- Email: [email protected]
Subdural pneumocephalus complicating labor epidural analgesia
Accepted Manuscript Correspondence Subdural Pneumocephalus Complicating Labor Epidural Analgesia M. Eddins, S. Klucsarits PII: DOI: Reference:
S0959-289X(17)30193-0 http://dx.doi.org/10.1016/j.ijoa.2017.05.003 YIJOA 2572
To appear in:
International Journal of Obstetric Anesthesia
Received Date: Revised Date: Accepted Date:
24 April 2017 1 May 2017 3 May 2017
Please cite this article as: Eddins, M., Klucsarits, S., Subdural Pneumocephalus Complicating Labor Epidural Analgesia, International Journal of Obstetric Anesthesia (2017), doi: http://dx.doi.org/10.1016/j.ijoa.2017.05.003
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1
1
2
3
4
Subdural Pneumocephalus Complicating
5
Labor Epidural Analgesia
6 7 8 9
M. Eddins, MD (Corresponding Author) Department of Anesthesiology and Pain Management
10
University of Texas Southwestern Medical Center
11
5323 Harry Hines Blvd.
12
Dallas, TX, USA 75390
13
[email protected]
14
S. Klucsarits, MD
15
Department of Anesthesiology and Pain Management
16
University of Texas Southwestern Medical Center
17
5323 Harry Hines Blvd.
18
Dallas, TX, USA 75390
19
[email protected]
2 20
Subdural Pneumocephalus Complicating Labor Epidural Analgesia
21
During the insertion of the epidural needle for labor analgesia, the epidural space is identified
22
using a loss-of- resistance technique to either air or saline, depending on the provider’s
23
preference. Pneumocephalus is a rare complication that can occur when using air.1 Headache is
24
the most common symptom.2 We present an unusual case of subdural pneumocephalus which
25
resulted in brainstem tamponade and loss of consciousness.
26
The patient was a 23-year-old primigravida at 40 weeks’ gestation who presented in active labor
27
following spontaneous rupture of membranes. She had no significant past medical or surgical
28
history other than an allergy to latex. Her vital signs were normal and her laboratory results were
29
unremarkable. Her body mass index was 34.2 kg/m2. Labor epidural analgesia was initiated
30
when the patient’s cervical dilation was 2 cm. With the patient in the sitting position, the
31
epidural catheter was successfully inserted after two attempts, using loss of resistance to air. A
32
test dose with 3 mL of 1.5% lidocaine with 1:200,000 epinephrine was negative. Analgesia was
33
achieved with 100 µg of fentanyl and 4 mL of 0.25% bupivacaine. Following a series of uterine
34
contractions, she quickly became somnolent. This progressed to unconsciousness. She
35
maintained spontaneous respiration. A neurological exam was performed, revealing a 4 mm
36
pupil on the right and a 2 mm pupil on the left, both unresponsive to light. Her systolic blood
37
pressure was 180 mmHg. Profound fetal bradycardia (fetal heart rate 60) was noted. The patient
38
was intubated uneventfully while the obstetricians performed an emergent instrumental vaginal
39
delivery. A viable female infant was delivered, with Apgar scores of 8 and 9 at 1 and 5 minutes
40
after delivery, respectively. Head computerized tomography (CT) showed subdural air within
41
the prepontine cistern and suprasellar cistern, causing brainstem compression (Fig.1). The patient
42
was placed in the Trendelenburg position, administered 100% oxygen, and administered 1 g of
43
mannitol intravenously. Following transfer to the intensive care unit, she regained consciousness
44
and followed commands. Six hours after epidural placement, she was extubated and continued
45
to receive 100% oxygen using a non-rebreather face mask. The patient continued to improve
46
neurologically and a repeat CT scan showed resolution of the pneumocephalus. She was
47
discharged home on postpartum day 4.
48
This case is unique in that the patient experienced a sudden loss of consciousness as a result of
49
subdural pneumocephalus following epidural placement. Subdural and subarachnoid blockade
3 50
are much more common etiologies for loss of consciousness following initiation of epidural
51
analgesia, and intracranial epidural or subarachnoid air does not lead to unconsciousness. The
52
incidence of pneumocephalus following epidural anesthesia is unknown, but only a few cases per
53
year have been reported.3 In order for pneumocephalus to occur, the dura must be punctured.
54
Unintentional dural puncture is not always evident, as pertains in our case. The fact that our
55
patient developed asymmetric pupils that were unresponsive to light helped to rule out a subdural
56
or subarachnoid block and made us aware that a brainstem insult had occurred.
57
It is interesting that pneumocephalus resulted in our patient experiencing loss of consciousness
58
rather than a headache. Headache is the most common presentation of pneumocephalus and
59
occurs as a result of meningeal irritation.2,4 The headache can be similar in nature to a post-dural
60
puncture headache, in which case a CT scan of the head should be performed to make the
61
diagnosis of pneumocephalus. We believe the atypical presentation occurred because of
62
formation of an air pocket around the pons, thereby causing brainstem compression, whereas
63
under most circumstances air accumulates in a more cephalic location adjacent to the cerebral
64
cortex.
65
In conclusion, subdural pneumocephalus should be included in the differential diagnosis of
66
sudden loss of consciousness following epidural placement. In addition, our case highlights an
67
important topic that remains a subject of debate in the realm of anesthesia: should loss of
68
resistance to air be abandoned? Van den Berg et al. argue in favor of this.5 Although
69
pneumocephalus is rare, the severity of neurological complications, as shown in our case,
70
supports the use of saline instead of air.
71 72
M. Eddins, S. Klucsarits
73
Department of Anesthesiology and Pain Management
74
University of Texas Southwestern Medical Center, Dallas, TX, USA
75
E-mail address: [email protected]
76
4 77
References
78
1. Mateo E, López-Alarcón MD, Moliner S, et al. Epidural and subarachnoidal pneumocephalus
79
after epidural technique. Eur J Anaesthesiol 1999;16:413–7.
80
2. Katz JA, Lukin R, Bridenbaugh PO, et al. Subdural intracranial air: an unusual cause of
81
headache after epidural steroid injection. Anesthesiology 1991;74:615–8.
82
3. Simopoulos T, Peeters-Asdourian C. Pneumocephalus after cervical epidural steroid injection.
83
Anesth Analg 2001;92:1576–7.
84
4. Kim YD, Lee JH, Cheong YK. Pneumocephalus in a patient with no cerebrospinal fluid
85
leakage after lumbar epidural block - a case report. Korean J Pain 2012;25:262–6.
86
5. van den Berg AA, Nguyen L, von-Maszewski M, et al. Unexplained fitting in patients with
87
post-dural puncture headache. Risk of iatrogenic pneumocephalus with air rationalizes use of
88
loss of resistance to saline. Br J Anaesth 2003;90:810–1.
89 90 91 92 93 94 95 96 97 98 99
5 100
Fig 1: Computerized tomography of the head showing subdural pneumocephalus with air
101
entrapment around the pons.
102
6
103 104
7 105 106
Subdural Pneumocephalus; Loss of Consciousness; Labor Epidural
8
107
•
Epidural analgesia can be achieved using a loss-of-resistance technique to either air or saline
108 109
•
Pneumocephalus is a complication that can occur with the use of air
110
•
Headache is the most common presenting symptom of pneumocephalus
111
•
In this case, pneumocephalus around the brainstem resulted in loss of consciousness
112
S0959-289X(17)30193-0 http://dx.doi.org/10.1016/j.ijoa.2017.05.003 YIJOA 2572
To appear in:
International Journal of Obstetric Anesthesia
Received Date: Revised Date: Accepted Date:
24 April 2017 1 May 2017 3 May 2017
Please cite this article as: Eddins, M., Klucsarits, S., Subdural Pneumocephalus Complicating Labor Epidural Analgesia, International Journal of Obstetric Anesthesia (2017), doi: http://dx.doi.org/10.1016/j.ijoa.2017.05.003
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1
1
2
3
4
Subdural Pneumocephalus Complicating
5
Labor Epidural Analgesia
6 7 8 9
M. Eddins, MD (Corresponding Author) Department of Anesthesiology and Pain Management
10
University of Texas Southwestern Medical Center
11
5323 Harry Hines Blvd.
12
Dallas, TX, USA 75390
13
[email protected]
14
S. Klucsarits, MD
15
Department of Anesthesiology and Pain Management
16
University of Texas Southwestern Medical Center
17
5323 Harry Hines Blvd.
18
Dallas, TX, USA 75390
19
[email protected]
2 20
Subdural Pneumocephalus Complicating Labor Epidural Analgesia
21
During the insertion of the epidural needle for labor analgesia, the epidural space is identified
22
using a loss-of- resistance technique to either air or saline, depending on the provider’s
23
preference. Pneumocephalus is a rare complication that can occur when using air.1 Headache is
24
the most common symptom.2 We present an unusual case of subdural pneumocephalus which
25
resulted in brainstem tamponade and loss of consciousness.
26
The patient was a 23-year-old primigravida at 40 weeks’ gestation who presented in active labor
27
following spontaneous rupture of membranes. She had no significant past medical or surgical
28
history other than an allergy to latex. Her vital signs were normal and her laboratory results were
29
unremarkable. Her body mass index was 34.2 kg/m2. Labor epidural analgesia was initiated
30
when the patient’s cervical dilation was 2 cm. With the patient in the sitting position, the
31
epidural catheter was successfully inserted after two attempts, using loss of resistance to air. A
32
test dose with 3 mL of 1.5% lidocaine with 1:200,000 epinephrine was negative. Analgesia was
33
achieved with 100 µg of fentanyl and 4 mL of 0.25% bupivacaine. Following a series of uterine
34
contractions, she quickly became somnolent. This progressed to unconsciousness. She
35
maintained spontaneous respiration. A neurological exam was performed, revealing a 4 mm
36
pupil on the right and a 2 mm pupil on the left, both unresponsive to light. Her systolic blood
37
pressure was 180 mmHg. Profound fetal bradycardia (fetal heart rate 60) was noted. The patient
38
was intubated uneventfully while the obstetricians performed an emergent instrumental vaginal
39
delivery. A viable female infant was delivered, with Apgar scores of 8 and 9 at 1 and 5 minutes
40
after delivery, respectively. Head computerized tomography (CT) showed subdural air within
41
the prepontine cistern and suprasellar cistern, causing brainstem compression (Fig.1). The patient
42
was placed in the Trendelenburg position, administered 100% oxygen, and administered 1 g of
43
mannitol intravenously. Following transfer to the intensive care unit, she regained consciousness
44
and followed commands. Six hours after epidural placement, she was extubated and continued
45
to receive 100% oxygen using a non-rebreather face mask. The patient continued to improve
46
neurologically and a repeat CT scan showed resolution of the pneumocephalus. She was
47
discharged home on postpartum day 4.
48
This case is unique in that the patient experienced a sudden loss of consciousness as a result of
49
subdural pneumocephalus following epidural placement. Subdural and subarachnoid blockade
3 50
are much more common etiologies for loss of consciousness following initiation of epidural
51
analgesia, and intracranial epidural or subarachnoid air does not lead to unconsciousness. The
52
incidence of pneumocephalus following epidural anesthesia is unknown, but only a few cases per
53
year have been reported.3 In order for pneumocephalus to occur, the dura must be punctured.
54
Unintentional dural puncture is not always evident, as pertains in our case. The fact that our
55
patient developed asymmetric pupils that were unresponsive to light helped to rule out a subdural
56
or subarachnoid block and made us aware that a brainstem insult had occurred.
57
It is interesting that pneumocephalus resulted in our patient experiencing loss of consciousness
58
rather than a headache. Headache is the most common presentation of pneumocephalus and
59
occurs as a result of meningeal irritation.2,4 The headache can be similar in nature to a post-dural
60
puncture headache, in which case a CT scan of the head should be performed to make the
61
diagnosis of pneumocephalus. We believe the atypical presentation occurred because of
62
formation of an air pocket around the pons, thereby causing brainstem compression, whereas
63
under most circumstances air accumulates in a more cephalic location adjacent to the cerebral
64
cortex.
65
In conclusion, subdural pneumocephalus should be included in the differential diagnosis of
66
sudden loss of consciousness following epidural placement. In addition, our case highlights an
67
important topic that remains a subject of debate in the realm of anesthesia: should loss of
68
resistance to air be abandoned? Van den Berg et al. argue in favor of this.5 Although
69
pneumocephalus is rare, the severity of neurological complications, as shown in our case,
70
supports the use of saline instead of air.
71 72
M. Eddins, S. Klucsarits
73
Department of Anesthesiology and Pain Management
74
University of Texas Southwestern Medical Center, Dallas, TX, USA
75
E-mail address: [email protected]
76
4 77
References
78
1. Mateo E, López-Alarcón MD, Moliner S, et al. Epidural and subarachnoidal pneumocephalus
79
after epidural technique. Eur J Anaesthesiol 1999;16:413–7.
80
2. Katz JA, Lukin R, Bridenbaugh PO, et al. Subdural intracranial air: an unusual cause of
81
headache after epidural steroid injection. Anesthesiology 1991;74:615–8.
82
3. Simopoulos T, Peeters-Asdourian C. Pneumocephalus after cervical epidural steroid injection.
83
Anesth Analg 2001;92:1576–7.
84
4. Kim YD, Lee JH, Cheong YK. Pneumocephalus in a patient with no cerebrospinal fluid
85
leakage after lumbar epidural block - a case report. Korean J Pain 2012;25:262–6.
86
5. van den Berg AA, Nguyen L, von-Maszewski M, et al. Unexplained fitting in patients with
87
post-dural puncture headache. Risk of iatrogenic pneumocephalus with air rationalizes use of
88
loss of resistance to saline. Br J Anaesth 2003;90:810–1.
89 90 91 92 93 94 95 96 97 98 99
5 100
Fig 1: Computerized tomography of the head showing subdural pneumocephalus with air
101
entrapment around the pons.
102
6
103 104
7 105 106
Subdural Pneumocephalus; Loss of Consciousness; Labor Epidural
8
107
•
Epidural analgesia can be achieved using a loss-of-resistance technique to either air or saline
108 109
•
Pneumocephalus is a complication that can occur with the use of air
110
•
Headache is the most common presenting symptom of pneumocephalus
111
•
In this case, pneumocephalus around the brainstem resulted in loss of consciousness
112