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Pneumocephalus in a Parturient With Methylenetetrahydrofolate Reductase Deficiency After a Lumbar Epidural Block
Abstract Number: S-50
Abstract Type: Case Report/Case Series
A 34 year old parturient with past medical history of methylenetetrahydrofolate reductase deficiency and gestational hypertension developed sudden onset of lethargy and difficulty swallowing half an hour after epidural catheter placement. The epidural was placed at the L4-L5 interspace using the loss of resistance to air technique with 3ml of air inserted. No cerebrospinal fluid was noted to have leaked back during placement of the epidural. Test dose 3ml of 1.5% Lidocaine with Epinephrine was given and was negative for dense motor block or tachycardia.
When summoned to the patient’s room 25 minutes after epidural placement, patient was lethargic and having difficulty swallowing but was answering questions appropriately, moving all extremities, and vital signs were stable. In light of the patient’s history of methylenetetrahydrofolate reductase deficiency, for which she had been taking Enoxaparin subcutaneously daily up until 3 days prior, cerebrovascular accident was high on the differential list. Patient’s symptoms remained constant for 20 minutes, at which point a stroke code was called. Five minutes later as the stroke team arrived, patient’s symptoms suddenly resolved and she was at her baseline. A decision was made to obtain an emergency MRI of the brain as part of the work-up. The MRI was read as diffuse intraventricular and subarachnoid pneumocephalus, likely secondary to recent epidural placement. The patient remained stable and at baseline for the remainder of her labor, and delivered via cesarean section under spinal analgesia 7 hours later.
Pneumocephalus is a rare consequence of inadvertent dural puncture, resulting from the injection of air into the subarachnoid or subdural space and subsequent cranial migration. Signs and symptoms can include headache, focal neurological deficits, lethargy, vomiting, nausea, seizures, cranial nerve palsies, and even cardiovascular instability, depending on the distribution of air. As seen on the attached MRI, there is a large air pocket in the anterior intraventricular space, which confirms the diagnosis.
Our patient did not have any worsening or recurrence of symptoms. She was discharged 3 days after presentation and had a repeat MRI performed 2 weeks later at an outside office which demonstrated resolution of the penumocephalus. The patient experienced no long term complications and was able to resume her normal activities of daily living.