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

Abstract

Purpose: Intracranial hypotension has been reported as a complication of accidental drainage after surgical treatment in several cases. Application of negative pressure systems (wound drains, VAC?-therapy, chest tube drainage) had typically led to severe intracranial hypotension including intracranial hemorrhage and tonsillar herniation. In the last year the authors observed 2 cases of accidental spinal drainage of CSF in patients with neurological deficits, regressing after reduction of the device suction. Material and Methods: We conducted a systematic PubMed-based research of the literature to study the variety and frequency of the reported symptoms from 1st of January 1980 until 1st of October 2015. Results: Reviewing the literature 24 relevant citations including 27 reported cases of posttraumatic or postoperative loss of CSF leading to neurological symptoms were identified. All 15 reported cases in which a negative pressure suction device had been applied showed severe neurological and radiological symptoms such as coma or brain herniation and intracranial hemorrhage. In all cases patients recovered rapidly after removal of the suction device. Milder symptoms were observed in the patients without negative pressure suction, mainly only presenting with headaches or cranial nerve involvement. Additionally, we give an overview about current recommendations regarding cranial and spinal imaging to rule out dural laceration and cranial hypotension. Conclusion: Patients with dural laceration complicated by accidental drainage of CSF can present with life-threatening conditions. Increasing use of negative pressure suction devices makes the reported condition an important differential diagnosis. A precise radiological examination can help to rule out dural laceration and intracranial hypotension. Key Points: ??Undetected dural laceration complicated by negative pressure suction drains can induce life-threatening symptoms. ??Increasing use of negative pressure suction devices makes the reported condition an important differential diagnosis for radiologists Citation Format: ??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 R?ntgenstr 2016; 188: 451???458

Intracranial Hypotension Syndrome: The Importance of Neurointensive Care

“…All 15 cases (of a total of 27 reported) in which a negative pressure suction device had been applied showed severe neurological and radiological symptoms such as coma or brain herniation and intracranial hemorrhage. In all cases, patients recovered rapidly after the removal of the suction device [ 8 ].…”

Lumbar drain for CSF leakage

“…The main factors described in the literature for CSF over drainage after CLD insertion can be insidious spinal fluid fistulas either due to side leaks from the catheter into the epidural space 5 , dura leaks due to multiple attempts during CLD insertion 6 , apart from the sudden changes in head position, drainage bag position, intracranial compression, etc. The diagnosis becomes more conveniently explorable if there is a demonstration of excessive spinal fluid in the drainage bag along with suggestive clinical symptomatology, but sometimes occult fistulas are unrecognizable and can prove fatal for the patient.…”

A case report of seizure during emergence from general anesthesia after lumbar spinal surgery—common cases can develop potentially life-threatening adverse intracranial events

“…The majority of severe complications following spinal surgery are related to dural injury and intracranial hypotension [6]. The incidence of dural injury during spinal surgery has been reported as 5.5 to 10.1% [5,7].…”

“…Although there was minimal output from the drainage tube, our surgical team suspected cauda equina incarceration or the other unknown cause of seizure in the surgical field, because they knew that any neurologic manifestation could appear by intracranial hypotension after spinal surgeries [5,6]. Six hours after the initial surgery, the patient was taken back to the surgical suite to confirm and repair a suspected spinal dural laceration.…”