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On-line version ISSN 1806-907X
Rev. Bras. Anestesiol. vol.56 no.5 Campinas Sept./Oct. 2006
Intraventricular pneumocephalus after accidental perforation of the dura mater. Case report*
Pneumoencéfalo intraventricular después de la perforación accidental de dura-mater. Relato de caso
Fabiano Timbó Barbosa, TSA, M.D.I; Rafael Martins da Cunha, M.D.II; Anita Perpétua Carvalho Rocha, M.D.III; Hélio José Leal Silva Júnior, M.D.IV
em Docência para o Ensino Superior conferido pelo Centro de Ensino Superior
de Maceió, Anestesiologista da Unidade de Emergência Dr. Armando
Lages e do Hospital Escola Doutor José Carneiro, Intensivista da Clínica
IIProfessor de Farmacologia do Centro de Ensino Superior de Maceió, Professor Convidado de Farmacologia da Escola de Ciências Médicas de
lagoas, Anestesiologista do Hospital Unimed, Maceió
IIIAnestesiologista do Hospital da Sagrada Família, Título de Especialista em Dor, Mestrado em Anestesiologia pela UNESP
IVAnestesiologista do Hospital Regional da Unimed, Fortaleza, Hospital do Coração, Hospital Geral de Fortaleza
OBJECTIVES: The loss of resistance to air to identify the epidural space
is widely used. However, the accidental perforation of the dura mater is one
of the possible complications of this procedure, with an estimated incidence
between 1% and 2%. The objective of this report was to describe the case of
a patient with intraventricular pneumocephalus after the accidental perforation
of the dura mater using the loss of resistance with air technique.
CASE REPORT: Female patient, 26 years old, 75 kg, 1.67 m, physical status ASA I, with a 38-week pregnancy, was referred to the obstetric service for a cesarean section. Venipuncture was performed after placement of the monitoring. The patient was placed in a sitting position for administration of the epidural anesthesia. During the identification of the epidural space with the loss of resistance with air technique, an accidental perforation of the dura mater was diagnosed by observing free flow of CSF through the needle. The technique was modified to epidural anesthesia and anesthetics were administered by the needle placed in the subarachnoid space. In the first 24 hours, the patient developed headache and she was treated with caffeine, dypirone, hydration, hydrocortisone, and bed rest; despite those measures, the patient's symptoms worsened and evolved to headache in decubitus. A CT scan of the head showed the presence of pneumocephalus. After evaluation by a specialist, the patient remained under observation, with progressive improvement of the symptoms and was discharged from the hospital in the fifth day, without complications.
CONCLUSIONS: Pneumocephalus after accidental perforation of the dura mater presented headache with the characteristics of headache secondary to loss of CSF, but with spontaneous resolution after the air was absorbed. Invasive measures, such as epidural blood patch, were not necessary.
Key Words: COMPLICATIONS: headache, pneumocephalus.
Y OBJETIVOS: El uso de aire para la realización de la prueba de la
pérdida de la resistencia con la finalidad de identificar el espacio
peridural está extremadamente difundido en el mundo entero, pero una
de las complicaciones posibles es la perforación accidental de dura-mater
que presenta incidencia estimada entre 1% y 2%. El objetivo de ese relato fue
el describir un caso de paciente con pneumoencéfalo intraventricular
después de la perforación accidental de dura-mater usando la técnica
de la pérdida de la resistencia con aire.
RELATO DEL CASO: Paciente del sexo femenino, 26 años, 75 kg, 1,67 m, estado físico ASA I, con 38 semanas de embarazo, llevada al centro obstétrico para la realización de cesariana. Después de la monitorización se realizó la punción venosa. La paciente fue posicionada en la posición sentada para la realización de anestesia peridural. Durante la realización de la identificación del espacio peridural con la técnica de la pérdida de la resistencia usando aire, fue diagnosticada una perforación accidental da dura-mater a través de la observación de flujo libre de licuor por la aguja. Se modificó entones la técnica para raquianestesia y administradas medicaciones anestésicas a través de la aguja que ya estaba posicionada en el espacio subaracnoideo. En la primeras 24 horas la paciente evolucionó con cefalea que fue tratada con cafeína, dipirona, hidratación, hidrocortisona y reposo, e incluso así, hubo un empeoramiento del cuadro, pasando a presentar cefalea hasta en la posición de decúbito. Fue realizada una tomografía computadorizada de cráneo que evidenció una presencia de pneumoencéfalo. Después de la consulta con especialista fue adoptada una conducta de espera con mejora progresiva del síntoma, con alta hospitalaria al quinto día de evolución, sin observar secuelas.
CONCLUSIONES: El pneumoencéfalo después de la perforación accidental de dura-mater presentó un cuadro de cefalea con características similares a aquella producida por la pérdida licuórica, pero con resolución espontánea después de la absorción del aire, dispensando medidas de invasión como la realización del tapón sanguíneo peridural.
The subatmospheric pressure in the epidural space varies with breathing, being higher in the cervico-thoracic region, especially when the patient is in the sitting position 1. Air, saline, or both are used to identify this space 2,3. The plunger of the syringe slides more easily and without resistance when the needle reaches the epidural space, since its pressure is below that of the atmosphere. Some authors state that the preference for air for the loss of resistance test is due to the greater tactile sensitivity when compared to saline or the combination of both 2,3.
The incidence of the accidental puncture of the dura mater is between 1% and 2% 4, while the incidence of the post-puncture headache reaches up to 80%, depending on the caliber of the needle 5. When there is perforation of the dura mater, the introduction of 2 to 4 mL of air is enough to cause pneumocephalus 4,6,7. Pneumocephalus after epidural anesthesia, without the apparent introduction of air in the subarachnoid space, has also been reported 4,8.
The objective of this report is to describe the case of a patient with intraventricular pneumocephalus after the accidental perforation of the dura mater using the loss of resistance technique to locate the epidural space.
A female patient, 26 years old, 75 kg, 1,67 m, in her first pregnancy, physical status ASA I, with a 38-week pregnancy, was admitted to the obstetric service to be submitted to a cesarean section. Monitoring with a cardioscope, pulse oximeter, and noninvasive blood pressure was performed, and their parameters were measured every 2 minutes. With the patient in a sitting position, venipuncture was performed with an 18G catheter, and Ringer's lactate (10 mL.kg-1) was administered. The skin was cleansed with iodine alcohol, a sterile field was placed, local anesthesia with 1% lidocaine (6 mL) was administered in the L3-L4 space and 18G Tuohy needle, and the loss of resistance to air was performed. There was accidental perforation of the dura mater, which was diagnosed by the free flow of CSF through the needle. The technique was abandoned and subarachnoidal anesthesia with hyperbaric bupivacaine (10 mg), morphine (0.1 mg), and fentanyl (0.025 mg) was performed using the needle placed in the subarachnoid space. The surgical procedure lasted 80 minutes, and there were no complications. After the end of the procedure, the patient was transferred to the postanesthetic recovery unit, where she remained for 100 minutes. In the first 24 hours after the surgery, the patient complained of occipital headache, which was diagnosed as secondary to the perforation of the dura mater and treated with oral caffeine (100 mg) every 6 hours, dypirone (2,000 mg) every 6 hours, IV hydrocortisone (100 mg) every 8 hours, Ringer's lactate (2000 mL) in 24 hours, and bed rest. The headache evolved to holocranial headache and pain in decubitus. A head CT scan was done (Figures 1 and 2) and a neurosurgical consult was requested. The diagnosis of intraventricular pneumocephalus was then established. It was decided for a conservative approach and the patient remained under observation. There was progressive improvement of the symptom and the patient was discharged on the fifth hospital day without any complications.
Two mechanisms were proposed to explain the headache that develops after the accidental puncture of the dura mater. The first is attributed to the loss of cerebrospinal fluid (CSF) through the needle, and the second refers to the injection of air in the subarachnoid space 9,10.
The headache that develops after loss of CSF is due to hypotension in the CSF system, causing traction of the painful structures in the cranium when the patient is sitting standing 1,11,12. The intensity of the headache can vary from moderate to severe, affect the frontal and/or occipital regions, and improve or disappear when the patient is in the supine position 1,11,12. The differential diagnosis includes 13: sinusitis, tension headache, migraine, cerebral hemorrhage, encephalic ischemia, cortical venous thrombosis, meningitis, and preeclampsia; the last two diagnoses also present fever and stiff neck or hypertension, respectively. The treatment recommended by the literature for less severe headache includes the administration of analgesics, hydration, caffeine, sumatriptan succinate, and tiapride 11. In cases of severe headache or failure of the conservative approach, the epidural blood patch is recommended 11,12. Reports in the literature also mention the use of adrenocorticotrophic hormone (ACTH) 9,11,14,15, its analogues 13, and hydrocortisone 5,9.
ACTH is effective in up to 70% of the cases, which is similar to epidural blood patch 13-15. It can be administered intramuscularly (20 µg.kg-1) 14 or intravenously (1.5 µg.kg-1) 14-16. Two mechanisms of action were proposed: secretion of cortisone, aldosterone, and dehydroepiandrosterone by the adrenal cortex 14,16 and increased production of b-endorphins13,14, since both endorphins and ACTH have the same precursor, proopiomelanocortin 14. Papilledema and fever are contraindications to the use of ACTH 15.
Hydrocortisone has been used to prevent and treat post-puncture headache 9. Its mechanism of action has not been defined, but it is believed that it acts in the Na+/K+ pump increasing CSF production 5,9, besides an anti-inflammatory action 9. Since ACTH is not available in our service, the fact that the action of this hormone may be through the secretion of corticosteroids 14,16, the large experience with hydrocortisone in neonatology 5,9, and the ease of administration of this corticosteroid, we decided to use it as adjuvant in the treatment of the headache presented by the patient before the CT scan.
Using air to identify the epidural space has a few complications, such as: retroperitoneal emphysema 17, cervical emphysema 18, failure of the block 17, delayed reversion of the block 17, compression of the cauda equina 6,18, gas embolization 6,18,19, and pneumocephalus 2,6,17-19.
Pneumocephalus is the accumulation of air in the cranial cavity, usually in the subarachnoid space 20. It is necessary the presence of a few conditions for its development 21: 1) There must be a communication between the central nervous system and the environment. 2) Air must enter through this communication. 3) The amount of air must be enough to cause symptoms and to be detected by radiological studies.
Symptoms of pneumocephalus may be a consequence of increased intracranial pressure 20. The patient may experience headache 10,17-19, seizures 19, decreased level of consciousness 19, nausea 17, vomiting 17, dizziness 17, and hemiparesis 17. Headache is usually frontal 18 and worsens when the patient is sitting or standing 10. The duration and intensity of the symptoms are related with the amount of air inside the cranium 18.
Head CT is the most appropriate diagnostic exam 19,20.
Pneumocephalus has a tendency to resolve spontaneously and usually it is absorbed after two days 7,22; however, in a few patients it might take more than five days 6,7. Surgery is indicated for those cases that do not show spontaneous absorption 20.
After accidental perforation of the dura mater, the time frame until the development of the headache and its evolution may indicate the etiology. When the headache starts immediately, less than one hour, after the perforation and has a short duration, it is possibly due to the injection of air in the subarachnoid space leading to a pneumocephalus 10. When the pain starts more than one hour after the perforation, one should think of leakage of the CSF, but when it starts immediately after the perforation and is long lasting, it is possible that the two etiologies coexist 10.
Some prophylactic measures, such as performing the block while the patient is sitting 21,23, reintroduce the mandrin only after CSF flow is seen 21, the patient should avoid deep breaths 21,23 and sudden movements 21, and use saline for the loss of resistance test 10.
When the patient is in a sitting position, the pressure is greater in the lumbar region 1,11,21 hindering, therefore, the entrance of air after perforating the dura mater. This pressure may reach 40 cmH2O, while in lateral decubitus the pressure varies from 5 to 15 cmH2O 11.
Deep breaths, especially with the glottis closed, and sudden movements, may increase the amount of air that enters through the needle 21. The increased negative pressure in the thorax decreases the pressure of the CSF, which may reach levels below atmospheric pressure, facilitating the entrance of air in the subarachnoid space 4.
Using saline to identify the epidural space has some advantages, such as a lower incidence of headache after accidental perforation 10,12,18, absence of air in the subarachnoid space after perforation of the dura mater 10, the quality of the analgesia is better 17, and lower incidence of accidental perforation 17.
Nitrous oxide should not be used after identification of the epidural space with air 7,18,22 because it expands air bubbles in closed cavities due to the faster entrance of this agent when compared to the exit of nitrogen from the same place 7.
The present case allowed us to conclude that pneumoencephalus after accidental perforation of the dura mater caused headache that was similar to the one produced by loss of CSF, but with spontaneous resolution after the air was absorbed. Therefore, there was no need for invasive measures, such as epidural blood patch.
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Dr. Fabiano Timbó Barbosa
Rua Comendador Palmeira, 113/202. Ed. Erich Fromm. Farol
57051-150 Maceió, AL
05 de janeiro de 2006
Aceito para publicação em 26 de junho de 2006
* Recebido do Hospital Unimed, Maceió, AL