Академический Документы
Профессиональный Документы
Культура Документы
d ns
Neurosciences; Centro Universitario de Ciencias de la Salud. Guadalajara, Jalisco; México
a
overdrainage n
lo o
resulted intimultifocal ICH. To the best of our
knowledge,w
Multiple simultaneous intracerebral hemorrhages (ICH) are
a report on massive CSF drainage as a
this is thecfirst
i
uncommon. We report the case of an 80-year-old woman
o
d ub l
cause of multiple simultaneous ICHs.
with previous diagnosis of normal pressure hydrocephalus
e
rf e w P m).Case Report
and who was brought to our hospital with altered mental
status and urinary incontinence. Medical history of
k
were unremarkable. An initial head computed tomography
e
l edThe
(CT) showed sulcal enlargement and ventricular dilatation,
o wrevealed
history that in the previous two months she suffered
b n
la M her
but no evidence of ICH. A tap test indicated as a guide to
from cognitive impairment and gait disturbance, which motivated
i
a by eclinical k
case selection for shunt surgery accidentally resulted in
caregivers to seek medical attention in another hospital. After
d evaluation and a head computed tomography (CT) scan,
v
cerebrospinal fluid (CSF) overdrainage. The patient
a d .m waswas
presented sudden neurological deterioration, withshe given a diagnosis of normal pressure hydrocephalus. She
is te w of hypertension,
sluggishly responsive pupils and generalized tonic-clonic
not on anticoagulation or antiplatelet therapy. Medical history
s
seizures. A new head CT demonstrated multiple supra and
F o w w
infratentorial ICH. The patient became comatose and had
hematological disorders or severe head trauma
D h (
was absent. The neurological examination at presentation to our
a fatal course. Hence, CSF overdrainage may either cause
P te hospital revealed a conscious woman with spatial disorientation
or precipitate multiple simultaneous ICHs, affecting both
is si
the infratentorial and supratentorial regions.
and bilateral hyperreflexia. Focal neurological signs were absent.
h
T a
Laboratory findings were normal, including platelet count (152 x
Key words: Cerebrospinal fluid, intracranial hemorrhage, 9
10 /liter) and coagulation profile (PT: 90% of control, APTT:
intracranial hypotension, lumbar drainage, neurological
27 seconds, fibrinogen: 225 mg/dl). Blood pressure was below
examination 130/90 mmHg during her hospital stay. A head CT scan
performed in our center showed ventriculomegaly, sulcal
enlargement and diffuse white matter disease, with chronic
bilateral subcortical infarctions [Figure 1]. No evidence of ICH
Introduction was found; nevertheless, a laminar collection of blood in the
posterior interhemispheric fissure was observed, suggestive of
Lumbar cerebrospinal fluid (CSF) drainage has several being secondary to previous head trauma for which we had no
diagnostic and therapeutic indications, with well documented knowledge on history-taking. In spite of this finding, a tap test
hazardous consequences including overdrainage, acute was indicated as a guide to case selection for shunt surgery, since
pneumocephalus, brain collapse and neurological deterioration.[1-3] no mass effect was observed. The procedure was performed by a
Intracerebral hemorrhage (ICH) has been reported after lumbar physician in training without supervision. Cerebrospinal fluid was
puncture and lumboperitoneal shunts, sometimes related to other clear, with opening pressure of 150 mmH2O. The catheter was
conditions.[4-6] We report the case of a woman in whom CSF not withdrawn on time and CSF continued to flow for almost 30
José L. Ruiz-Sandoval
Servicio de Neurología y Neurocirugía, Hospital Civil de Guadalajara , “Fray Antonio Alcalde” Hospital 278. Guadalajara, Jalisco; Mexico 44280.
E-mail: jorusan@mexis.com
Discussion
om
affecting the basal ganglia (thus denouncing the hypertensive
nature seen in most cases).[8] However, most of the knowledge
fr
regarding multiple simultaneous ICHs is derived from case
lo tio
white matter lesions with chronic bilateral subcortical infarctions
the strongest reporting bias. Therefore, the clinical picture,
(i.e., vascular leukoencephalopathy), as well as sulcal enlargement
(i.e., cortical atrophy) and ventricular dilatation are evident, but
without evidence of ICH. Collections of blood over the left parietal
n
outcome and even the putative causes may vary more than is
w lica
reflected in case reports. Since most of the causative factors
convexity and posterior interhemispheric fissure are observed
o
previously attributed to multiple simultaneous ICHs were excluded
d ub
in the case presented here and given that neurological deterioration
min, until the fluid initiated to drain bloody, with a final CSF
e P ).
as well as the hemorrhagic findings in the second head CT began
e
collection of 250 mL, as measured in a graduated flask. After the
procedure the patient presented sudden neurological deterioration, f rimmediately after CSF overdrainage, it seems reasonable to think
w om
with pupils sluggishly reacting to light and generalized tonic-clonic r o
that this procedure was the cause or at least, a precipitating factor
o
f kn .cof multifocal ICH. To our knowledge, this patient had a cause of
seizures. A new head CT was practiced 18h after CSF
e
overdrainage, showing multiple infra and supratentoriall ICHs d w
multiple simultaneous ICHs not previously reported [Table 1].
o
b patient e
In the present case, the putative pathophysiological mechanism
la M dkn
with irruption into the ventricular system [Figure 2]. The
became comatose, requiring ventilatory assistance.iReplacement
that led to multiple simultaneous ICHs points to a continuous
of CSF volume could not be practiced. Two days a y e and massive lumbar CSF evacuation resulting in a reduction of
a v b
later the patient CSF volume with the associated lowering in intraspinal and
is te w.m d
developed pneumonia, which resulted in sepsis and death in one intracranial pressure, which eventually increased the transmural
week more.
pressure gradient of the vessels, leading to a secondary wall stress
P te h (w
disease could be the other important contributing factors.[9] The
widespread and prolonged degeneration of the intracerebral
Table 1: Case reports and case series describing nontraumatic, nonaneurysmal multiple simultaneous Intracerebral
hemorrhages and the associated causal factors
Reference Year of publication Number of cases Putative causal factors
Pant SS and Dreyfus PM 1967 1 Amyloid angiopathy
McCormick WF and Rosenfield DB 1973 16 Leukemia, coagulopathy, vasculitis, neoplasms
Brismar J 1980 1 Cerebral vein thrombosis
Tucker WS, et al. 1980 2 Amyloid angiopathy
Beal MF, et al. 1982 1 Cerebral vein thrombosis
Tyler KL, et al. 1982 1 Amyloid angiopathy
Hickey WF, et al. 1983 2 Idiopathic
Tanikake T, et al. 1983 2 Hypertension
Assad F and Lins E 1984 1 Mycotic aneurysm
Gilles C, et al. 1984 11 Amyloid angiopathy
Patel DV, et al. 1984 2 Amyloid angiopathy
Kobayashi Y, et al. 1987
m 1 Amyloid angiopathy
rf o
Nakamura T, et al. 1988 1 Hypertension
Wakui K, et al. 1988 1 Amyloid angiopathy associated to head injury
Mori H, et al.
Tanno H, et al.
1989
1989
ad ns 1
5
Evacuation of chronic subdural hygroma
Hypertension
lo tio
Green RM, et al. 1990 1 Cocaine abuse
Kase CS, et al. 1990 2 tPA administration
Hasegawa Y, et al .
Nagano N, et al .
1991
1991
n
w lica
1
2
Vasculitis
Anticoagulant therapy
Uno M, et al.
Verstichel P, et al.
1991
1991
o
d ub
9
1
Hypertension
Hypertension
Yanagawa Y, et al . 1994
e 1 Amyloid angiopathy
rf e w P m).
Komiyama M, et al. 1995 1 Hypertension
Ozawa T, et al. 1995 1 Vasculitis
Seijo M, et al.
r
fo kno .co
1996 7 Hypertension, coagulopathy
Dromerick AW, et al. 1997 1 tPA administration
Liou HH, et al. 1997 1 Churg-Strauss syndrome
Nakamura K, et al.
le d ow
1997 1 Amyloid angiopathyassociated to migraine
b
la Me dkn
Nighoghossian N, et al . 1998 1 Antimigrainous drug abuse
Daloze A, et al. 1999 1 Hypertension associated to renal cell carcinoma
Kimura T, et al.
Kohshi K, et al.
i 2000
a by e
1 Vasculitis
Mauriño J, et al.
av 2000
2001
2
4
Hypertension
Hypertension
si ted w.m
Chen CY, et al. 2003 1 Hydrops fetalis
Oide T, et al. 2003 6 Amyloid angiopathy
Shiomi N, et al.
Okuno S and Sakaki T
DF os w 2004
2005
11
1
Hypertension
Systemic lupus erythematosus
P te h (w
Yen CP, et al. 2005 10 Hypertension
Ruiz-Sandoval, et al. 2006 1 CSF overdrainage
his si
CSF indicates cerebrospinal fluid; tPA, tissue plasminogen activator.
An up-to-date MEDLINE search (in February 2006) was performed using the terms “multiple intracerebral hemorrhage (haemorrhage) (s)”, “multiple simultaneous
T a
intracerebral hemorrhage (haemorrhage) (s)”, “multiple intracranial hemorrhage (haemorrhage) (s)” and “multiple simultaneous intracranial hemorrhage (haemorrhage)
(s)”. Only reports available in English or Spanish describing the number of patients and causative factors were referenced; however, information of abstracts
written in other languages were also included in table. The following reports on cases with multiple ICHs were excluded: non-simultaneous, traumatic, aneurysmal
(except mycotic) and arteriovenous malformation ICH.
have caused mild head trauma cannot be discarded. Nevertheless, should not exceed 20-25 mL/h.[12] When used as a guide to case
even though delayed traumatic ICH exists,[10,11] it is mainly selection for a shunting procedure in normal pressure
associated with severe head trauma and would hardly cause more hydrocephalus[2] or as treatment of CSF fistula,[12] lumbar CSF
than two ICHs affecting both the infratentorial and supratentorial drainage of 40 to 50 mL per session is considered safe and
regions. effective.[1,2]
When a tap test is indicated, intermittent lumbar or continuous Another concern with respect to the case discussed here is the
CSF drainage at controlled rate are safe strategies in avoiding medical error that led to this catastrophe. This complication has
overdrainage,[1,2] especially because the lower threshold of CSF the possibility to be repeated, especially in teaching hospitals in
volume compatible with life in humans is rather unknown.[2] In which physicians in training perform without expert supervision.
our patient, an advanced age, sulcal enlargement and ventricular Appropriate measures were taken in our center to avoid another
dilatation allowing a large CSF volume might have permitted accident like this. Excessive work must not be an exception of a
such drainage of the fluid (250 mL in 30 min). Any time lumbar tight supervision to junior doctors.
CSF drainage is indicated as diagnostic procedure, it is necessary In conclusion, CSF overdrainage can either cause or precipitate
to be warned about an excessive rate of CSF drainage, which multiple simultaneous ICHs, affecting both the infratentorial and
ad ns
nlo tio
ow lica
d ub
e
rf e w P m).
r
fo kno .co
ble ed ow
ila M dkn
va by e
a
si ted w.m
DF os w
P te h (w
his si
T a