Chiari I Malformation Presenting as Recurrent Spinal Headache

Abstract

ostdural puncture headache (PDPH) is a wellrecognized complication after spinal anesthesia P (1). When conservative treatment or epidural blood patch (EBP) fail, alternative causes of the headache need to be reconsidered. We present a previously unreported association of recurrent PDPH with a Chiari I malformation. Case ReportA 31-yr-old woman (gravida 1, para 0), with an unremarkable medical history, received analgesia for labor via a lumbar epidural catheter. Subsequently, when she required cesarean section for failure of the labor to progress, satisfactory lumbar epidural anesthesia could not be established. Good surgical anesthesia was provided by subarachnoid block, although spinal needle placement proved technically difficult and required several attempts before successful dural puncture with a 22-gauge needle. The surgery and immediate postoperative period were uneventful. Although she reported a mild positional headache, her surgeon discharged her on the third postoperative day. However, over the following several days, the patient's headache became progressively more severe. The headache was associated with mild neck pain, which worsened when the patient was sitting or standing. Moderate relief was obtained by caffeine ingestion. On the sixth postoperative day, although afebrile, she developed hearing changes (echoing), visual disturbances (blurring and color distortion), and nausea. The diagnosis of PDPH was made. An EBP using 15 mL of autologous blood was administered, with marked improvement of all symptoms.The patient had a recurrence of the headache 4 days

Spinal neuraxial anaesthesia for Caesarean section in a parturient with Type I Arnold–Chiari malformation and syringomyelia

“…In two case reports, the ACM was unknown at the time of delivery and only diagnosed subsequently because of adverse neurological outcomes. 4,5 There have also been reports of successful spinal neuraxial anaesthesia in women with surgically corrected Type I ACM. In these cases, there was active involvement of the neurosurgical team, and it was determined that a neuraxial anaesthesia was not contraindicated because a dural puncture should neither impair CSF flux nor precipitate bulbar compression.…”

Anesthetic management during Cesarean section in a woman with residual Arnold-Chiari malformation Type I, cervical kyphosis, and syringomyelia

“…However, neuraxial anesthesia techniques are not contraindicated if a post-surgical MRI shows that the cerebellar tonsils ascend above the foramen magnum. Spinal neuraxial anesthesia performed in mothers who were found later to have uncorrected Type I ACM and syringomyelia was complicated by neurological worsening, persistent headaches,[13] nystagmus, and oscillopsia. [4] Signs and symptoms may develop up to 2 weeks after a dural puncture.…”

“…[4] Signs and symptoms may develop up to 2 weeks after a dural puncture. [413] On the other hand, there are reports of successful neuraxial spinal anesthesia in women with surgically corrected Type I ACM. [141721] There are case reports of epidural anesthesia done with injection of small local anesthetic bolus (3–4 ml) doses at 5-min intervals, with a total divided dose of 20 ml of 0.5% bupivacaine plus fentanyl 50 μ g, with excellent results.…”

Epidural anesthesia for Cesarean delivery in a patient with post-traumatic cervical syringomyelia

“…Two case reports of aggravated signs and symptoms within two weeks of dural puncture have been described in syringomyelia associated with Arnold-Chiari malformation. [18][19][20] Daskalakis et al 1 described an uncomplicated elective Cesarean delivery under general anesthesia in the presence of PTS. The authors discussed both general and epidural anesthesia as possible techniques.…”