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.
Résumé
Objectif
Décrire un cas de paralysie du nerf moteur oculaire externe provoquée iatrogéniquement suite à une ponction lombaire diagnostique, et passer en revue les preuves de l’efficacité du colmatage sanguin dans le traitement d’une paralysie du sixième nerf crânien suite à une ponction de la dure-mère.
Eléments cliniques
Une femme âgée de 45 ans a développé une céphalée post ponction de la dure-mère accompagnée d’une paralysie bilatérale des nerfs moteurs oculaires externes suite à une ponction lombaire diagnostique. L’imagerie par résonance magnétique a démontré des résultats compatibles avec une hypotension intracrânienne. Une péridurale avec sang autologue a été administrée cinq jours après l’apparition de diplopie et dix jours après la ponction de la dure-mère. Suite à cette péridurale, la céphalée fut soulagée, mais la patiente se plaignait encore de diplopie. Les paralysies disparurent spontanément 21 mois après la ponction de la dure-mère.
Conclusion
Ce cas clinique s’ajoute à plusieurs autres qui suggèrent qu’une péridurale avec sang autologue effectuée plus de 24 h après l’apparition d’une paralysie du sixième nerf crânien est inefficace pour soulager la diplopie. Une péridurale avec sang autologue exécutée dans les 24 h après l’apparition de diplopie pourrait peut-être l’améliorer partiellement et / ou permettre une résolution plus précoce des symptômes.
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Béchard, P., Perron, G., Larochelle, D. et al. Case report: Epidural blood patch in the treatment of abducens palsy after a dural puncture. Can J Anesth 54, 146–150 (2007). https://doi.org/10.1007/BF03022012
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DOI: https://doi.org/10.1007/BF03022012