with a postural character. This headache persisted on the first and second day after LP. On the second day he suddenly became more unwell, with increased headache, nausea and vomiting. A right-sided central facial palsy and a right hemiplegia were diagnosed. A CT scan showed a subdural hematoma over the left hemisphere. Burr hole exploration was performed, and the SDH was evacuated. Postoperatively the signs and symptoms disappeared within two months. Eight months after operation, neurological examination showed only the minimal left sided weakness that existed before the LP.
Case 2- A 61-year old man was admitted to the hospital because of memory disorders and loss of dexterity. He had been well until 3 months earlier when he suffered one evening from dyspnoea, sweating and chest pain. From that time on he had difficulties in writing and in remembering phone numbers. He experienced no weakness but was yet unable to open and close doors and to manipulate faucets. His past medical history included essential hypertension for which he was treated with labetalol and dipyridamol. General physical examination was normal. On neurological examination, speech was fluent and speech comprehension was normal. On reading, however, he showed perseveration, and on writing there were disphasic errors of spelling. There was also constructional apraxia and a disturbance of visual orientation, but no finger agnosia. In the limbs, a minima1 left-sided hemiparesis was found. Haematological screen-
After LP the spinal needle leaves a small hole in the dura mater, through which CSF can leak to the epidural space. If leakage of CSF exceeds the production of CSF, the CSF volume will decrease. PLPH is caused by CSF hypotension. The volume depletion is partially compensated by (painful) venous dilatation and by an increase of brain vo1ume2. The brain, normally kept afloat by the CSF, will be displaced downwards when the patient assumes a vertical position, with stretching of the pain-sensitive veins and meninges. This explains the typical postural character of PLPH’x*,“. The same pathogenesis as that for PLPH can be invoked to explain the occurrence of SDH after LP. Congestion of bridging veins, in combination with traction by downward displacement of the brain, may cause tearing of these veins in the subdural space, and unilateral or bilateral SDH will develop. Other causes of SDH associated with reduced counter pressure
128
Discussion
Table
1. Review
Study
of cases of SDH following
lumbar
puncture
for anesthetic
Age --
Procedure
Sex
Indication
0
spinal anesthesia
Gerlach
purposes
Diagnosis
PLPH
Therapy
Outcome
? 10d
RSDH
+
none
CR
Interval
Welch
69/M 421F
spinal anesthesia spinal anesthesia
22 7w ? 5m
Bil. SDH LSDH
+ f
surgery surgery
: CR
Arseni
2.7130 46/49 58162 M 42/F
spinal anesthesia
?
LSDH
?
surgery
CR
IF
accidental LP Iabour accidental LP labour accidental LP labour spinal anesthesia rectal abcess accidental LP labour spinal anesthesia
Ganz McDonald Jack
29/F
Pavlin
23iF 37/M
Edelman
22lF
Reinhold
36/F
Reynolds
22/F
Mantia
27iF
l-4m
ref
PI
(4) Bil. SDH accidental
LP
?
llw
(2) SDH
+
surgery
CR
?
?
RSDH
+
surgery
CR
?
28d
Bil. SDH
+
surgery
CR
18 8d
Bil. SDH
+
surgery
CR
22 6d
RSDH
+
surgery
PR
16 4od
Bil. SDH
i-
non
t
1171
18 18d
LSDH
+
surgery
CR
1231
25 35h
LSDH
-
surgery
PR
1241
26 Sd
RSDH
+
CR
1251
25 Ild
RSDH
+
?
1261
18 4w
Bil. SDH
-
conservative conservative surgery
PR
1271
22 13d
LSDH
-
surgery
-t
21 26d
LSDH
+
surgery
CR
I91
22 2Od
RSDH
+
surgery
CR
1281
24 13d
LSDH
-
surgery
CR
1291
22 21d
Bil. SDH
+
surgery
CR
I301
22 Jm
LSDH
+
surgery
CR
1311
?
3od
LSDH
+
surgery
CR
1321
?
16d
SDH
-
surgery
CR
I331
25 21d
LSDH
-
surgery
CR
1341
?
Bil. SDH
?
surgery
CR
1351
Jonsson
63/M
Personne
70/M
Kiersz
79/M
Giamundo
SO/M
Ruutiainen
69/M
Blake
67/M
Lam-My
3.5/M
accidental LP labour spinal anesthesia labour spinal anesthesia urological operation accidental LP labour spinal anesthesia inguinal hernio~haphy spinal anesthesia cesarean section spinal anesthesia inguinal hemiorrhaphy spinal anesthesia inguinal hemiorrhaphy spinal anesthesia hydrocele spinal anesthesia spermatocele spinal anesthesia inguinal terniorrhaphy spinal anesthesia urological operation spinal anesthesia urotogical operation accidental LP
Kunz
70/M
spinal anesthesia
25 43d
LSDH
?
surgery
CR
[361
Brinquin
47/M
spinat anesthesia
?
3w
RSDH
+
surgery
CR
1371
Degiaire
70/M
accidentai
17 30h
RSDH
?
surgery
*
I381
BCal
67/M
spinal anesthesia
22 6d
I.. SDH
+
surgery
PR
1391
61/M
diagnostic
?
LSDH
+
surgery
CR
Eernla Newrick
29/F 67iM
Miyazaki
33/F
Rudehi
LP
LP
6Od
12d
Abbreviations: M = mate; F = female; LP = lumbar puncture; 8 = needle diameter (Gauge); h = hours; d = days; w = weeks; m = months; L = left; R = right; Bil. = bilateral; SDH = subdural hematoma; PLPH = post lumbar puncture headache; CR = complete recovery; PR = partial recovery; : = died; ref = reference.
129
Table 2. Review of cases of SDH following
lumbar
puncture
for lumbar
myelopraphy
_-_ ..- -_.. ._ Age
Iel
Study
SCX
Indication
0
Interval
Diagnosis
PLPH
Therapy
Gabriele
58/M
low back pain
”
id
RSDH
+
none
Alemohammed
40/M
low back pain
IX hw
Bil. SDH
t
surgery
CR
Von E. Heiss
60/M
low back pain
‘!
Sd
LSDH
+
surgery
CR
Dohrmann
65/M
low back pain
9
Zld
RSDH
surgery
CR
50/M
low back pain
?
Xd
RSDH
-
surgery
:
Benzon
58/F
sciatica
?
5d
LSDH
-
none
t
1161
Gupta
62/M
lumbar stenosis
‘?
2w
LSDH
?
none
CR
1441
Dan
31/F
sciatica
7
26d
R SDH
‘?
surgery
CR
1451
Megele
50/F
low back pain
20 16d
RSDH
?
surgery
CR
1461
Lam-My
52/F
low back pain
?
RSDH
surgery
CR
I351
Llewellyn
40/M
low back pain
20 4d
LSDH
+
surgery
CR
I471
vos
54/M
cervical root syndrome
22 44d
LSDH
+
surgery
CR
60d
Gutcomc
Abbreviations: M = male; F = female; LP = lumbar puncture; 0 = needle diameter (Gauge); h = hours; d = days; w = weeks; m = months; L = left; R = right; BiI. = bilateral; SDH = subdural hematoma; PLPH = post lumbar puncture headache; CR = complete recovery; PR = partial recovery; t = died; ref = reference.
of the brain, are cerebral atrophy, brain shrinkage from alcoholism and operative shunting of the ventricular system4s5*6.SDH also complicated an operation on a tumor of the cauda equina with withdrawal of large amounts of CSF7. Another theory for the development of acute or chronic SDH was proposed by ArakiB and later by Miyazaki et aP. They hypothesized that acute SDH results from laceration of the superior sagittal sinus. If only the arachnoid granulation in the parasagittal subdural region ruptures and the sinus itself remains intact, leakage of CSF will only cause a chronic hygroma. The incidence of SDI-I after LP is not known. We expect that a patient with severe PLPH, and therefore probably with a greater displacement of the brain, is at more risk of developing SDH than a patient with minor PLPH complaints. All 35 reported cases of SDH in relation to spinal or epidural anesthesia have been summa130
rized in table 1. In table 2 we listed all 12 reported cases of SDH after LP for myelographic procedures. All cases were clearly related to the lumbar puncture, without a history of trauma or other predisposing factors. In 25 of the 47 reviewed cases a clear history of PLPH preceded the demonstration of SDH, in 10 cases it was recorded absent and in 12 cases it could not be distilled from the text. This association gives support to the role of CSF hypotension in the development of SDH. The tables make clear that the use of a small bore needle does not absolutely protect against SDH. Use of a 26G needle, however, diminishes the incidence of PLPH’O and therefore will probably also diminish the chance of developing SDH after LP. Only one case has been reported with this needle size. In the elderly patient, cerebral atrophy and vulnerability of the venous wall may increase the risk of SDH”.
Our review also shows that SDH is a potentially serious complication; of the 47 reported patients 8 died and 4 were left with serious neurological deficits. PLPH can be easily differentiated from other forms of headache by its postural character. Other rare causes of headache are lumbar puncture induced meningitis and, in case of a preexistent brain shift, tentorial or tonsillar herniation. SDH should be suspected if PLPH lasts for longer than a week, if it loses its typical postural character, or when it returns after an initial disappearance. Cases with small SDH’s may be missed, if these spontaneously resolve’2*13. Treatment of PLPH may also prevent development of SDH. A safe and successful therapy for PLPH is E13P1~*2~‘4. By means of an epidural needle 10 cc autologous blood is introduced in the epidural space. A clot will form over and in the dural rent, thus stopping further leakage of CSFi2. In patients with chronic PLPH, the success rate of this procedure is very high (859.5%)s*‘4.1*.In the cases reviewed by us SDH developed as early as 30 hours and as late as 5 months after LP. The average interval was 25 days. Apparently, intracranial hypotension usually exists for a long time before SDH develops. If patients with severe and prolonged postural headache would be treated with EBP not only the symptoms would disappear, but so might the risk of SDH16.“. References DE BOER WA. Hoofdpijn na lumbale punctie. Ned Tijdschr Geneeskd 1987; 131:2(X%12. HILTON JONES D. What is post lumbar puncture headache and is it avoidable? In Wharlow C, Garfield T, eds. Dilemmas in the management of the neurological patient. Edinburgh: Churchill Livingstone, 1984; 144-57. ARSENI C,IONESCUS,L~NU M. Intracranialhypotension, an etiologic factor of subdural hematoma (chronic subdural hematoma following spinal subarachnoid block anesthesia). Rev Roum de Nemo1 1970; 7~283-6. MARKWALDER T-M. Chronic subdural hematomas: a review. J Neurosurgery 1981; 54637-45. SAMUELSON S,LONGDM,SHOU SN. Subduralhematoma as a complication of shunting procedures for normal pressure hydrocephalus. J Neurosurg 1972; 37548-51. WHITTIER JR. Deaths related to pneumoencephalography during a six year period. Arch Neural Psychiat 1951; 65:463-71. COONEY JF,BAKER GS. Subdural hematoma following an operation on the spinal cord Report of acase. Proc. Staff Meet. Mayo Clin. 1953; 28~364-7. ARAKI C. Pathology of chronic subdural hematoma and
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” ”
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J3
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45 uI 37
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