Bone Marrow Transplantation (2008) 41, 791–795 & 2008 Nature Publishing Group All rights reserved 0268-3369/08 $30.00 www.nature.com/bmt ORIGINAL ARTICLE Lumbar puncture and subdural hygroma and hematomas in hematopoietic cell transplant patients H Openshaw1, JA Ressler2 and DS Snyder3 1Department of Neurology, City of Hope National Medical Center, Duarte, CA, USA; 2Division of Diagnostic Radiology, City of Hope National Medical Center, Duarte, CA, USA and 3Division of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA We reviewed records ofhematopoietic cell transplantation transplantation (HCT). Prevalence varies from 0 to 12% in (HCT) patients seen over the past 10 years who had head autopsy series,1,2 and up to2.6% in retrospectiveclinical scan documentation ofsubdural fluid collections. A total reports.3 Subdurals can be easily overlooked early in the of17 patients were identified: 13 with allogeneic and 4 transplant course. They may present with reduced sensor- with autologous HCT (0.71% ofallogeneic and 0.13% of ium without abnormal motor signs or they may present autologous HCT patients seen in this time interval). with nausea, vomiting and headache, masquerading as Although less than 20% ofHCT patients have lumbar toxicity from the preparatory regimen. puncture, 8 ofthe 17 subdural patients had lumbar Intrathecal therapy as part of the preparatory regimen puncture. The lumbar puncture was done 5–112 days has been suggested as a risk factor for subdural hemato- (median 46 days) before subdural detection. Acute mas.3,4 In a retrospective study, 17 subdural hematomas lymphocytic leukemia was the diagnosis in five ofthese were found in 657 transplant patients in Australia, and 16 eight; whereas, either acute myelogenous leukemia or of the 17 subdural patients had received intrathecal myelodysplasia was the diagnosis in seven ofthe nine methotrexate.3 An association of subdural hematomas patients without lumbar puncture. In the patient group and lumbar puncture has also been reported in nontrans- with lumbar puncture, subdurals were diagnosed earlier plant patients with leukemia.5 after HCT (median 25 days versus 5 months in the patient In the present review, we describe the known association group without lumbar puncture) and were more often of lumbar puncture, intracranial hypotension and subdural hygromas (37.5 versus 0%). These results support the formation; and we determine how often subdurals in HCT suggestion oflumbar puncture or intrathecal therapy as a patients are associated with lumbar puncture. The term risk factor for subdurals. The presumptive mechanism subdural in this report is used to include nonhemorrhagic involves lumbar cerebrospinal leak, low intracranial fluid collections (hygromas) as well as hemorrhagic fluid pressure, downward displacement ofthe brain, cerebro- collections (hematomas). spinal fluid accumulation into the inner dural layers of the cerebral convexities (hygromas) and bleeding into these fluid collections (hematomas). Methods Bone Marrow Transplantation (2008) 41, 791–795; doi:10.1038/sj.bmt.1705971; published online 4 February 2008 Medical records of patients admitted to the Hematopoietic Keywords: intracranial hypotension; post-lumbar puncture Cell Transplantation Unit at the City of Hope National headache; subdural hygroma; subdural hematoma Medical Center between 1996 and mid 2006 were reviewed for diagnosis of subdural hygroma or hematoma within 25 months of transplant. Brain imaging and medical records were reviewed and the following aspects recorded: patient’s age and sex, hematological diagnosis, the type of trans- Introduction plantation, presence or absence of lumbar puncture for diagnosis or intrathecal therapy, neurological symp- Subdural hematomas are a well-recognized, infrequent but toms at the time of the diagnostic head scan, time interval serious neurological complication of hematopoietic cell of subdural detection post transplant (and, if relevant, post- lumbar puncture), need for neurosurgery and ultimate course of the subdural. Correspondence: Dr H Openshaw, Department of Neurology, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, Results CA 91010-3000, USA. E-mail: [email protected] Received 2 March 2007; revised 20 November 2007; accepted 26 Table 1 summarizes information on 17 patients seen November 2007; published online 4 February 2008 between 1996 and mid 2006 whohad subdurals after Lumbar puncture and subdural hygroma and hematomas H Openshaw et al 792 HCT (13 allogeneic and 4 autologous). A total of 1838 none of the patients in the other group. Subdurals were allogeneic and 2974 autologous HCT were done for diagnosed earlier in the transplant course in patients with hematological malignancies at the City of Hope National lumbar puncture (median 25 days post-HCT) than patients Medical Center in this time interval. The subdural without lumbar puncture (median 5 months post-HCT). complication rate, therefore, was 0.71% in allogeneic and Minor head trauma soon after HCT was a feature in two 0.13% in autologous HCT. As shown in the two columns patients in the non-lumbar puncture group; with these two of Table 1, just less than half of subdural patients had patients excluded, the median time of subdural diagnosis in lumbar puncture. The age range was similar in the two the non-lumbar puncture group would be 11 months. On groups, there was male predominance in the group without the basis of head scan characteristics, three patients in the lumbar puncture, and there was the expected difference in lumbar puncture group had hygromas; whereas, all patients hematological diagnoses (predominance of acute lympho- in the non-lumbar puncture group had hematomas. The cytic leukemia in lumbar puncture group and acute median platelet count on the day the subdural was detected myelogenous leukemia and myelodysplasia in non-lumbar was lower in the non-lumbar puncture group. The main puncture group). Leptomeningeal disease was present in neurological problem leading to the head scan which five of the eight patients in the lumbar puncture group and diagnosed the subdural in the lumbar puncture group was confusion and reduced sensorium in four patients, head- ache in three patients (but with characteristics of low- pressure headache in only one of these three) and seizure in Table 1 HCT patients with subdural hematomas or hygromas one patient. Presentation was similar in the non-lumbar Lumbar puncture No lumbar puncture puncture group but none of the three headache patients had characteristics of low-pressure headache (that is, headache Patients 8 9 on assuming the upright position). Overall, patients in the Male/female 4/4 7/2 non-lumbar puncture group did worse: four of the nine Age (median) 27–60 (46) 15–65 (51) patients required surgery, twopatients died withoutsurgery as a consequence of their subdural, 14 and 44 days after Diagnosis subdural detection (both patients had recurrent hemato- AML 0 4 ALL 5 0 logical disease post-HCT) and only one patient survived CML 2 1 to resolve the subdural without surgery. In comparison, MD 0 3 there were nofatal subdurals in the lumbar puncture NHL 1 1 group, four patients resolved the subdurals without surgery, tworequired surgery and twosuccumbed to Leptomeningeal disease 5 0 hematological disease recurrence 4 and 69 days after Transplant subdural diagnosis. Allogeneic 7 6 Table 2 gives information on the eight patients who had Autologous 1 3 lumbar puncture, listed in order of the time post-HCT that Head trauma 02subdural was diagnosed. As indicated in the fourth column, all patients had the subdural diagnosed after the lumbar Time post-HCT of subdural diagnosis puncture. Patient 1 had small bilateral subdural hematomas Range (median) 0 day—9 months 13 days—25 months diagnosed 1.5 weeks prior to preparatory therapy for (25 days) (5 months) transplant. The subdural increased in size at the time of this o30 days 5 2 o60 days 6 3 patient’s death from disease recurrence 51 days after HCT. Four other patients (Patients 2, 3, 5 and 6) had lumbar Platelet count per ml (median) 5–101 k (46 k) 10–36 k (20 k) punctures prior to HCT, 14–62 days (median 27 days as shown in column 4). Three patients had lumbar puncture Type of subdural Hematoma 5 9 after HCT: on day þ 5 in Patient 4 as ongoing treatment of Hygroma 3 0 leptomeningeal disease, on day þ 155 in Patient 7 for leptomeningeal disease recurrence after HCT and on day Clinical presentation þ 158 in Patient 8 because of symptoms of meningoence- Headache 3 3 phalitis. As shown in Table 2, subdurals were diagnosed Seizure 1 3 Encephalopathy 4 3 5–112 days after the last lumbar puncture (median 46 day). All three patients with head scan characteristic of hygromas Outcome subdurala had bilateral lesions; whereas only two of the five patients Resolve 4 1 with hematomas had bilateral lesions. Magnetic resonance Neurosurgery 2 4 Present terminally 2 2 imaging (MRI) scans and clinical synopsis of the two Fatal 0 2 patients whorequired neurosurgeryare presented in Figures 1a and b. The clinical course of Patient 8 presented Abbreviations: ALL ¼ acute lymphocytic leukemia; AML ¼ acute myelo- in the legend toFigures 1c and d was typical forrecurring genous leukemia; CML ¼ chronic myelogenous leukemia; HCT ¼ hemato- post-spinal tap headache; and her MRI showed changes of poietic cell transplantation; MD ¼ myelodysplasia; NHL ¼ non-Hodgkin’s low intracranial pressure (including subdural hygroma, lymphoma. aPresent terminally, subdural