Mechanism of chronic iatrogenic CSF leak following dural puncture-ventral dural leak: Case report

Authors

Ian R. Carroll, Department of Anesthesiology, Stanford University, Stanford, California, USA ic38@stanford.edu.
Olivia Lansinger, Brigham and Women's Hospital Department of Anesthesiology Perioperative and Pain Medicine, Boston, Massachusetts, USA.
Huy M. Do, Departments of Radiology, Neurosurgery and Otolaryngology, Stanford University School of Medicine, Stanford, California, USA.
Rob Dodd, Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA.
Kelly Mahaney, Department of Neurosurgery, Department of Pediatric Neurosurgery, Stanford University School of Medicine, Stanford, California, USA.
Daphne Li, Advocate Health - MidwestFollow

Recommended Citation

Carroll IR, Lansinger O, Do HM, Dodd R, Mahaney K, Li D. Mechanism of chronic iatrogenic CSF leak following dural puncture-ventral dural leak: case report. Reg Anesth Pain Med. 2024;49(4):293-297. Published 2024 Apr 2. doi:10.1136/rapm-2023-105197

Affiliations

Advocate Lutheran General Hospital

Abstract

Background:Postdural puncture headache has been traditionally viewed as benign, self-limited, and highly responsive to epidural blood patching (EBP) when needed. A growing body of data from patients experiencing unintended dural puncture (UDP) in the setting of attempted labor epidural placement suggests a minority of patients will have more severe and persistent symptoms. However, the mechanisms accounting for the failure of EBP following dural puncture remain obscure. An understanding of these potential mechanisms is critical to guide management decisions in the face of severe and persistent cerebrospinal fluid (CSF) leak.

Case presentation:We report the case of a peripartum patient who developed a severe and persistent CSF leak unresponsive to multiple EBPs following a UDP during epidural catheter placement for labor analgesia. Lumbar MRI revealed a ventral rather than dorsal epidural fluid collection suggesting that the needle had crossed the thecal sac and punctured the ventral dura, creating a puncture site not readily accessible to blood injected in the dorsal epidural space. The location of this persistent ventral dural defect was confirmed with digital subtraction myelography, permitting a transdural surgical exploration and repair of the ventral dura with resolution of the severe intracranial hypotension.

Conclusions:A ventral rather than dorsal dural puncture is one mechanism that may contribute to both severe and persistent spinal CSF leak with resulting intracranial hypotension following a UDP.

Document Type

Article

PubMed ID

38388018