The following outlines the case of a 60-year-old man presenting with ataxia and bradycardia as a consequence of a lateral medullary syndrome.A 60-year-old right-handed man presented with a witnessed sudden loss of right arm coordination followed by brief loss of consciousness. Prior to symptom onset, while eating with his wife, the patient was suddenly unable to coordinate his fork, held in his right hand, between his plate and his mouth. He felt faint, his vision clouded and sounds became distant. The patient lost consciousness for a few seconds and fell onto the floor. Immediately upon awakening, he was alert and oriented. There was no tongue biting or urinary or fecal incontinence.On initial assessment by paramedics the patient was dysarthric, had right-sided clumsiness and was profoundly bradycardic but normotensive (heart rate: 26 bpm, Figure 1). The dysarthria and clumsiness continued and diplopia (worse on right lateral gaze) and oscillopsia developed.Past medical history included remote tonsillectomy and measles as a child. There was no history of smoking, alcohol consumption, diabetes mellitus, ischemic heart disease, hypertension or previous stroke. The patient was not taking any medications, alternative therapies, or illicit drugs. He did not have any known allergies.On arrival in the emergency department, physical examination revealed a blood pressure of 140/74 mmHg, respiratory rate within normal limits and normal oxygen saturations. The heart rate was initially 26 beats per minute with a normal QRS complex and ST segment on electrocardiogram. Upon arrival in the emergency department, the electrocardiogram demonstrated a heart rate of 58 beats per minute with sinus rhythm. Recovery of heart rate and blood pressure occurred without medical intervention. Despite the bradyarrhythmia, heart sounds were normal with no added sounds or murmurs. Breath sounds were normal bilaterally and the abdomen was soft.The patient was alert and oriented to person, place and time. Cranial nerve examination demonstrated full extraocular movements. Left beating horizontal nystagmus was present in primary position and in all directions of gaze. Right-sided partial ptosis was present, with a right pupil measuring 3 mm and a left pupil measuring 3.5 mm in bright light. In darker light, the right pupil measured 4 mm and the left pupil measured 5 mm. Both pupils were reactive to light. Funduscopy was not possible due to significant nystagmus. Left facial sensation was impaired. There was mild dysarthria. Motor examination was normal, there was no pronator drift and there were symmetrical reflexes with bilateral flexor plantar responses. Sensory examination revealed a left hemibody decrease in sharp touch and temperature

Purpose: Epidurals are widely used in the management of pain in labor and delivery. Although dural puncture headaches affects approximately one in three hundred patients more serious neurologic complications are rare. We present a case of an 18 year old primigravida who requested an epidural and developed some very rare complications. We will show imaging and review some of the known cases of patients that developed similar symptoms and review management strategies for low pressure syndromes due to epidural complications. Clinical Features: Clinical features: Patient consent was obtained. An 18 year old, primigravida was treated with Fragmin for a deep vein thrombosis which developed at 27 weeks gestation. She presented in premature labor at 34 weeks gestation. She requested an epidural after 25 hours of her last Fragmin dose. An uneventful epidural at L3-4 was placed and several hours later delivered a healthy female . The following morning she awoke with a fronto-occipital headache, left sided T5-T8 numbness and neck pain. The headache eventually waned, and was discharged by the obstetric team with an advice to use acetaminophen. On post delivery day four she was admitted for worsening symptoms. Anesthesia,Neurology,and spine surgery were urgently consulted. She underwent MRI head and spine: the imaging showed epidural air at multiple levels. The patient was given a diagnosis of possible post dural puncture headache with nerve root irritation secondary to epidural air. She was managed conservatively. She returned on Day 12 with severe rightward gaze diplopia and a general worsening of symptoms. She was admitted and repeat imaged by MRI. There was no evidence of epidural air but meningeal enhancement was observed. Low pressure syndrome was diagnosed and the patient was treated with an epidural blood patch. Her diplopia improve over twenty-four hours and her other symptoms resolved over the next few weeks. A literature search of Medline and Pub Med was done to find similar cases and treatment strategies. The literature search found six case reports and several management strategies. We will summarize and present the results of the literature search. Conclusion: Inadvertent unrecognized dural tap can often have rare and unusual presentation such as diplopia. The development of a chronic low pressure syndrome following a dural tap is rare and can create treatment dilemmas. References: 1. Gielen M. Post dural puncture headache (PDPH): a review.

No abstract