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

Abstract

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.

Accidental Dural Puncture and Subsequent Intrathecal Catheter Placement for Labor Analgesia leads to Cranial Nerve VI Palsy

“…By the next day the bilateral cranial nerve palsies had resolved. Other case reports, however, show no immediate improvement in cranial nerve palsy following blood patch [12,13] and most palsies resolved with or without blood patch.…”

“…By the next day the bilateral cranial nerve palsies had resolved. Other case reports, however, show no immediate improvement in cranial nerve palsy following blood patch [12,13] and most palsies resolved with or without blood patch.Cranial nerve palsy is a relatively rare but severe complication of accidental dural puncture. Given the rarity of this complication and the inherent risks of epidural blood patch performance, it is unlikely that the benefits outweigh the risks of prophylactic blood patching for prevention of cranial nerve palsies, although we could not find studies that evaluated such a treatment approach.…”

Intravenous mannitol for treatment of abducens nerve paralysis after spinal anesthesia

“…Abducens paralysis (AP) is a well-known but rare complication following spinal anesthesia, recovery from which may take up to 21 months, 3-6 with little evidence suggesting any alternative to 'watchful waiting'. Although the etiology is unknown, literature review shows that symptoms begin almost immediately after the postdural puncture headache (PDPH) develops but these do not respond to standard PDPH treatments, [1][2][3][4][5][6][7][8] suggesting that the pathophysiological mechanisms are different. Cerebrospinal fluid leak contributes to headache after dural puncture.…”

Intracranial Hypotension Presented with Abducens Nerve Palsy: Case Report

“…10 Abdusens sinirin değişen derecelerdeki tutulumu ve prognozu; sinirin varyasyon derecesi ile ilişkili olarak hafif nöropraksi ya da ciddi aksonotmezis gelişimi ile açıklanmaktadır. 2 Kraniyal sinir felci ilk dört günde nadirdir, sıklıkla LP'den 10 gün sonra ortaya çıkmaktadır. Olgumuzda girişimden dört gün sonra abdusens sinir felci gelişmişti.…”