Reactions 1169 - 15 Sep 2007

SBupivacaine

Postdural puncture headache associated withposterior reversible encephalopathy syndrome:case report

A 33-year-old woman developed a postdural punctureheadache and then posterior reversible encephalopathysyndrome after receiving bupivacaine for spinal anaesthesiaprior to caesarean section.

The woman received IV Ringer’s solution, then a slowinjection of hyperbaric 0.5% bupivacaine 12mg at L3–4.Surgery was uneventful. Two days after surgery, shedeveloped a severe postural headache over her bifrontal area,with a visual analogue scale (VAS) pain score of 8/10. Theheadache was particularly severe when she was in an erectposition and was relieved when she was recumbent. She wasdiagnosed with postdural puncture headache.

The woman received 4 days of supportive therapy includingoral paracetamol [acetaminophen], aggressive intravascularhydration with lactated Ringer’s solution, and best rest. Herheadache improved to a VAS score of 2/10. She then reporteda severe throbbing headache (VAS 10/10) over her occipitalarea, which was no longer postural. Gradually, she presentedwith confusion, somnolence, visual hallucinations, right-sidedlimb and facial numbness, and slurred speech within 1 day.Diagnostic lumbar puncture showed an open pressure of21 cm H20. The following day, a brain MRI scan showedoedema of her bilateral posterior parieto-occipital lobes.Diffusion-weighted images were consistent with cytotoxicoedema in the early phase of cerebral ischaemia. Magneticresonance angiography (MRA) revealed diffuse vasospasm ofthe main arteries of her bilateral cerebral hemispheres,particularly posterior circulations. High flow with turbulence atthe right proximal middle cerebral artery and bilateralposterior cerebral arteries was revealed by transcranialDoppler. She started receiving intravascular magnesiumsulfate. After 1 day, her numbness and headaches hadsubsided. After 5 days, she had no headache and aneurological examination was normal. Magnesium sulfate wasstopped. One week later, an MRI scan showed dramaticimprovement with a slight residual signal of her abnormalities.Complete resolution of her diffuse cerebral vasospasm wasshown by MRA, and a transcranial Doppler was normal. Shewas discharged without any neurological deficit and, 1 monthlater, was still asymptomatic.

Author comment: "[T]he temporal association ofencephalopathy with diffuse cerebral vasospasm after anepisode of postdural puncture headache may have beencausative in this patient. Persistent leakage of CSF through thedural opening left by the lumbar puncture needle can resultin sagging of the brain and traction on nerves and meningealvessels. . . and, in theory, could induce vasospasm."Ho C-M, et al. Posterior reversible encephalopathy syndrome with vasospasm in apostpartum woman after postdural puncture headache following spinal anesthesia.Anesthesia and Analgesia 105: 770-772, No. 3, Sep 2007 - Taiwan 801091312

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Reactions 15 Sep 2007 No. 11690114-9954/10/1169-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved