Supratentorial extradural hematoma secondary to intracranial hypotension following spinal cerebrospinal fluid release: A case report and review of literature

Closed continuous lumbar subarachnoid drainage is an accepted strategy in the management of cerebrospinal fluid (CSF) leaks. Post lumbar drain haematoma as a complication has been reported in various planes including intraventricular, subdural, subarachnoid, intraparenchymal and spinal extradural locations, most often in patients receiving anticoagulants. Supratentorial extradural haematoma secondary to intracranial hypotension due to spinal CSF drainage are extremely rare and have been reported in a few cases. We present a rare case of near fatal fronto-temporo-parietal extradural haematoma following a lumbar CSF drain and review the literature. We report a 50 year old lady who developed CSF rhinorrhea following trans-sphenoidal decompression of non-functioning pituitary macroadenoma. A lumbar CSF drainage was placed to manage the CSF leak. She became unconscious within 24 hours of placement of lumbar drain and an urgent CT scan demonstrated a large supratentorial extradural hematoma which required an emergency evacuation. A review of the five previously reported similar cases was performed in the light of the present case and salient features highlighted. The present report emphasizes the fact that a simple procedure like lumbar CSF drainage can have rare life threatening complications and needs immediate recognition and management. Neurology Asia 2013; 18(3) : 331 – 336 Address correspondence to: Dr. Arivazhagan A, Associate Professor, Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India. Tel: +91-080-26995403, Email: [email protected] INTRODUCTION Cerebrospinal fluid (CSF) rhinorrhoea is a known complication following trans-sphenoidal surgery. The management strategy includes placement of a lumbar subarachnoid drain, bed rest and sometimes re-exploration and packing of the sella using fibrin glue and fat-muscle graft. Lumbar CSF release either for therapeutic drainage or for spinal anaesthesia sometimes causes intracranial hypotension manifesting as postural headache. Hematomas have been rarely reported in subdural, subarachnoid and intraparenchymal compartments following lumbar CSF drainage. In patients on anticoagulation therapy, spinal epidural hematomas with neurological deficits requiring surgery have been documented. Supratentorial extradural hematoma (EDH) secondary to intracranial hypotension due to spinal CSF drainage are extremely rare and have been reported in a few cases. We present a rare case of near fatal fronto-temporo-parietal extradural hematoma following a lumbar CSF drain and review the literature of this rare phenomenon. CASE REPORT A 50 year old lady was diagnosed to have a sellar-suprasellar tumour and planned for surgical management.(Figure 1 A, B) She had diabetes, hypertension and hypothyroidism which were treated with medications. Her coagulation profile including prothrombin time, international normalized ratio (INR) and activated partial thromboplastin time (APTT) were normal. She underwent endoscope assisted microscopic transnasal near total decompression of pituitary adenoma. A Mayfield’s clamp was used for head fixation during surgery. There was no CSF leak intra-operatively. She withstood the procedure well. Post-operative CT scan on the first day following surgery showed good decompression of tumour with a small parasellar residue. (Figure 2) She developed CSF rhinorrhoea on the first postoperative day, which was managed with the placement of lumbar CSF drain. Around 300 ml of CSF drained over the next 24 hours in the lumbar drain and the patient developed severe headache, but was conscious and had no Neurology Asia September 2013 332 (Figure 4) She recovered well from the surgery and was discharged from the hospital without any fresh deficits after a few days.