После поясничных проколов аракноидное кровотечение и плачущая дура - устойчивая с низким потоком CSF-Leak.

Background and importance

Post-dural puncture headache (PDPH) is a well-recognized and frequently encountered complaint of Lumbar puncture. It usually resolves spontaneously over two weeks or with an epidural blood patch [ 1 ]. Although known for a long time, post-dural puncture syndrome and post-dural puncture headaches linked to a lumbar puncture can persist and are caused by cerebrospinal fluid (CSF) leakage. We report on surgical findings and impressive findings with low-flow CSF leakage in the context of an arachnoidal bleb. This pathology can have significant functional repercussions and limits patients’ daily activities. The topic’s relevance is underestimated, and the study aims to contribute to its spread in the scientific community.

Clinical presentation

We report the case of a 42-year-old neuroscientist with a 23-month history of positional headaches following a lumbar puncture (LP) performed in February 2021 for suspected Multiple Sclerosis (MS), which was ultimately ruled out. The patient initially experienced position-dependent headaches localized at the back of the head and neck, accompanied by intermittent dizziness and tinnitus. Despite conservative treatments, including bed rest, caffeine tablets, IV hydration, and five non-targeted high-volume epidural blood patches (EBP), the symptoms persisted, with only temporary improvement lasting about six weeks. Over time, the patient’s condition worsened, leading to cognitive difficulties such as brain fog and an impaired work ability.

Diagnostic imaging was performed, and a high-resolution T2Space fat-saturated MRI revealed a small, nodular, hyperintense structure adjacent to the dorsal dural sac at the L3-L4 level, suggesting a possible post-puncture ‘arachnoid bleb’ corresponding to the alleged puncture site. A subsequent dynamic myelography and post-myelography CT on 03/05/2022 demonstrated unremarkable intrathecal contrast distribution without evidence of an epidural contrast leak or structural irregularities, particularly at the L3-L4 level, even during delayed imaging.

The MRI findings indicated the presence of an ‘arachnoid bleb’ at the suspected puncture site ( Fig. 1 ). Given the persistent, debilitating symptoms and lack of long-term improvement from the blood patches, a decision for surgical exploration at the L3-L4 level was made.

Sagittal MRI with high-resolution T2Space fat-saturated MRI, an ‘arachnoidal bleb’ on the level L3-L4 was detected corresponding to the alleged puncture site.

Microsurgical exploration identified an arachnoid bleb as a cause of a low-flow CSF leak. The patient gave his consent for the surgical management. The video depicts Neomenbranes overlaying the dura mater. Underneath, we identified an Arachnoid bleb and CSF oozing out, washing a layer of blood away. The CSF leaked like a tear, and we had the impression of a weeping dura ( Fig. 2a — Video 1 ). Treatment was performed by bipolar shrinking of the bleb; the dura was sealed and reinforced using a collagen Matrix—TachoSil (Takeda Pharmaceuticals, Zurich, Switzerland), a Dural substitute, and fibrin glue. The patient’s symptoms gradually improved following the surgery.

( a ): Intraoperative photograph (posterior extradural view) depicts on the left panel the intra-operative view of the arachnoid bleb and the oozing of CSF washing a layer of blood away like a ‘weeping dura’. If you separate them in two panels it's all good, but if its only one panel with the three images please Put (B) for the image in the middle and (C) for the image on the right panel shows the graphical representation of the membranes and the arachnoid bleb. ( b ): The lower or right panel depending if you put it on the same line or indeed in a panel underneath panel shows the graphical representation of the focal outpouching of arachnoid membranes leading to chronic CSF loss and interfering with the dura maters’ healing process.

Discussion

Post-dural puncture headache (PDPH) is a well-recognized and frequently encountered complaint of Lumbar puncture. It usually resolves spontaneously over two weeks or with an epidural blood patch [ 1 ]. However, some patients develop chronic and challenging PDPH. One cause of suspected chronic PDPH is chronic and low-flow CSF leaks caused by arachnoid blebs [ 2 ]. These were first described by MacRobert in 1918 based purely on drawings. Arachnoid blebs are rare and are presumed to be focal outpouching of the arachnoid membranes, leading to chronic CSF loss and interfering with the dura maters’ healing process. ( Fig. 2b ) The exact etiology of arachnoid blebs is uncertain, but they have been associated with congenital and acquired factors.

Conclusion

This case emphasises the importance of considering atypical causes of post-lumbar puncture complications, such as arachnoid blebs, and the role of surgery in identifying and treating these rare conditions. [ 3 ].

Maybe cite the video?

Supplementary data is available at the Oxford Medical Case Reports online.

Consent to participate

Consent from the Patient, file attached.

Consent for publication

Consent of all authors.

Supplementary Material

Contributor Information

Amir El Rahal,
Medical Center University of Freiburg, Breisacher strasse 64, 19106 Freiburg im Breisgau, Germany;
Faculty of Medicine, University of Geneva, Rue Michel Servet 1, 1206 Geneva, Switzerland.

Katharina Wolf,
Medical Center University of Freiburg, Breisacher strasse 64, 19106 Freiburg im Breisgau, Germany.

Florian Volz,
Medical Center University of Freiburg, Breisacher strasse 64, 19106 Freiburg im Breisgau, Germany.

Jürgen Beck,
Medical Center University of Freiburg, Breisacher strasse 64, 19106 Freiburg im Breisgau, Germany.

Conflict of interest

None.

Funding

None.

Ethical approval

EK-Freiburg: Nr: 22–1512-S1.

References

Associated Data

Supplementary Materials