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Subdual pneumophalus after epidural blood patch for spontaneous intracranial hypotension treatment : Case Report
Department of Anesthesiology and Pain Medicine, Incheon St. Mary’s Hospital, The Catholic University of Korea, College of Medicine, Incheon, Republic of Korea
-Introduction
In spontaneous intracranial hypotension(SIH),epidural blood patch is used as a treatment.The main techniques for finding epidural space include LORA(Loss Of Resistance to air) and LORS(LOR to saline),and LORA has a risk of complication including pneumocephalus(PC).The purpose of this presentation is to present a case of subdual PC that occurred after an epidural blood patch for SIH treatment.
-Case
A 58-year-old female patient with no underlying disease.She had a headache depending on the posture which is aggravated during sitting and relieved when lying down without trauma history.Under diagnosed of SIH,epidural blood patch was performed.At the L4-5 level,18G tuohy needle was used with the LORA technique via the median approach with LLD position. After confirming that no CSF leakage,15cc of autologous blood was injected.
At 5 minutes later,she complained of sudden thunder-lightning,frontal area headache(NRS 7).In the brain CT, subdural PC was found in both frontal convexity,middle cranial fossa and falx cerebri.We applied oxygen(5L/min),30 degree fowler position and pain control medication.After 24 hrs on f/u CT,PC was regressed. At POD 4, headache was improved(NRS 2) and discharged at pod 5.
-Conclusion
The PC is caused by several causes but rare cases occurs after neuraxial approach.When finding epidural space,LORA and LORS techniques are the most commonly used. but they have their own pros and cons. The saline method can cause confusion when subarachnoid puncture did. The air method also have some complications including PC.
PC is the situation which air inadvertently enter the cranium through subdural/subarachnoid space.Most of the cases are about the subarachnoid space PC and cases of subdural space PC are rarely reported.The air in the subdual space is more painful and it goes into the head faster. This finding can explain the result of our case.
In our case,there was no CSF leakage,symptoms of fast onset severe headache,and the result of CT finding which confirmed subdural PC. In order not to cause these side effect,if possible,we should use LORS method and fluoroscopy guided technique with contrast than blind technique.
-reference
White B,Lopez V,Chason D,Scott D,Stehel E,Moore W.The lumbar epidural blood patch:A Primer.Appl Radio2019;48(2019;48(2):25-30
Martin A,Luis O,Ricardo O,Maria L,Juan N. Anesthesiology Aug.1996,Vol.85.4235
In spontaneous intracranial hypotension(SIH),epidural blood patch is used as a treatment.The main techniques for finding epidural space include LORA(Loss Of Resistance to air) and LORS(LOR to saline),and LORA has a risk of complication including pneumocephalus(PC).The purpose of this presentation is to present a case of subdual PC that occurred after an epidural blood patch for SIH treatment.
-Case
A 58-year-old female patient with no underlying disease.She had a headache depending on the posture which is aggravated during sitting and relieved when lying down without trauma history.Under diagnosed of SIH,epidural blood patch was performed.At the L4-5 level,18G tuohy needle was used with the LORA technique via the median approach with LLD position. After confirming that no CSF leakage,15cc of autologous blood was injected.
At 5 minutes later,she complained of sudden thunder-lightning,frontal area headache(NRS 7).In the brain CT, subdural PC was found in both frontal convexity,middle cranial fossa and falx cerebri.We applied oxygen(5L/min),30 degree fowler position and pain control medication.After 24 hrs on f/u CT,PC was regressed. At POD 4, headache was improved(NRS 2) and discharged at pod 5.
-Conclusion
The PC is caused by several causes but rare cases occurs after neuraxial approach.When finding epidural space,LORA and LORS techniques are the most commonly used. but they have their own pros and cons. The saline method can cause confusion when subarachnoid puncture did. The air method also have some complications including PC.
PC is the situation which air inadvertently enter the cranium through subdural/subarachnoid space.Most of the cases are about the subarachnoid space PC and cases of subdural space PC are rarely reported.The air in the subdual space is more painful and it goes into the head faster. This finding can explain the result of our case.
In our case,there was no CSF leakage,symptoms of fast onset severe headache,and the result of CT finding which confirmed subdural PC. In order not to cause these side effect,if possible,we should use LORS method and fluoroscopy guided technique with contrast than blind technique.
-reference
White B,Lopez V,Chason D,Scott D,Stehel E,Moore W.The lumbar epidural blood patch:A Primer.Appl Radio2019;48(2019;48(2):25-30
Martin A,Luis O,Ricardo O,Maria L,Juan N. Anesthesiology Aug.1996,Vol.85.4235
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