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TRIGEMINAL AND FACIAL NERVE PALSIES FOLLOWING DURAL PUNCTURE IN PARTURIENTS
Abstract Number: F-34
Abstract Type: Case Report/Case Series
Introduction: Cranial nerve (CN) palsies following dural puncture are reported in the literature, with an incidence of 1:300 to 1:8000.1 We present a case series of 2 patients who developed CN V palsies and 1 patient who developed CN VII palsy following dural puncture.
1. 40yo Hispanic G5P1 parturient @38.5 weeks gestation presented in labor for elective repeat cesarean delivery. Combined spinal-epidural (CSE) was complicated by difficult placement and unintentional dural puncture with 17g Tuohy needle and intrathecal catheter placement. On postpartum day (PPD)#1, she developed a post-dural puncture headache (PDPH), which was managed conservatively until she developed visual floaters and tinnitus on PPD#10, at which point epidural blood patch (EBP) was performed. One day after EBP, she developed transient right facial numbness, but recurred on PPD#15. Patient was scheduled to see neurology as outpatient, however was lost to follow-up.
2. 39yo G2P1 parturient @39.0 weeks gestation underwent an uncomplicated spinal for repeat cesarean delivery. On PPD#1, she developed a PDPH, for which she received an EBP placed on PPD#2, resulting in complete resolution of headache. On PPD#4, she developed left eye pain and facial numbness, which spontaneously resolved by PPD#8.
3. 27yo G5P2 parturient @35.2 weeks gestation with twin gestation underwent CSE complicated by inadvertent dural puncture with 17G Tuohy needle. On PPD#1, she developed PDPH, which was managed conservatively. On PPD#5, she developed right facial droop. Neurology was consulted, providing a diagnosis of Bell’s palsy and prescribed prednisone and acyclovir. EBP was subsequently performed on the same day due to persistent PDPH, with improvement in headache. On PPD#7, facial droop was completely resolved.
Discussion: Although rare, CN VI and VIII palsies are the two most common CN palsies presenting with PDPH. The incidences of CN V or VII palsies presenting with PDPH are unknown, and are limited to a few case reports in the literature.1,2 In our first two cases involving CN V, it should be noted that the palsy developed after EBP placement. Although there are reports of CN palsy after EBP placement, these are most often associated with CN VII.3,4 In the case of our third patient, the rapid resolution of her CN VII palsy is inconsistent with the neurologist’s diagnosis of Bell’s palsy. Although the incidence of Bell’s palsy is indeed increased in the peripartum period,5 the clinical findings and rapid resolution of symptoms after EBP point towards dural puncture as the likely cause.
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