Pneumocephalus with headache complicating labour epidural analgesia: should we still be using air?

doi:10.1016/j.ijoa.2005.10.011

International Journal of Obstetric Anesthesia

Volume 15, Issue 3, July 2006, Pages 237-239

https://doi.org/10.1016/j.ijoa.2005.10.011 Get rights and content

Summary

Pneumocephalus is a rare complication of epidural block which typically occurs when the loss of resistance to air technique is used to identify the epidural space. We present a case of pneumocephalus with headache in a parturient following apparently uncomplicated labour epidural analgesia.

Introduction

The epidural space is commonly identified using loss of resistance to saline or air.¹ The medium (saline or air) is often chosen according to the preference of the anaesthesiologist. Although there have been several reports criticising loss of resistance to air (LORA),[2], [3], [4] it continues to be favoured by many anaesthesiologists. When postural headache occurs after an epidural block, it is commonly assumed to be due to overt or cryptic breaching of the dura and arachnoid with consequent cerebrospinal fluid (CSF) leak. Another potential cause of headache after epidural placement is pneumocephalus.⁵ Most cases of pneumocephalus have occurred following accidental dural tap when the LORA technique was used to identify the epidural space, with the patient in the sitting position.⁴ We report a case of pneumocephalus with headache in a patient following apparently uncomplicated epidural analgesia in labour.

Section snippets

Case report

A 40-year-old, obese, full-term primigravida requested epidural analgesia in labour. Except for a history of severe reactive depression due to prolonged secondary infertility, she was previously fit and well. Pregnancy had been uneventful and there was no contraindication to regional anaesthesia.

After a trial of Entonox (50:50 mixture of nitrous oxide and oxygen) and one dose of intramuscular pethidine, she requested epidural analgesia at a cervical dilation of 4-5 cm. Under strict aseptic

Discussion

Headache occurring after an epidural block is commonly attributed to inadvertent dura puncture with consequent CSF leakage through the hole in the dura resulting in low CSF pressure.⁵ The classic description of PDPH is moderate to severe postural headache, which typically begins 24-48 h after dura puncture and often interferes with the patient’s activities of daily living.⁶ Headache due to pneumocephalus is usually of sudden onset with gradual improvement over 4-5 days as the air gets resorbed.

Conclusion

This report adds to the numerous reports of adverse events associated with the use of air as a medium for identifying the epidural space. We wonder if obstetric anaesthetists should justifiably continue to use the LORA technique, especially since a suitable and probably better alternative, loss of resistance to saline, exists. It may also be necessary to mention pneumocephalus as a potential complication to patients whenever loss of resistance to air is used so that they can make an informed

References (15)

C. Gleeson et al.
Accidental dural puncture rates in UK practices
Int J Obstet Anesth
(1998)
L.R. Saberski et al.
Identification of the epidural space: is loss of resistance to air a safe technique? A review of the complications related to the use of air
Reg Anesth
(1997)
J.A. Reid et al.
Headache after spinal anaesthesia [editorial]
Br J Anaesth
(1991)
H.S. Chadwick
An analysis of obstetric anesthesia cases from the American Society of Anesthesiologists closed claims project database
Int J Obstet Anesth
(1996)
M.W. Davies et al.
Current practice of epidural analgesia during normal labour: A study of maternity units in the United Kingdom
Anaesthesia
(1993)
S. Laviola et al.
Pneumocephalus with intense headache and unilateral pupillary dilatation after accidental dural puncture during epidural anesthesia for cesarean section
Anesth Analg
(1999)
B.I. Hatfalvi
Postulated mechanisms for postdural puncture headache and a review of laboratory models
Reg Anesth
(1995)

There are more references available in the full text version of this article.

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Treatment of symptomatic PNC ranges from supplemental oxygen to surgical decompression of tension PNC.3 Two methods for localizing the epidural space used during blood patch placement and epidural anesthesia include the LORA and LORS techniques.13 It has been postulated that the LORA technique might allow for the introduction of air though an existing dural defect, leading to potential PNC, a complication avoided by the use of LORS.11,14
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Loss of resistance to air (LORA) is widely used by anesthesiologists, but there are several complications involved, such as pneumocephalus,1,2 subcutaneous emphysema,3 venous air embolism,4 and spinal cord and nerve root compression.5 Pneumocephalus is a rare complication of inadvertent dural puncture and injection of air into the subarachnoid or subdural space.2,6 The symptoms of pneumocephalus depend on the distribution and amounts of intracranial air.7
Both pneumocephalus and pneumorrhachis are rare but serious complications following epidural anesthesia. We report a rare case of simultaneous pneumocephalus and pneumorrhachis in a patient after undergoing epidural anesthesia. The patient lost consciousness and received emergent external ventricular drainage for pneumocephalus in another medical center. The patient was clear after external ventricular drain placement until 4 days later, when sudden onset of subdural hemorrhage occurred and an emergent craniectomy was performed. The patient passed away 2 days after craniectomy, due to multiorgan failure. Pneumocephalus with or without pneumorrhachis should be kept in mind when there is a sudden change of consciousness or persistent convulsions after epidural anesthesia.
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Pneumocephalus is a rare cause of altered mental status in patients presenting to the Emergency Department. Occurring as a result of traumatic or iatrogenic violation of the dura, it can cause significant morbidity and mortality if tension physiology develops whereby air continues to accumulate with no mechanism for escape.
This case report will review the underlying pathophysiology, clinical presentation, diagnosis, and management of tension pneumocephalus.
We present the case of an 89-year-old man who presented to the Emergency Department with declining mental status 9 h after endoscopic sinus surgery. He was subsequently found to have tension pneumocephalus and underwent emergent burr hole evacuation. Despite resolution of the pneumocephalus, the patient had persistent neurologic deficits related to ischemic infarcts that occurred as a result of the tension physiology and subsequently expired in the hospital.
This case illustrates the importance of considering tension pneumocephalus on the differential diagnosis for any patient presenting with altered mental status after surgical or diagnostic procedures with potential to violate the dural space.
Unusually early onset of post-dural puncture headache after spinal anaesthesia using a 27G Whittacre needle
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Central venous thrombosis and pre-existing brain pathology (e.g. tumours, chiari malformation) would also be unlikely in a patient with no evidence on CT scan, and complete resolution of all symptoms except a postural headache within 6 h. Migraines affect 18% of the female population,5 but the chance of a migraine de novo in someone with no history in this situation is unknown. Pneumocephalus is increasingly recognized as a cause of early headache when using loss of resistance to air as a technique for epidural placement,6 7 and an earlier onset and resolution of PDPH has been demonstrated in these patients when compared with LORS. The majority of patients demonstrated intrathecal air on brain CT which was normal in this case.8

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^☆: Abstract presented at the May 4-7, 2005 Society of Obstetric Anesthesia and Perinatology (SOAP) meeting.

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Case ReportPneumocephalus with headache complicating labour epidural analgesia: should we still be using air?☆

Summary

Introduction

Section snippets

Case report

Discussion

Conclusion

Int J Obstet Anesth

Reg Anesth

Br J Anaesth

Int J Obstet Anesth

Current practice of epidural analgesia during normal labour: A study of maternity units in the United Kingdom

Anaesthesia

Pneumocephalus with intense headache and unilateral pupillary dilatation after accidental dural puncture during epidural anesthesia for cesarean section

Anesth Analg

Postulated mechanisms for postdural puncture headache and a review of laboratory models

Reg Anesth

Case Report
Pneumocephalus with headache complicating labour epidural analgesia: should we still be using air?☆