Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 54, Num. 4, 2006, pp. 421-424

Neurology India, Vol. 54, No. 4, October-December, 2006, pp. 421-424

Case Report

Multiple simultaneous intracerebral hemorrhages following accidental massive lumbar cerebrospinal fluid drainage: Case report and literature review

Ruiz-Sandoval José L, Campos Ariel, Romero-Vargas Samuel, Jiménez-Rodríguez María I, Chiquete Erwin

Department of Neurology and Neurosurgery, Hospital Civil de Guadalajara “Fray Antonio Alcalde” and the Department of Neurosciences; Centro Universitario de Ciencias de la Salud. Guadalajara, Jalisco
Correspondence Address:Servicio de Neurología y Neurocirugía, Hospital Civil de Guadalajara , “Fray Antonio Alcalde”, Hospital 278. Guadalajara, Jalisco; 44280, jorusan@mexis.com

Code Number: ni06144

Abstract

Keywords: Cerebrospinal fluid, intracranial hemorrhage, intracranial hypotension, lumbar drainage, neurological examination

Introduction

Case Report

Discussion

Multiple simultaneous ICHs is defined as the presence of two or more intracerebral hemorrhages affecting different arterial territories, without continuity between them and with identical CT density profiles.[7],[8] This is a rare presentation of the hemorrhagic cerebrovascular disease, accounting for 0.6 to 2.8% of the cases of nontraumatic, nonaneurysmal ICH.[7],[8] The main causative factors are hypertension, cerebral amyloid angiopathy and forms of vasculitis, among other conditions [Table - 1]. There is a strong preponderance for the supratentorial space, especially affecting the basal ganglia (thus denouncing the hypertensive nature seen in most cases).[8] However, most of the knowledge regarding multiple simultaneous ICHs is derived from case reports, which are possibly the type of communications subject to the strongest reporting bias. Therefore, the clinical picture, outcome and even the putative causes may vary more than is reflected in case reports. Since most of the causative factors previously attributed to multiple simultaneous ICHs were excluded in the case presented here and given that neurological deterioration as well as the hemorrhagic findings in the second head CT began immediately after CSF overdrainage, it seems reasonable to think that this procedure was the cause or at least, a precipitating factor of multifocal ICH. To our knowledge, this patient had a cause of multiple simultaneous ICHs not previously reported [Table - 1]. In the present case, the putative pathophysiological mechanism that led to multiple simultaneous ICHs points to a continuous and massive lumbar CSF evacuation resulting in a reduction of CSF volume with the associated lowering in intraspinal and intracranial pressure, which eventually increased the transmural pressure gradient of the vessels, leading to a secondary wall stress rupture.[1] Advanced age and the presence of diffuse white matter disease could be the other important contributing factors.[9] The widespread and prolonged degeneration of the intracerebral arterioles in older people may also predispose to the development of multiple ICHs. Unfortunately, amyloid angiopathy or other age-related cerebrovascular conditions were not completely excluded in our patient because no cerebral biopsy was performed. Moreover, we were not able to obtain a necropsy. Since amyloid angiopathy is very common in older people and is also an important cause of multiple simultaneous ICHs [Table - 1], our patient might have had an underlying susceptibility (e.g., amyloid angiopathy) of presenting ICH, which in turn was precipitated by CSF overdrainage. Nevertheless, the association of CSF overdrainage with ICH in this patient seems clear, either as an independent causative or precipitating factor.

Indeed, the laminar collection of blood over the left parietal convexity and the posterior interhemispheric space seen in the head CT performed at presentation to our hospital [Figure - 1] need comments. We were not told about the antecedent of head trauma that might explain this abnormality; however, considering the gait instability that the patient was presenting, falls that might have caused mild head trauma cannot be discarded. Nevertheless, even though delayed traumatic ICH exists,[10],[11] it is mainly associated with severe head trauma and would hardly cause more than two ICHs affecting both the infratentorial and supratentorial regions.

When a tap test is indicated, intermittent lumbar or continuous CSF drainage at controlled rate are safe strategies in avoiding overdrainage,[1],[2] especially because the lower threshold of CSF volume compatible with life in humans is rather unknown.[2] In our patient, an advanced age, sulcal enlargement and ventricular dilatation allowing a large CSF volume might have permitted such drainage of the fluid (250 mL in 30 min). Any time lumbar CSF drainage is indicated as diagnostic procedure, it is necessary to be warned about an excessive rate of CSF drainage, which should not exceed 20-25 mL/h.[12] When used as a guide to case selection for a shunting procedure in normal pressure hydrocephalus[2] or as treatment of CSF fistula,[12] lumbar CSF drainage of 40 to 50 mL per session is considered safe and effective.[1],[2]

Another concern with respect to the case discussed here is the medical error that led to this catastrophe. This complication has the possibility to be repeated, especially in teaching hospitals in which physicians in training perform without expert supervision. Appropriate measures were taken in our center to avoid another accident like this. Excessive work must not be an exception of a tight supervision to junior doctors.

In conclusion, CSF overdrainage can either cause or precipitate multiple simultaneous ICHs, affecting both the infratentorial and supratentorial regions.

References

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