Cortical venous thrombosis after lumbar puncture

Abstract

Sirs: Lumbar puncture is not a completely innocuous procedure. Severe neurological complications including meningitis, cranial nerve or nerve root involvement, brain stem herniation, subdural hematoma, subarachnoid hemorrhage and cerebral venous thrombosis occur in less than 0.5 % of the cases [8]. We report a patient who developed an isolated cortical venous thrombosis after a lumbar puncture.A right-handed, 35-year-old woman, taking oral contraceptives, presented with chronic paresthesias and weakness of the left hand for 4 years. She was also complaining of recurrent buccal aphthosis. The clinical examination revealed a tetrapyramidal syndrome with left predominance and a mild paresis of the left upper and lower limbs with no facial involvement. Cervical magnetic resonance imaging (MRI) showed a left chronic myelitic lesion in the 3 first cervical segments (Fig. 1). The auditory brain-stem, the visual monocular pattern, and the median and the posterior tibial nerve evoked potentials were normal. The motor evoked potentials (MEPs) were elicited by transcranial and cervical magnetic stimulations and recorded from the abductor pollicis brevi (APB) muscles. The left APBMEPs were delayed after transcranial stimulations but normal after cervical stimulations. These findings suggested an involvement of the pyramidal pathways originating from the right motor cortex either at a right supramedullary level or a left cervical spinal level. A lumbar puncture was performed in the sitting position, using a non atraumatic needle (22G). The cerebrospinal fluid (CSF) was acellular with a normal total protein content. Oligoclonal bands of IgG, specific for the CSF, were found. Serum antinuclear antibody, anti-borrelia and anti-viral (including HIV, EBV, CMV, Hepatitis B and C, herpes zoster and simplex) serologies were negative.Two days after the lumbar puncture, the patient developed a positional post-dural-puncture headache which rapidly progressed to an intense and continuous headache complicated by confusion and left motor partial epileptic seizures with worsening and extension of the left hemiparesis to the face. The EEG showed focal slow waves and spikes in the right fronto-parietal derivations. Cranial computed tomography (CT) revealed focal edema with hemorrhagic effusions over the right fronto-parietal cortex. Brain MRI (Figs. 2 and 3) showed right frontal and fronto-parietal cortical venous thrombosis with no dural sinus involvement. High signal intensity lesions on T2 and FLAIR were also found in the periventricular white matter. Blood studies showed a neutrophilic leukocytosis (15.300 WBC/mm 3 , 89 % neutrophils) and an inflammatory reaction (C reactive protein at 56 mg/L, N < 10). Coagulation tests were unremarkable including protein C, protein S and antithrombin III levels. No mutations of coagulation factors II and V were found and anticardiolipin antibodies were absent.A mild hyperhomocystinemia was found (20.4mMol/L, N < 15).Angiotensin converting enzyme level was normal. She was given valproate (600 mg/day), fo...

Intracranial Venous Thrombosis After Placement of a Lumbar Drain

“…Aidi et al [8] reviewed 13 cases reported between 1986 and 1999. We found 16 additional cases [9][10][11][12][13][14][15][16][17][18] including our own. In addition, IVT has occurred after a variety of forms of spinal dural injury, suggesting a correlation with the dural injury itself and not with the particular manner in which the injury occurred.…”

Lumbar Puncture: It Is Time to Change the Needle

“…Another group of patients at increased risk for complications associated with LP are the hematologic patients, including patients undergoing hematopoietic stem cell transplantation and those receiving intrathecal therapy with methotrexate and corticosteroids which are prone to life-threatening complications following LP such as subdural hematoma [6], cerebellar infarction [54] and superior sagittal sinus thrombosis [55]. The occurrence of additional signs and symptoms following PLPH should alert the clinician to the presence of more prominent intracranial pathology [3,56].…”

Lumbar Puncture and Dural Sinus Thrombosis – A Causal or Casual Association?

“…A small number of cases of CVT were described after a dural puncture, either for epidural or spinal anesthesia [1, 2, 3, 4, 5], myelography [4, 6, 7], intrathecal administration of drugs [8, 9]or diagnosis [4, 10, 11, 12, 13, 14, 15, 16]. However, in most of those reports other risk factors for CVT were also present, leading to some doubt about the actual influence of the lumbar puncture (LP) in CVT occurrence.…”