Case report: Epidural blood patch in the treatment of abducens palsy after a dural puncture

Philippe Bchard MSc FRCPC Gino Perron FRCPC Denis Larochelle FRCPC Mlanie Lacroix FRCPC Annie Labourdette FRCPC Pierre Dolbec FRCPC [Prsentation de cas : La pridurale avec sang autologue dans le traitement d'une paralysie du nerf moteur oculaire externe aprs une ponction de la dure-mre] Purpose: To describe a case of iatrogenically induced abducens nerve palsy following a diagnostic lumbar puncture, and to review the evidence for blood patching in the management of sixth cranial nerve palsy after dural puncture. Clinical features: A 45-yr-old woman developed post-dural puncture headache with bilateral abducens palsy following a diagnostic lumbar puncture. Magnetic resonance imaging showed findings compatible with intracranial hypotension. An epidural blood patch was performed five days after the onset of diplopia and ten days following the dural puncture. After blood patching, the patient reported relief of the headache, but still complained of diplopia. The palsies recovered spontaneously 21 months after the dural puncture. Conclusion: Experience from this case as well as other case report evidence suggest that an epidural blood patch performed more than 24 hr after the onset of a sixth cranial nerve palsy consistently fails to relieve diplopia. An epidural blood patch executed within 24 hr from the onset of diplopia could possibly lead to partial improvement and/or earlier resolution of symptoms. - CAN J ANESTH 2007 / 54: 2 / pp 146150 Objectif : Dcrire un cas de paralysie du nerf moteur oculaire externe provoque iatrogniquement suite une ponction lombaire diagnostique, et passer en revue les preuves de lefficacit du colmatage sanguin dans le traitement dune paralysie du sixime nerf crnien suite une ponction de la dure-mre. Elments cliniques : Une femme ge de 45 ans a dvelopp une cphale post ponction de la dure-mre accompagne dune paralysie bilatrale des nerfs moteurs oculaires externes suite une ponction lombaire diagnostique. Limagerie par rsonance magntique a dmontr des rsultats compatibles avec une hypotension intracrnienne. Une pridurale avec sang autologue a t administre cinq jours aprs lapparition de diplopie et dix jours aprs la ponction de la dure-mre. Suite cette pridurale, la cphale fut soulage, mais la patiente se plaignait encore de diplopie. Les paralysies disparurent spontanment 21 mois aprs la ponction de la dure-mre. Conclusion : Ce cas clinique sajoute plusieurs autres qui suggrent quune pridurale avec sang autologue effectue plus de 24 h aprs lapparition dune paralysie du sixime nerf crnien est inefficace pour soulager la diplopie. Une pridurale avec sang autologue excute dans les 24 h aprs lapparition de diplopie pourrait peut-tre lamliorer partiellement et / ou permettre une rsolution plus prcoce des symptmes. Wof lumbar puncture or spinal anesthesia. EAKNESS of the external rectus muscle of the eye is an uncommon complication Epidural blood patch (EBP) is a well accepted treatment for post-dural puncture headache (PDPH) but little is known about its efficacy in the treatment of iatrogenic abducens nerve palsy. This case report describes a patient who developed a PDPH with bilateral sixth cranial nerve palsy following a diagnostic lumbar puncture. An EBP relieved the headache but failed to resolve the diplopia. Complete spontaneous recovery was achieved 84 weeks later. The literature was reviewed regarding the efficacy of blood patching in the management of abducens palsy. The possible relationship between the timing of the EBP in relation to the onset of visual symptoms and the efficacy of blood patching was also assessed. Consent for publication of this report was obtained in accordance with the institutional guidelines of the Htel-Dieu de Lvis Hospital, affiliated center to Laval University. Case report A 45-yr-old woman without any significant past medical history presented to the emergency room two days after the onset of a severe headache associated with nausea and vomiting. A cerebral computed tomogram (CT) was normal and a diagnostic spinal puncture with a 22G Quincke needle was undertaken. The CSF opening pressure was not estimated. The CSF microscopy and bacteriology examinations were normal. The headache subsided with oral hydromorphone and the patient was discharged with a diagnosis of migraine. The following day, the headache became worse and developed a postural character. Five days after her lumbar puncture the patient developed diplopia with horizontal gaze. She returned to the emergency room where she was admitted to the neurology ward for further investigation. The physical examination at that time revealed evidence of a postural headache associated with an abduction limitation of both eyes, more prominent on the left side. Magnetic resonance imaging (MRI) showed small ventricles. Meningeal thickening was apparent in both infratentorial and supratentorial regions. The signal was hyperintense in the T2weighted spinecho sequence. A gadolinium injection demonstrated non-nodular diffuse meningeal enhancement in the T1-weighted spin-echo sequence (Figure). There was no other abnormality on the MRI. The diagnoses of intracranial hypotension, PDPH and secondary bilateral abducens palsy were made. Five days after the onset of diplopia, the anesthesia department was consulted for consideration of an EBP. After reviewing the case and obtaining informed FIGURE Diffuse meningeal thickening in the T2-weighted spin-echo sequence (A) and diffuse non-nodular meningeal enhancement in the T1-weighted spin-echo sequence after gadolinium injection (B) five days after the lumbar puncture. Normalization of the magnetic resonance imaging four months after the onset of diplopia before (C) and after (D) gadolinium injection. consent from the patient, the anesthesia consultant agreed to perform an EBP. With the patient lying in the lateral decubitus position, 25 mL of autologous blood was injected using standard aseptic procedures into the epidural space at the L4L5 level with an 18G Tuohy needle. The L4L5 level was selected since the diagnostic spinal puncture was carried at this level. The patient reported relief of the headache within two hours of the EBP, but was still complaining about double vision. An ophthalmology consultation confirmed the presence of persistent bilateral sixth cranial nerve palsy. The patient was discharged on the third day following her admission with a patch over her left eye. The two-month orthoptic follow-up examination showed some clinical improvement and a prism glass was prescribed to the patient. Four months after the onset of diplopia, a repeat MRI documented normal meninges with normalization of the post-gadolinium meningeal enhancement. The left eye recovered more rapidly since the orthoptic examination showed similar abnormalities in both eyes 17 months after the onset of diplopia. Abducens palsies completely recovered simultaneously 21 months after the dural puncture, with full restoration of (...truncated)