Intracranial Venous Thrombosis After Placement of a Lumbar Drain

Abstract

When a lumbar drain is placed for treatment of a spinal CSF leak, the patient should remain flat in bed. Any patient with post-dural injury headache that intensifies after an initial plateau, persists for longer than a week, or loses its orthostatic character should be evaluated for intracranial sinus or venous thrombosis.

Cerebral venous thrombosis: an unexpected complication from spinal surgery

“…However, to our knowledge, only Miglis and Levine have previously reported a case of CVT following spinal surgery complicated by durotomy, which was treated with the aid of external CSF drainage, presenting a more dramatic outcome and a much shorter follow-up period [4]. Nevertheless, a few reports have associated CVT with other forms of spinal meningeal injury, including spontaneous intracranial hypotension, diagnostic lumbar puncture, myelography, and epidural and spinal anesthesia, as well as intrathecal administration of steroids and cytostatics [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23]. The temporal gap between the iatrogenic injury to the spinal meninges and the diagnosis of CVT has ranged from a few hours to a few days.…”

“…Second, the clinical presentation of CVT is nonspecific and isolated intracranial hypertension may be the sole manifestation of CVT, especially in patients with dural sinus thrombosis without involvement of superficial or deep veins [1][2][3]. CVT should be excluded every time in patients with symptoms of intracranial CSF hypotension after spinal surgery and/or external lumbar CSF drainage show the following: (1) complaint of headache that worsens after an initial plateau, loses its orthostatic character or lasts for more than a few days after the introduction of proper treatment; and (2) a decreased level of consciousness, encephalic focal neurologic deficits or seizures [4,5,20,23]. However, the change in headache pattern may not reliably predict the development of CVT [20].…”

Isolated cortical vein thrombosis: a rare cause of venous stroke with good prognosis after timely diagnosis and treatment

“…[6][7][8][9][10] Recently, a growing body of evidence has linked intracranial hypotension syndrome with CVT in all its forms. [11][12][13] Thrombosis of the cerebral veins is a relatively uncommon but potentially life-threatening condition, accounting for 1-2% of strokes in young adults. Reported death rates generally range between 5% and 30%, but one study of 49 patients showed a 48% mortality rate in untreated patients.…”

Intracranial hemorrhage after spine surgery

“…Additionally, drain placement and continued suction at the site of dural repair have also been proposed as a mechanism for sustained cerebral hypotension. 1,2,10,13,14,24,32 Left unrecognized or untreated, this complication can have debilitating and even fatal consequences. Thus, early detection and diagnosis is critical for implementing appropriate treatment and ensuring the best possible outcome.…”

“…32 That same year, Miglis and Levine described the case of a patient who was neurologically intact after anterior cervical discectomy and fusion but who experienced acute onset of headache, vomiting, and visual defects 15 hours after the insertion of a lumbar drain. 24 Such reports implicate drain placement, whether subcutaneous or subarachnoid, as a critical precipitating factor in the onset of ICH after spine surgery, possibly through CSF diversion. One author found that the subgaleal suction system exerted enough negative pressure to remove CSF from between the stitches of a watertight dural repair.…”