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    Abstract
   Introduction
   Case Report
   Discussion
    References
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Table of Contents
CASE REPORT  
Year : 2012  |  Volume : 15  |  Issue : 3  |  Page : 244-246
Headache and seizures after cervical epidural injection in a patient undergoing coronary artery bypass grafting


Medanta Institute of Critical Care and Anaesthesiology & Medanta Heart Institute, Medanta-The Medicity, Gurgaon, Haryana, India

Click here for correspondence address and email

Date of Submission08-Dec-2011
Date of Acceptance23-Apr-2012
Date of Web Publication4-Jul-2012
 

   Abstract 

Epidural analgesia is widely used in cardiothoracic surgery. Most of the complications associated with epidural analgesia are related to the insertion techniques of epidural catheter. A 68-year-old obese patient posted for coronary artery bypass grafting surgery developed headache followed by seizures after insertion of the thoracic epidural catheter. Magnetic resonance imaging revealed air in the basal cisterns and in the left frontal region. The patient was managed conservatively and the symptoms subsided after 24 h. Later, the patient underwent coronary angioplasty.

Keywords: Coronary artery bypass grafting, Cervical epidural, Pneumocephalus

How to cite this article:
Arora D, Mehta Y, Jain A, Trehan N. Headache and seizures after cervical epidural injection in a patient undergoing coronary artery bypass grafting. Ann Card Anaesth 2012;15:244-6

How to cite this URL:
Arora D, Mehta Y, Jain A, Trehan N. Headache and seizures after cervical epidural injection in a patient undergoing coronary artery bypass grafting. Ann Card Anaesth [serial online] 2012 [cited 2017 Nov 19];15:244-6. Available from: http://www.annals.in/text.asp?2012/15/3/244/97983



   Introduction Top


Epidural analgesia at the cervical and thoracic levels has been extensively used for cardiac surgery, the major success of which depends on the correct identification of the epidural space. This can be done by using the loss-of-resistance technique with isotonic saline or air or by the hanging drop method. Injection of air into the subarachnoid space may rarely lead to headache and seizures in these patients. We present a patient who developed severe headache and seizures after cervical epidural injection.


   Case Report Top


A 68-year-old obese hypertensive, diabetic male weighing 105 kg, with triple vessel coronary artery disease (CAD) was admitted for coronary artery bypass grafting (CABG). There was no history of seizures, dizziness or loss of consciousness. Systemic examination was within normal limits except for decreased breath sounds at both the lung bases on auscultation. Routine hematological and biochemical investigations were within normal limits. Echocardiography revealed normal left ventricular function. Pulmonary function test (PFT) revealed moderate obstructive pattern. In order to provide good analgesia, thereby decreasing pulmonary complications, it was planned to provide epidural analgesia with general anesthesia (GA). Informed consent was obtained for the same. Standard premedication drugs and monitoring techniques were used.

Epidural catheter (Portex, Smiths Medical, Kent, UK) insertion was done in the sitting position. After cleaning and draping, local anesthesia was administered at the 7 th cervical and 1 st thoracic vertebral interspace and a 16 gauge Tuohy needle was inserted. Epidural space was detected with the hanging drop method in the first attempt by an experienced anesthesiologist. After successful detection, the epidural catheter was inserted leaving 5 cm of the catheter into the space. A test dose of 2 mL of 2% lignocaine plain was administered through the catheter to rule out subarachnoid insertion.

After administering the test dose, the patient complained of severe headache along with rigidity, developed jerky involuntary movements of the limbs, which looked like generalized tonic clonic seizures (GTCS). The patient was made supine immediately and 100% oxygen was administered by the face mask, and midazolam 2 mg was administered intravenously. GTCS were controlled immediately. There was no hypotension, bradycardia or arrhythmia. After about 10 min, the patient regained consciousness and responded to verbal commands. The surgical procedure was abandoned and the patient was shifted to the recovery room. Neurologist opinion was taken and magnetic resonance imaging (MRI) of the brain and intracranial vessels was done, which revealed air in the basal cisterns and subarachnoid spaces (pneumocephalus) along with chronic ischemic lesions in the left frontal region. There was no evidence of acute infarction, intracerebral hemorrhage or vascular stenosis [Figure 1] and there was no any neurological deficit. The epidural catheter was removed and the patient was kept in the recovery room for observation. Headache disappeared after 24 h of bed rest and the patient was shifted to the ward. After that event, the patient did not give consent for CABG; instead, he opted for coronary angioplasty. Angioplasty and stenting of the left anterior descending and right coronary artery were done after 2 days, and the procedure was uneventful. The patient was discharged 3 days after angioplasty and he is on regular follow-up.
Figure 1: MRI of the brain showing pneumocephalus

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   Discussion Top


Pneumocephalus, the presence of air in the cranial cavity, may occur when air is used for identification of the epidural space. [1],[2] It can occur when the puncture is complicated by a dural breach, either evident or unnoticed. It is usually associated with disruption of the skull: after head and facial trauma, tumor of the skull base, after neurosurgical or otorhinolaryngeal procedure and, rarely, spontaneously. The patient may present with sudden-onset headache, altered sensorium, dizziness or GTCS.

Pneumocephalus has been reported immediately after epidural for labor analgesia in obstetric patients as well as in patients with intestinal carcinoma after 10 days of continuous epidural infusion for postoperative analgesia. [3],[4] Some authors indicated surgical etiology for this, which was previously attributed to thoracic epidural injection. [5] Moreover, in obese patients, the epidural space is reduced due to presence of excessive fat and distended and tortuous epidural veins; therefore, there are more chances of dural breach. In acute cases, the etiology is sudden introduction of air into the subarachnoid space after dural puncture while in continuous infusion, it may be due to entrainment of air along the epidural catheter. In a majority of the cases reported, air was used for the detection of epidural space.

In this case, thoracic epidural analgesia (TEA) was performed due to the presence of obesity with reduced PFT, which we have shown to be of benefit in the past. [6] Also, in patients with obstructive sleep apnea (OSA), there are several advantages of TEA, like better PFTs postoperatively and avoidance of narcotic analgesics. [7]

A retrospective analysis of techniques for detection of epidural space described loss of resistance with saline as a safe and reliable method, and use of air for detection was associated with a number of complications like pneumocephalus, air embolism, insufficient analgesia, higher incidence of dural puncture, nerve root compression and subcutaneous emphysema. [8] Other authors have also suggested preference of saline over air for the detection of epidural space. [9],[10] Pneumocephalus has been reported with cervical epidural steroid injection, although not in relation with cardiac surgery. [11] Lignocaine may cause similar symptoms like headache, irritation or disorientation if accidentally injected intravenously. However, in this patient, only test dose was used, which is unlikely to cause these symptoms; moreover, there was no bloody tap during catheter insertion.

Pneumocephalus is usually diagnosed by imaging, and MRI is the modality of choice. Clinically, it is difficult to differentiate the cause of headache, whether it is because of air or stretching of meninges or secondary to cerebrospinal fluid leakage. Moreover, other causes of seizures like metabolic, subarchnoid hemorrhage. AV malformation, space-occupying lesion or drug intoxication should be ruled out. Management includes bed rest, hydration and symptomatic treatment. Most of the patients become asymptomatic by 72 h. Permanent neurological deficit is rare.

In the present case, although saline was used for detection of epidural space, air might have been sucked along the epidural catheter or through the dural puncture, which was not detected while inserting the catheter. The patient was managed with bed rest and proper hydration, and no active neurological intervention was required.

To conclude, regional analgesia should be used judiciously in patients undergoing CABG and administered under expert guidance. Complications of epidural catheter insertion, like inadvertent puncture of dura, may lead to postponement and delay in the therapeutic procedure.

 
   References Top

1.Smarkusky L, DeCarvalho H, Bermudez A, González-Quintero VH. Acute onset headache complicating labor epidural caused by intrapartum pneumocephalus. Obstet Gynecol 2006;108:795-8  Back to cited text no. 1
    
2.van den Berg AA, Nguyen L, von-Maszewski M, Hoefer H. Unexplained fitting in patients with post-dural puncture headache. Risk of iatrogenic pneumocephalus with air rationalizes use of loss of resistance to saline. Br J Anaesth 2003;90:810-1; author reply 811-2.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Nafiu OO, Urquhart JC. Pneumocephalus with headache complicating labour epidural analgesia: should we still be using air? Int J Obstet Anesth 2006;15:237-9.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Kasai K, Osawa M. Pneumocephalus during continuous epidural block. J Anesth 2007;21:59-61.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Gentile A, Germain A, Ouattara A, Janvier G. Pneumocephalus following thoracic surgery: the implication of the epidural anesthesia is still exceptional. Interact Cardiovasc Thorac Surg 2010;11:515-7.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Sharma M, Mehta Y, Sawhney R, Vats M, Trehan N. Thoracic epidural analgesia in an obese patient with body mass index more than 30kg/ m2 for off pump coronary artery bypass surgery. Ann Card Anaesth 2010;13:28-33.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.Mehta Y, Manikappa S, Juneja R, Trehan N. Obstructive sleep apnea syndrome: anesthetic implications in the cardiac surgical patient. J Cardiothorac Vasc Anesth 2000;14:449-53.  Back to cited text no. 7
    
8.Figueredo E. Techniques for identifying the epidural space. Rev Esp Anestesiol Reanim 2005;52:401-12.  Back to cited text no. 8
    
9.Lin HY, Wu HS, Peng TH, Yeh YJ, Cheng IC, Lin IS, Liu CH. Pneumocephalus and respiratory depression after accidental dural puncture during epidural analgesia--a case report. Acta Anaesthesiol Sin 1997;35:119-23.  Back to cited text no. 9
    
10.Saberski LR, Kondamuri S, Osinubi OY. Identification of the epidural space: is loss of resistance to air a safe technique? A review of the complications related to the use of air. Reg Anesth 1997;22:3-15.  Back to cited text no. 10
    
11.Simopoulos T, Peeters-Asdourian C. Pneumocephalus after cervical epidural steroid injection. Anesth Analg 2001;92:1576-7.  Back to cited text no. 11
    

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Correspondence Address:
Yatin Mehta
Medanta Institute of Critical Care and Anaesthesiology, Medanta-The Medicity, Gurgaon, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.97983

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This article has been cited by
1 Cervical epidural analgesia in current anaesthesia practice: systematic review of its clinical utility and rationale, and technical considerations
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[Pubmed] | [DOI]



 

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