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///2018 Abstract Details
2018 Abstract Details2019-08-02T15:57:01-05:00

Unilateral Cranial Nerve VI Palsy After Placement of Labor Epidural

Abstract Number: F3D-6
Abstract Type: Case Report/Case Series

Hillary J Rockey M.D., M.P.H.1 ; Lora Levin MD2

Case: 21-year-old G2P1 at 39.4 weeks female with no significant PMH who received an uneventful labor epidural, who needed a repeat epidural as the first was dislodged. Repeat placement of the epidural was difficult, but no dural puncture was noted. The patient had a vaginal delivery and her epidural catheter was removed with the tip intact. The patient was evaluated on Post Spontaneous Vaginal Day (PSVD) 1 with no complaints of headache (HA). Later on PSVD 1, she was evaluated for possible spinal HA. The patient was ambulatory and able to care for her baby, but reported HA pain of 9/10, mild photophobia and nuchal rigidity on exam. Conservative management and Epidural Blood Patch (EBP) were discussed with the patient and she chose conservative management. The patient was discharged home on PSVD 2; on PSVD 6 during nurse phone call the patient had no complaints of HA. On PSVD 9 the patient was admitted with dull frontal HA, mild photophobia, and diplopia. Exam was significant for decreased abduction of left eye consistent, partial Left CNVI palsy, and neurology recommended EBP. She was discharged with conservative therapy and an eye patch, but returned on PSVD 14 with continued symptoms. MRI was consistent with intracranial hypotension. EBP was performed on PSVD 15 with some resolution of symptoms. At 4 weeks post epidural placement, the patient has improved vision with resolution of CNVI palsy. Discussion: Cranial Nerve Palsy (CNP) is a known, but uncommon complication of spinal anesthesia and lumbar punctures, and unintentional dural puncture during epidural placement.1 Ophthalmoplegia may occur from CNP with CNVI being the most commonly affected nerve. The likely mechanism for injury is due to cerebrospinal fluid leak, leading to intracranial hypotension and caudal displacement of the brainstem, which results in stretch and traction of CNVI, leading to CNP. Symptoms may be unilateral or bilateral, and include horizontal diplopia and blurred vision with ranges in severity of diplopia up to lateral rectus palsy with deviated gaze. Symptoms typically present 4 to 10 days after dural puncture and are frequently associated with post dural puncture headache (PDPH), nausea, neck stiffness and/or tinnitus.2 Magnetic Resonance Imaging (MRI) of the brain, Nuclear Cisternography or Computed Tomography (CT), can be performed to evaluate for intracranial hypotension. Most CNVI palsy symptoms fully resolve between 2 weeks and 8 months, with the average being 2.5 months. Although conservative management can be used, there are some case reports that document EBP can resolve symptoms of CNVI palsy when placed within 24 hours of symptom development. It is also important to educate patients on CNVI palsy symptoms, as CNP can develop even after resolution of PDPH.3 References: 1. Silva M, Halpern SH (2010) Local Reg Anesth 3:143-153 2. Hofer JE, Scavone BM (2015) Anesth Analg 120(3):644-6 3. Kim YA et al. (2012) Korean J Pain 25(2):112-115

SOAP 2018