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Undetected Dural Leaks Complicated by Accidental Drainage of Cerebrospinal Fluid (CSF) Can Lead to Severe Neurological Deficits

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Undetected Dural Leaks Complicated by Accidental Drainage of Cerebrospinal Fluid (CSF) Can Lead to Severe Neurological Deficits Review 451 Undetected Dural Leaks Complicated by Accidental Drainage of Cerebrospinal Fluid (CSF) can Lead to Severe Neurological Deficits Intrakranielle Hypotension und schwere neurologische Defizite nach akzidenteller Drainage von Liquor bei zuvor undetektierten Duraver- letzungen Authors P. B. Sporns, W. Schwindt, C. D. Cnyrim, W. Heindel, T. Zoubi, S. Zimmer, U. Hanning, T. U. Niederstadt Affiliation Department of Clinical Radiology, University Hospital Münster, Germany Key words Zusammenfassung Abstract ●▶ dural tear ! ! ●▶ accidental drainage Ziel: Ausgeprägte intrakranielle Hypotension Purpose: Intracranial hypotension has been re- ●▶ negative pressure suction wurde bereits mehrfach als Komplikation akziden- ported as a complication of accidental drainage ●▶ overdrainage teller Liquordrainage nach chirurgischen Eingriffen after surgical treatment in several cases. Applica- ●▶ cranial hypotension beschrieben. Der Einsatz von Vakuum-basierten tion of negative pressure systems (wound drains, Drainagesystemen (Wunddrainagen, VAC®-Wund- VAC®-therapy, chest tube drainage) had typically systemen, Thoraxdrainagen) führte in diesen Fällen led to severe intracranial hypotension including zu lebensbedrohlichen Komplikationen wie intra- intracranial hemorrhage and tonsillar hernia- kraniellen Blutungen und zerebraler Herniation. tion. In the last year the authors observed 2 cases Im vergangenen Jahr konnten die Autoren 2 Fälle of accidental spinal drainage of CSF in patients mit akzidenteller spinaler Drainage von Liquor with neurological deficits, regressing after re- diagnostizieren. Beide Patienten zeigten schwere duction of the device suction. neurologische Defizite, welche nach Entfernung Material and Methods: We conducted a systema- des Sogs der Drainage komplett rückläufig waren. tic PubMed-based research of the literature to Material und Methoden: Systematische Recherche study the variety and frequency of the reported in der Datenbank PubMed im Zeitraum 1. Januar symptoms from 1st of January 1980 until 1st of 1980 – 1. Oktober 2015 zur Erfassung der Häufig- October 2015. keit und Varietät der beschriebenen Symptome. Results: Reviewing the literature 24 relevant cita- Ergebnisse: Die Literaturrecherche erbrachte 24 tions including 27 reported cases of posttraumat- Fallberichte mit insgesamt 27 Fällen von posttrau- ic or postoperative loss of CSF leading to neurolo- matischem oder postoperativem Liquorverlust, gical symptoms were identified. All 15 reported received 29.10.2015 welche zu neurologischen Defiziten führten. Die cases in which a negative pressure suction device accepted 7.12.2015 15 Patienten, bei denen Drainagen mit Unterdruck had been applied showed severe neurological and verwendet wurden, zeigten schwere neurologische radiological symptoms such as coma or brain her- Bibliography und radiologische Symptome wie Koma, zerebrale niation and intracranial hemorrhage. In all cases DOI http://dx.doi.org/ Herniation und intrakranielle Blutungen. Bei allen patients recovered rapidly after removal of the This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. 10.1055/s-0035-1567034 Published online: 4.2.2016 Patienten waren die Symptome nach Entfernung suction device. Milder symptoms were observed Fortschr Röntgenstr 2016; 188: des Sogs der Drainagen schnell rückläufig. Bei den in the patients without negative pressure suction, 451–458 © Georg Thieme Patienten ohne Applikation von Unterdruck-Drai- mainly only presenting with headaches or cranial Verlag KG Stuttgart · New York · nagen zeigten sich vorwiegend leichtere Symp- nerve involvement. ISSN 1438-9029 tome, wie Kopfschmerzen und Irritationen von Additionally, we give an overview about current Correspondence Hirnnerven. Zusätzlich gibt diese Arbeit einen recommendations regarding cranial and spinal Dr. med Peter Bernhard Sporns Überblick über aktuelle Empfehlungen zur krania- imaging to rule out dural laceration and cranial Institut für Klinische Radiologie, len und spinalen Bildgebung bei Verdacht auf in- hypotension. Universitätsklinikum Münster trakranielle Hypotension und zum Ausschluss spi- Conclusion: Patients with dural laceration com- Albert-Schweitzer-Campus 1 naler Liquorleckagen. plicated by accidental drainage of CSF can present Gebäude A1 Schlussfolgerung: Undetektierte Liquorleckagen with life-threatening conditions. Increasing use of 48149 Münster kompliziert durch akzidentelle postoperative/ negative pressure suction devices makes the re- Germany Tel.: ++ 49/2 51/8 34 73 01 posttraumatische Drainage von Liquor können zu ported condition an important differential diag- Fax: ++ 49/2 51/8 34 96 56 schweren neurologischen Defiziten bei den be- [email protected] troffenen Patienten führen. Die zunehmende Ver- Sporns PB et al. Undetected Dural Leaks… Fortschr Röntgenstr 2016; 188: 451–458 452 Review wendung von Vakuum-basierten Drainagesystemen führt zu ei- nosis. A precise radiological examination can help to rule out ner hohen Relevanz dieses Krankheitsbildes, welches somit eine dural laceration and intracranial hypotension. wichtige Differentialdiagnose darstellt. Key Points: Kernaussagen: ▶ Undetected dural laceration complicated by negative pressure ▶ Undetektierte Liquorleckagen kompliziert durch akzidentelle suction drains can induce life-threatening symptoms. postoperative/posttraumatische Drainage von Liquor können ▶ Increasing use of negative pressure suction devices makes the zu lebensbedrohlichen Symptomen führen. reported condition an important differential diagnosis for ▶ Die zunehmende Verwendung von Vakuum-basierten Draina- radiologists gesystemen führt zu einer hohen Relevanz der Differential- Citation Format: diagnose „Liquorunterdrucksyndrom“. ▶ Sporns PB, Schwindt W, Cnyrim CD et al. Undetected Dural Leaks Complicated by Accidental Drainage of Cerebrospinal Fluid (CSF) can Lead to Severe Neurological Deficits. Fortschr Röntgenstr 2016; 188: 451–458 Introduction retrospective observational study 13 % of all patients with traumat- ! ic cervical spine injury featured a dural tear [12]. Patients with ini- Intracranial hypotension may ensue spontaneously after dural tial poor neurological state and disruption of the ligamentum fla- puncture or accidental (intraoperative) surgical opening of the vum were more often affected [11]. Likewise, 25 % of lumbar burst dura [1 – 3]. As a complication of this, several cases of accidental fractures exhibited dural tears; all of these patients showed a neu- drainage after surgical treatment and application of negative rological deficit [12]. Despite the dural tear, none of the studied pa- pressure systems (wound drain, VAC®-therapy, chest tube drain- tients exhibited critical intracranial hypotension [13]. age) have been reported. Under these circumstances severe intra- cranial hypotension leading to tonsillar herniation and subdural Clinical Presentation hemorrhage has been reported [4 – 7]. In the last year the authors Clinical presentation of intracranial hypotension is heterogenous noticed 2 cases of accidental drainage of CSF in which patients [1]. Typical neurological symptoms of CSF overdrainage include showed neurological deficits which were regressive after reduc- nausea, emesis, diplopia, orthostatic headaches, dizziness, diffi- tion of the device suction. In times of increasing use of negative culties in hearing, visual blurring [2, 10] and cranial nerve palsy pressure suction devices, the reported condition presents an im- [14, 15]. Current publications report on reversible coma, intra- portant differential diagnosis. To the authors´ knowledge this is cranial vasospasms [17] or even stroke and death due to intracra- the first review that systematically investigates the frequency nial hypotension [11]. and variety of emerging symptoms. After a loss of CSF of around 10 % a dilatation of cerebral sinuses, a sagging of the brain and therefore tension on sensible vessels, nerves and meninges leads to headaches [18]. Methods ! Reported complications by application of negative An English-language PubMed database search using combina- pressure suction devices tions of the descriptors “intracranial hypotension”, “intracranial Postoperative wound drains hypovolemia”, “spinal CSF leak”, “lumbar drain”, “subdural he- Several reports of patients with severe neurological symptoms matoma”, “subdural hygroma”, “tonsillar herniation”, “overdrai- after spinal surgery and application of suction drains exist [5, nage”, “coma”, “suction”, “dural tear”, “accidental drainage” and 16, 20 – 24]. An overview of a few cases of postsurgical intracra- “cerebrospinal fluid” was conducted regarding the period from nial hypotension after mainly cranial and only in 2 cases spinal 1st of January1980 until 1st of October 2015. surgery reports about similar symptoms after opening of the dura [19]. Of sixteen patients who remained unconscious or did not become fully responsive after surgery, 4 died and 2 showed Results brain stem signal intensity changes in MRI. All patients had rapid ! intraoperative/postoperative CSF loss documented on CT and/or This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. Reviewing the literature, 24 relevant citations including 27 re- MR imaging studies. The authors came to the conclusion that in- ported cases of posttraumatic or postoperative loss of CSF leading tracranial hypotension after intracranial and spinal surgery with to neurological symptoms were identified (●▶ Table 1). All 15 re-
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