Epidural blood patch for hypoactive–hypoalert behaviour secondary to spontaneous intracranial hypotension

Abstract

Editor-We thank Dr Sadacharam for his comments on our study. 1 As a calcium channel blocker, magnesium sulphate causes a dose-dependent negative inotropic effect and peripheral vasodilation. However, in our study, no significant inter-group haemodynamic differences were observed. Some possible explanations are; in our study, ASA I and II patients were enrolled and patients with cardiovascular, hepatic, or renal dysfunction and neuromuscular diseases were excluded. Furthermore, pre-hydration was performed and the magnesium sulphate loading dose was infused slowly over 15 min. In elderly patients and patients with a co-existing medical disease, drugs with potential cardiovascular effects including magnesium sulphate should be administered carefully, as the pharmacokinetics and pharmacodynamics are different from those in young, healthy patients.Magnesium sulphate prolongs and potentiates neuromuscular block by non-depolarizing neuromuscular blocking agents. However, a previous study reported that this effect did not prolong emergence from general anaesthesia, if neuromuscular block was adequately monitored with a nerve stimulator. 6 In addition, minor side-effects of magnesium sulphate such as flushing, nausea, and headache are expected at the serum magnesium level .2 mmol litre 21 , and potentially life-threatening complications involving the neuromuscular, cardiovascular, or both systems occur when the serum Mg concentration exceeds 5 mmol litre 21 . 7 In our study, the peak magnesium concentration [1.31 (0.13), mean (SD)] measured administration was much lower than the level associated with a minor side-effect. Therefore, it is our opinion that magnesium sulphate can be used safely not only with regional anaesthesia but also with general anaesthesia.

Intracranial hypotension headache after uncomplicated caudal epidural injection

“…Recently, four patients have been reported with a syndrome of hypoactive‐hypoalert behaviour associated with spontaneous cerebrospinal fluid leak [13, 14]. The patients in these reports are described as suffering from persistent headache, fatigue with somnolence, general apathy, impaired attention and stereotypical motor activity.…”

Frontotemporal brain sagging syndrome

“…10 The marked distortion of the deep midline and brainstem structures in FBSS may disrupt these networks in a similar pattern. Nevertheless, a variety of presentations of CSF leaks are becoming increasingly recognized [17][18][19][24][25][26][27][28][29][30][31][32][33] : pachymeningeal enhancement can be absent, opening pressure can be normal in a significant minority, [34][35][36] CT myelography may only show meningeal diverticula as leaks can be difficult to visualize, 22 early bladder activity on cisternography occurs in high frequency in active leaks, 22,37,38 and lack of sustained improvement with epidural blood patch is not uncommon. 11 The sagging brain in FBSS may be due to a CSF leak or spontaneous intracranial hypotension, where brain sag is also a common imaging finding.…”

Brain Sagging Dementia—Diagnosis, Treatment, and Outcome

“…8,16,19,[21][22][23] Although signs and symptoms mimicking bvFTD were an inclusion criterion, most cases with an insidious onset and gradual progression, 1 without an acute event that triggered immediate medical attention (more than 3-4 weeks), were included in the analysis. Some common characteristics were outlined in most reports: antegrade amnesia, 22,[24][25][26] distractibility and impersistence, 23,24,[27][28][29][30] preservative and stereotyped behavior, 7,8,21,[30][31][32][33] and altered speech output. 8,16,21,[27][28][29][30][31][32][33] A decline in social and interpersonal conduct, including bizarre behavior and social and sexual inappropriateness, was a prominent future in most reports.…”

“…Some common characteristics were outlined in most reports: antegrade amnesia, 22,[24][25][26] distractibility and impersistence, 23,24,[27][28][29][30] preservative and stereotyped behavior, 7,8,21,[30][31][32][33] and altered speech output. 8,16,21,[27][28][29][30][31][32][33] A decline in social and interpersonal conduct, including bizarre behavior and social and sexual inappropriateness, was a prominent future in most reports. [5][6][7][8]16,17,[29][30][31][32][33][34][35][36][37] In contrast to bvFTD, 60% of patients with BSD also presented with cerebellar symptoms such as ataxia, gait disturbance, and dysarthria.…”

“…[5][6][7][8]16,17,[29][30][31][32][33][34][35][36][37] In contrast to bvFTD, 60% of patients with BSD also presented with cerebellar symptoms such as ataxia, gait disturbance, and dysarthria. [6][7][8]16,17,21,22,24,25,[27][28][29][30]32,[36][37][38][39] Therefore, the clinical pictures of BSD and bvFTD differ. Nevertheless, although rare, one should be aware of bvFTD mimicking signs and symptoms that may as well occur in the autosomal dominant disorder spinocerebellar ataxia type 17.…”