- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Dr. East, Salt Lake City, UT 84132, USA
Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Dr. East, Salt Lake City, UT 84132, USA
DOI:10.4103/2152-7806.141751Copyright: © 2014 Guan J. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Guan J, Couldwell WT, Taussky P. Intracranial hypotension as a complication of lumbar puncture prior to elective aneurysm clipping. Surg Neurol Int 26-Sep-2014;5:
How to cite this URL: Guan J, Couldwell WT, Taussky P. Intracranial hypotension as a complication of lumbar puncture prior to elective aneurysm clipping. Surg Neurol Int 26-Sep-2014;5:. Available from: http://sni.wpengine.com/surgicalint_articles/intracranial-hypotension-as-a-complication-of-lumbar-puncture-prior-to-elective-aneurysm-clipping/
Background:Lumbar dural defects are an uncommon but important cause of persistent intracranial hypotension in the neurosurgical population. We present a case of intracranial hypotension after elective craniotomy due to a lumbar puncture performed 3 weeks earlier.
Case Description:A 55-year-old female underwent uneventful craniotomy for clipping of an unruptured left middle cerebral artery bifurcation aneurysm. Postoperatively, the patient showed a gaze deviation and failed to wake up. Computed tomography demonstrated significant postoperative pneumocephalus. Family members indicated that the patient underwent a lumbar puncture 3 weeks prior to surgery to rule out a subarachnoid hemorrhage. The excessive pneumocephalus was initially interpreted as a result of spinal cerebrospinal fluid leak, and the patient was placed in the Trendelenburg position. This positioning resulted in some improvement in her mental status, although she was unable to tolerate any subsequent elevation in the head of her bed. Magnetic resonance imaging analysis of her spinal axis did not demonstrate any evidence of cerebrospinal fluid leak, but a subsequent lumbar blood patch resulted in rapid and dramatic improvement in the patient's status. She was subsequently discharged after an uneventful hospital stay.
Conclusion:Although uncommon, persistent intracranial hypotension caused by lumbar dural defects must be considered in patients who have recently undergone procedures that compromise the lumbar dura because prompt intervention can significantly improve the patient's condition.
Keywords: Defect, intracranial hypotension, lumbar dura, lumbar puncture, tension pneumocephalus
Intracranial hypotension is an uncommon, but well-described sequela of lumbar access procedures.[
A 55-year-old female who began to experience severe headaches, dizziness, and nausea was admitted to an outside hospital for evaluation. During the course of these investigations, an unruptured left middle cerebral artery bifurcation aneurysm was discovered. The patient's history includes multiple family members whose deaths resulted from ruptured cerebral aneurysms. The patient's symptoms improved without intervention, except for her headache, which, although improved, remained severe.
After extensive consideration with the patient, she presented 3 weeks later for craniotomy for clipping of her aneurysm at our institution. The procedure proceeded uneventfully, and the aneurysm was successfully clipped. Postoperatively, the patient was extremely lethargic and was unable to follow commands or be safely extubated. The patient was taken to the neurocritical care unit and closely monitored for improvement. During this time, the patient's examination slowly improved and initial plans for emergent imaging were postponed. Approximately 5 h after surgery, however, the patient was noted to no longer be following commands and had developed a left lateral and inferior gaze deviation.
A computed tomography (CT) scan of the brain showed significant pneumocephalus [
After the blood patch procedure, the patient's neurological status improved dramatically, with extubation occurring the following morning and a return to her baseline neurological status within 24 h. The patient was subsequently discharged without any persistent deficits.
Persistent intracranial hypotension is a known complication of dural access procedures including lumbar puncture,[
Management of intracranial hypotension is complicated by difficulties in diagnosis. Many patients, like ours, present with headaches, making a headache due to persistent cerebrospinal fluid leak more difficult to diagnose.[
Treatment for persistent intracranial hypotension due to cerebrospinal fluid leak is often conservative. Measures such as bed rest can allow the defect to close, while caffeine can ameliorate symptoms.[
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