Undetected Dural Leaks Complicated by Accidental Drainage of Cerebrospinal Fluid (CSF) can Lead to Severe Neurological Deficits

Abstract

Purpose: Intracranial hypotension has been reported as a complication of accidental drainage after surgical treatment in several cases. Application of negative pressure systems (wound drains, VAC^®-therapy, chest tube drainage) had typically led to severe intracranial hypotension including intracranial hemorrhage and tonsillar herniation. In the last year the authors observed 2 cases of accidental spinal drainage of CSF in patients with neurological deficits, regressing after reduction of the device suction.

Material and Methods: We conducted a systematic PubMed-based research of the literature to study the variety and frequency of the reported symptoms from 1st of January 1980 until 1st of October 2015.

Results: Reviewing the literature 24 relevant citations including 27 reported cases of posttraumatic or postoperative loss of CSF leading to neurological symptoms were identified. All 15 reported cases in which a negative pressure suction device had been applied showed severe neurological and radiological symptoms such as coma or brain herniation and intracranial hemorrhage. In all cases patients recovered rapidly after removal of the suction device. Milder symptoms were observed in the patients without negative pressure suction, mainly only presenting with headaches or cranial nerve involvement.

Additionally, we give an overview about current recommendations regarding cranial and spinal imaging to rule out dural laceration and cranial hypotension.

Conclusion: Patients with dural laceration complicated by accidental drainage of CSF can present with life-threatening conditions. Increasing use of negative pressure suction devices makes the reported condition an important differential diagnosis. A precise radiological examination can help to rule out dural laceration and intracranial hypotension.

Key Points:

• Undetected dural laceration complicated by negative pressure suction drains can induce life-threatening symptoms.

• Increasing use of negative pressure suction devices makes the reported condition an important differential diagnosis for radiologists

Citation Format:

• Sporns PB, Schwindt W, Cnyrim CD et al. Undetected Dural Leaks Complicated by Accidental Drainage of Cerebrospinal Fluid (CSF) can Lead to Severe Neurological Deficits. Fortschr Röntgenstr 2016; 188: 451 – 458

Zusammenfassung

Ziel: Ausgeprägte intrakranielle Hypotension wurde bereits mehrfach als Komplikation akzidenteller Liquordrainage nach chirurgischen Eingriffen beschrieben. Der Einsatz von Vakuum-basierten Drainagesystemen (Wunddrainagen, VAC®-Wundsystemen, Thoraxdrainagen) führte in diesen Fällen zu lebensbedrohlichen Komplikationen wie intrakraniellen Blutungen und zerebraler Herniation. Im vergangenen Jahr konnten die Autoren 2 Fälle mit akzidenteller spinaler Drainage von Liquor diagnostizieren. Beide Patienten zeigten schwere neurologische Defizite, welche nach Entfernung des Sogs der Drainage komplett rückläufig waren.

Material und Methoden: Systematische Recherche in der Datenbank PubMed im Zeitraum 1. Januar 1980 – 1. Oktober 2015 zur Erfassung der Häufigkeit und Varietät der beschriebenen Symptome.

Ergebnisse: Die Literaturrecherche erbrachte 24 Fallberichte mit insgesamt 27 Fällen von posttraumatischem oder postoperativem Liquorverlust, welche zu neurologischen Defiziten führten. Die 15 Patienten, bei denen Drainagen mit Unterdruck verwendet wurden, zeigten schwere neurologische und radiologische Symptome wie Koma, zerebrale Herniation und intrakranielle Blutungen. Bei allen Patienten waren die Symptome nach Entfernung des Sogs der Drainagen schnell rückläufig. Bei den Patienten ohne Applikation von Unterdruck-Drainagen zeigten sich vorwiegend leichtere Symptome, wie Kopfschmerzen und Irritationen von Hirnnerven. Zusätzlich gibt diese Arbeit einen Überblick über aktuelle Empfehlungen zur kranialen und spinalen Bildgebung bei Verdacht auf intrakranielle Hypotension und zum Ausschluss spinaler Liquorleckagen.

Schlussfolgerung: Undetektierte Liquorleckagen kompliziert durch akzidentelle postoperative/posttraumatische Drainage von Liquor können zu schweren neurologischen Defiziten bei den betroffenen Patienten führen. Die zunehmende Verwendung von Vakuum-basierten Drainagesystemen führt zu einer hohen Relevanz dieses Krankheitsbildes, welches somit eine wichtige Differentialdiagnose darstellt.

Kernaussagen:

• Undetektierte Liquorleckagen kompliziert durch akzidentelle postoperative/posttraumatische Drainage von Liquor können zu lebensbedrohlichen Symptomen führen.

• Die zunehmende Verwendung von Vakuum-basierten Drainagesystemen führt zu einer hohen Relevanz der Differentialdiagnose „Liquorunterdrucksyndrom“.

Key words

dural tear - accidental drainage - negative pressure suction - overdrainage - cranial hypotension

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