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Correspondence |
Clichy, France
To the Editor:
Intracerebral hemorrhage (ICH) is most frequently a spontaneous event. When following regional anesthesia, the link seems a priori evident and relevant.
A 50-yr-old alcoholic woman became comatose two days after hemorroidectomy. For the procedure, a combined spinal-epidural (CSE) had been performed at the L4–L5 level using a 27-gauge pencil-point needle (Whitacre®) through a 16-gauge Tuohy needle (Portex®). Ten milligrams of plain bupivacaine were injected intrathecally for anesthesia and ropivacaine was infused continuously in the epidural catheter for postoperative analgesia. Subcutaneous enoxaparin (20 mg) was given on the first postoperative day. The patient did not complain of any headache and blood pressure remained normal. On the second postoperative day, the patient was found unconscious, biting her tongue.
A cerebral computed tomography scan revealed a recent frontal hematoma with subarachnoid hemorrhage. A conventional cerebral angiogram revealed no vascular abnormality. Twelve hours later, the patient recovered normal neurological function.
Several neurological complications have been described after spinal anesthesia (headache, hearing loss, and subdural hematoma). All these complications have been related to cerebrospinal fluid (CSF) leakage, leading to intracranial hypotension. Intracerebral hematoma has rarely been associated to spinal puncture except after procedures such as lumbar myelography.1
Arguments for coincidence are the lack of headache suggesting if any, a small CSF leakage, a known alcohol abuse and the possibility of spontaneous ICH or secondary to other causes (trauma, hypertensive crisis, alcohol withdrawal seizure).
Arguments for causative association are: no vascular abnormalities detected by extensive brain imaging, the time course of events compatible with a causative association, CSE technique increasing the risk of dural puncture and CSF leakage and the hemorrhagic suffusion compatible with a venous lesion secondary to CSF leakage.
In our opinion, in this case, a direct and univoque implication of the CSE as the unique cause of ICH is questionable.
A cause-effect association is difficult to demonstrate in very rare events. Mantia et al. discussed the possibility that ICH may be frequent after spinal anesthesia.2 However, since then, only two cases of ICH associated with regional anesthesia have been published.3,4 To date, considering the paucity of the literature relating spinal anesthesia to ICH, other risk factors must be discussed. Regional anesthesia is indeed "easy to blame" and the idea that any neurological complication is unequivocally due to the associated spinal anesthetic is misleading.
References
1 Suess O, Stendel R, Baur S, Schilling A, Brock M. Intracranial haemorrhage following lumbar myelography: case report and review of the literature. Neuroradiology 2000; 42: 211–4.[Medline]
2 Mantia AM. Clinical report of the occurrence of an intracerebral hemorrhage following post-lumbar puncture headache. Anesthesiology 1981; 55: 684–5.[Medline]
3 Sharma K. Intracerebral hemorrhage after spinal anesthesia. J Neurosurg Anesthesiol 2002; 14: 234–7.[Medline]
4 Crofts TR, Monagle J, Buist M, Burnes J. Bilateral frontal haemorrhages associated with continuous spinal analgesia. Anaesth Intensive Care 2001; 29: 51–3.[Medline]
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