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Case report: Epidural blood patch in the treatment of abducens palsy after a dural puncture

[Présentation de cas : La péridurale avec sang autologue dans le traitement d’une paralysie du nerf moteur oculaire externe après une ponction de la dure-mère]

Philippe Béchard, MD MSc FRCPC^*, Gino Perron, MD FRCPC^*, Denis Larochelle, MD FRCPC^*, Mélanie Lacroix, MD FRCPC^*, Annie Labourdette, MD FRCPC and Pierre Dolbec, MD FRCPC^*

^* From the Department of Anesthesiology, and
Radiology, Hôtel-Dieu de Lévis Hospital, affiliated center to Laval University, Lévis, Québec, Canada.

Address correspondence to: Dr. Philippe Béchard, Department of Anesthesiology, Hôtel-Dieu de Lévis Hospital, Affiliated center to Laval University, 143, rue Wolfe, Lévis, Québec G6V 3Z1, Canada. Phone: 418-835-7121, ext. 3218; Fax: 418-835-3969; E-mail: morphee{at}ssss.gouv.qc.ca

Purpose: To describe a case of iatrogenically induced abducens nerve palsy following a diagnostic lumbar puncture, and to review the evidence for blood patching in the management of sixth cranial nerve palsy after dural puncture.

Clinical features: A 45-yr-old woman developed post-dural puncture headache with bilateral abducens palsy following a diagnostic lumbar puncture. Magnetic resonance imaging showed findings compatible with intracranial hypotension. An epidural blood patch was performed five days after the onset of diplopia and ten days following the dural puncture. After blood patching, the patient reported relief of the headache, but still complained of diplopia. The palsies recovered spontaneously 21 months after the dural puncture.

Conclusion: Experience from this case as well as other case report evidence suggest that an epidural blood patch performed more than 24 hr after the onset of a sixth cranial nerve palsy consistently fails to relieve diplopia. An epidural blood patch executed within 24 hr from the onset of diplopia could possibly lead to partial improvement and/or earlier resolution of symptoms.

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