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PERSISTENT PNEUMOCEPHALUS AFTER EPIDURAL
Abstract Number: F-57
Abstract Type: Case Report/Case Series
Introduction: Pneumocephalus is defined as the presence of air or gas within the cranial cavity. Typically, it is seen in the settings of cranio-facial trauma, neurosurgery, otolaryngologic surgery or in cases of tumors involving the skull base. In rare cases, it can occur spontaneously as well. We present a case of a 22 year old female who received a lumbar epidural for labor analgesia which was complicated by pneumocephalus.
Case: 22 year old G4P1 female at 38 weeks gestation presented to ER after fall and was admitted to labor and delivery for induction of labor. Her past medical history was noncontributory. At 4 cm cervical dilation, request was made for a labor epidural. Using an 18g Touhy needle in the midline position at the L4 – L5 interspace, loss of resistance to air was obtained at 7.5 cm. Epidural catheter was threaded without resistance and clear fluid was noted to be exiting the distal tip. Catheter was deemed to be in the intrathecal space and was removed. A second attempt was made and epidural successfully placed at L3- L4 interspace using 18g Touhy needle, with loss of resistance to air. Within minutes of procedure completion, patient complained of severe headache. Initially, headache was noted to be occipital in location and later migrated frontally. She described it as a pounding sensation that worsened with change of posture from lying to sitting or standing. Symptoms were worsened with any type of movement or standing. Patient had good labor analgesia from epidural and successfully delivered vaginally 4 hours after placement of epidural. A trial of conservative therapy with IV hydration, oxygen via face mask, bed rest and NSAIDs was attempted. After six hours of no relief, patient underwent an epidural blood patch under fluoroscopic guidance with little improvement. Symptoms persisted through post-partum day (PPD) 2 and on PPD 3 she underwent bilateral occipital nerve block by acute pain service for suspected occipital neuralgia. Patient reported worsening of headache symptoms after block and was evaluated by neurology and started on dihydroergotamine and analgesics for suspected migraine headaches without aura. Failure of all these therapies led to a CT and MRI scan of the brain which led to the diagnosis of pneumocephalus.
Discussion: There are several case reports on pneumocephalus secondary to LOR using air. However, the pneumocephalus seems to resolve in about 72 hours. In our case, the pneumocephalus did not respond to any treatment modalities and persisted for over 10 days.
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