Pneumocephalus after difficult SAB

[G0S2]

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20-something F presents in premature labor at 30 wks. Tocolysis started and steroids completed. Unreassuring fetal rhythm so off to CS.

Not obese. Good palpation of spinous process. Standard spinal kit with 25G needle. 1.6 cc of 0.75% Bupivacaine with 200 mcg Duramorph in syringe. I always get air out. 2x attempt with 25G no go with continued hitting bone. I believe I checked for CSF twice after pop but no return. Repositioning doesn't help. 1x attempt with 24G and in. Good CSF. T4 level. Never used LOR approach. Pt very hypotensive but Ephedrine helps. Pt c/o neck pain. CS complete and pt with return of LE strength 5/5 checked 3 hrs later.

12-24 hrs later pt with c/o severe HA. Colleague evaluates pt and not typical PDPH. Blood patch performed anyway without improvement of symptoms. OB orders CT, which notes moderate air in ventricles and air in subQ of posterior scalp and neck. Noted pituitary enlargement as well.

I placed pt of O2 for reabsoption. Feeling better. Never detected focal neuro deficit.

I know pneumocephalus is rare and is seen mostly with epidurals and use of LOR. I cannot figure out how all that air entered the CSF, never mind subQ.

I'm approaching 3 years in PP and 20% of my case load is OB. Perplexed and troubled by this case.

Any ideas?

Thank you.

 

[caligas]

20-something F presents in premature labor at 30 wks. Tocolysis started and steroids completed. Unreassuring fetal rhythm so off to CS.

Not obese. Good palpation of spinous process. Standard spinal kit with 25G needle. 1.6 cc of 0.75% Bupivacaine with 200 mcg Duramorph in syringe. I always get air out. 2x attempt with 25G no go with continued hitting bone. I believe I checked for CSF twice after pop but no return. Repositioning doesn't help. 1x attempt with 24G and in. Good CSF. T4 level. Never used LOR approach. Pt very hypotensive but Ephedrine helps. Pt c/o neck pain. CS complete and pt with return of LE strength 5/5 checked 3 hrs later.

12-24 hrs later pt with c/o severe HA. Colleague evaluates pt and not typical PDPH. Blood patch performed anyway without improvement of symptoms. OB orders CT, which notes moderate air in ventricles and air in subQ of posterior scalp and neck. Noted pituitary enlargement as well.

I placed pt of O2 for reabsoption. Feeling better. Never detected focal neuro deficit.

I know pneumocephalus is rare and is seen mostly with epidurals and use of LOR. I cannot figure out how all that air entered the CSF, never mind subQ.

I'm approaching 3 years in PP and 20% of my case load is OB. Perplexed and troubled by this case.

Any ideas?

Thank you.

Maybe the air came during the blood patch.

 

[G0S2]

Maybe the air came during the blood patch.

HA before EBP.

 

[Pooh & Annie]

How it got injected in and in such quantity I don't know, but I'm guessing you were entraining air through inadequate seal between the syringe/needle. When you say "I always get air out", do you mean you got CSF initially through the needle, then air after hooking up and aspirating with the syringe through the needle?

 

[G0S2]

How it got injected in and in such quantity I don't know, but I'm guessing you were entraining air through inadequate seal between the syringe/needle. When you say "I always get air out", do you mean you got CSF initially through the needle, then air after hooking up and aspirating with the syringe through the needle?

Air out of syringe containing spinal meds. Tight seal, and good CSF aspiration before injection.

 

[BLADEMDA]

http://anesthesiology.pubs.asahq.org/Article.aspx?articleid=1948541


Case Reports | August 1996
Pneumocephalus after Spinal Anesthesia

negative subarachnoid pressure caused by a deep inspiration may be a possible mechanism [

 

[PainDrain]

I had a case in residency, I think it became a poster presentation eventually. 30ish G3p2 pregnant with triplets for c section after SROM at like 32 weeks. Case went fine but about an hour after arrival in PACU she started c/o severe headache, photophobia, and blurred vision. BPs were fine but my attending was concerned about intracranial hemorrhage so we got a stat CT of her head. Came back clear except for a cluster of air around the optic chiasm. The best we could guess was there was some air either left in the syringe or pulled in during the spinal.

 

[deleted87051]

Was the patient sitting or lateral during the initial SAB? Seems like it would be less likely to entrain air into subarachnoid space if the patient is sitting.

 

[deleted162650]

Air out of syringe containing spinal meds. Tight seal, and good CSF aspiration before injection.

Hmmm. Did you sneeze just before you attached the syringe?

 

[Pooh & Annie]

http://anesthesiology.pubs.asahq.org/Article.aspx?articleid=1948541


Case Reports | August 1996
Pneumocephalus after Spinal Anesthesia

negative subarachnoid pressure caused by a deep inspiration may be a possible mechanism [

I bet that's right. I'm not an aspirator myself, and there's another good reason to dissuade folks.

 

[Pooh & Annie]

Air out of syringe containing spinal meds. Tight seal, and good CSF aspiration before injection.

Oh I see what you mean.

 

[Planktonmd]

Not unusual at all, low or negative intrathecal pressure allows for air to be sucked in after placement of a spinal needle.
More common after epidural with wet tap but a traumatic spinal with multiple insertions could definitely do it.
Don't worry about it.

 

[G0S2]

http://anesthesiology.pubs.asahq.org/Article.aspx?articleid=1948541


Case Reports | August 1996
Pneumocephalus after Spinal Anesthesia

negative subarachnoid pressure caused by a deep inspiration may be a possible mechanism [

Thanks. Didn't notice any coughing. Free flow, aspirated more then injected.

 

[G0S2]

Hmmm. Did you sneeze just before you attached the syringe?

I was actually thinking what a relief it was given it was 20 mins and entire OR team staring at me at 5am.

 

[G0S2]

Not unusual at all, low or negative intrathecal pressure allows for air to be sucked in after placement of a spinal needle.
More common after epidural with wet tap but a traumatic spinal with multiple insertions could definitely do it.
Don't worry about it.

Thank you. I think this is what it was. With prior attempt I did feel good pop but w/o CSF. I bet I didn't recognize I was intrathecal.

 

[G0S2]

Was the patient sitting or lateral during the initial SAB? Seems like it would be less likely to entrain air into subarachnoid space if the patient is sitting.

Actually good call and I forgot to mention this important point bc I only tried for 2 min. She was initially lateral. I did "pop" through but no CSF. Lateral bc cord was palpable at os.

 

[lobelsteve]

OB orders CT, which notes moderate air in ventricles and air in subQ of posterior scalp and neck.


Any ideas?

Thank you.

Would like to know about subQ air under scalp and neck.

 

[G0S2]

Would like to know about subQ air under scalp and neck.

So would I. No idea. Saw pt today. Doing much better. I think hypovolemic going into section and first SAB attempt lateral entrained air. First SBP after spinal was 54. Tried to get CT images to load at hospital to assess both CSF and subQ air but images wouldn't load.

I will update once I see images. Importantly the pt is doing well.

 

[Planktonmd]

The subcutaneous air may very well be in the radiologist's head!

 

[CaliDreamin4Life]

I am missing why lateral position would make this more lateral, just distribution of CSF?

QUOTE="G0S2, post: 17441003, member: 32172"]So would I. No idea. Saw pt today. Doing much better. I think hypovolemic going into section and first SAB attempt lateral entrained air. First SBP after spinal was 54. Tried to get CT images to load at hospital to assess both CSF and subQ air but images wouldn't load.

I will update once I see images. Importantly the pt is doing well.[/QUOTE]

 

[gasp]

HA before EBP.

Yes, but CT was done after EBP right? Caligas is saying maybe the pt had a HA which was a PDPH after the spinal. THEN, when you performed the EBP, air was introduced during your LOR technique (Did you say you used air or saline for LOR during the blood patch?). And THEN, a CT was obtained which showed air in the ventricles which you may be incorrectly assuming was done during the spinal when in fact it was done during the EBP. As far as how air got into the subq, no clue!