Anesth Analg 2003;97:580-582
© 2003 International Anesthesia Research Society
OBSTETRIC ANESTHESIA
Neurocysticercosis: A New Differential in the Diagnosis of Postdural Puncture Headache
Ingrid M. Browne, FFARCSI*, and
David J. Birnbach, MD
*St. Vincent’s University Hospital, Dublin, Ireland; and
University of Miami School of Medicine, Miami, Florida
Address correspondence to David J. Birnbach, MD, Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami School of Medicine, Jackson Memorial Hospital, 1611 N.W. 12th Ave., Room C-301, Miami, FL 33136. Address e-mail to dbirnbach{at}miami.edu Reprints will not be available from the author.
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Abstract
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IMPLICATIONS: Positional headache after spinal anesthesia is considered pathognomonic for postdural puncture headache. This report describes a patient who developed a positional headache after spinal anesthesia that was due to neurocysticercosis, a parasitic central nervous system infestation caused by the tapeworm Taenia solium.
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Introduction
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Spinal anesthesia is often used for cesarean delivery because of its technical ease, reliability, speed of onset, and safety for both mother and neonate (1). This technique has become increasingly popular since the advent of pencil-point (atraumatic) spinal needles, which have greatly reduced the incidence of postdural puncture headaches (PDPH). Although there are numerous causes of postpartum headache, it has previously been suggested that the diagnosis of PDPH is rarely in doubt because it has a unique positional quality (2). Although a positional headache that begins after a spinal anesthetic is considered pathognomonic for PDPH and may be treated with an epidural blood patch, other etiologies are possible and should be considered (3). We present a case of a patient who presented with a severe positional headache that began 5 days after she received a spinal anesthetic for cesarean delivery. Although initially considered to be a PDPH, this headache was subsequently found to be due to neurocysticercosis, a parasitic central nervous system (CNS) infestation caused by the tapeworm Taenia solium.
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Case Report
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A 31-yr-old Ecuadorian woman was admitted to the emergency department 8 days after a cesarean delivery, complaining of a severe headache that had worsened over the previous 3 days. The patient had a cesarean delivery at 39 wk of gestation because of a classic uterine scar with a previous cesarean delivery. On the day of her cesarean delivery, she was afebrile and had intact amniotic membranes and a normal leukocyte count. She denied any history of pelvic inflammatory disease, urinary tract infections, sexually transmitted diseases, or human immunodeficiency virus infection. Physical examination was otherwise normal for a parturient at term.
Spinal anesthesia was administered under strict sterile technique consisting of povidone-iodine skin preparation, sterile drape, and a disposable spinal kit. A sterile 24-gauge Gertie Marx spinal needle (IMD, Park City, UT) was easily inserted via an introducer needle on the first attempt via a midline approach at the L3-4 interspace. There was free flow of clear colorless cerebrospinal fluid (CSF). A sensory level to the fourth thoracic dermatome was obtained after injection of 1.5 mL of 0.75% hyperbaric bupivacaine with 10 µg of fentanyl. The expiration dates of all injected drugs were checked. The anesthetic and surgical courses were uneventful; the spinal block began resolving at 100 min and had totally worn off at 3 h. Postoperatively, the patient denied the presence of headache, backache, or residual block. There was no evidence of postoperative infection, and the patient was discharged home functioning normally and without complaints on her third postoperative day.
Eight days after discharge from the hospital, the patient presented to the emergency department complaining of a severe, throbbing, positional headache; neck ache; and nausea and vomiting of 3 days’ duration and stated that her symptoms were getting worse. On examination, she was afebrile and in moderate pain. The remainder of the physical examination, including funduscopy, was normal. Because of the severity of her symptoms, however, the patient remained in the observation area of the emergency room for the next 12 h, where she was given IV fluid therapy and opioid analgesics. When it was realized that the patient had received a spinal anesthetic 8 days previously, the anesthesiologist on call was called and requested to perform a blood patch. However, because the anesthesiologist elicited positive Kernig and Brudzinski signs during a neurologic examination, a decision was made to postpone the epidural blood patch, and a neurology consultation was requested.
After evaluation by the neurologist, the patient was admitted to the neurology service with a differential diagnosis of "PDPH with meningismus versus meningitis after spinal anesthesia." The patient complained of right occipital and parietal pain that was severe when she stood up and totally resolved when she was supine. In addition, she stated that the headache was the "worst pain" that she had ever experienced. Lumbar puncture was performed, and the CSF examination revealed leucocytosis with 80% polymorphonuclear leukocytes, decreased glucose, and increased protein. No organisms were identified on Gram staining, and CSF culture was negative.
Because of her worsening symptoms, approximately 16 h after admission, a computerized tomographic scan of the brain was performed, which revealed obstructive hydrocephalus and a cystic abnormality at the right frontoparietal region that was indicative of neurocysticercosis (Fig. 1). A magnetic resonance imaging scan of the lumbar spine showed no evidence of abnormality or CSF leak, and magnetic resonance imaging of the brain confirmed the cystic lesion with ring enhancement, considered to be pathognomonic for neurocysticercosis. The patient was treated as an outpatient with albendazole, an orally administered broad-spectrum antihelminthic, and had total resolution of her headache symptoms. After completion of her antibiotic course, despite numerous attempts to reach her, the patient was lost to follow-up, so that further radiologic workup to evaluate cyst resolution was not possible.
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Figure 1. Computerized tomography of the brain revealing a cystic abnormality of the right frontoparietal region that is indicative of neurocysticercosis.
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Discussion
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Headaches are very common in the postpartum period, with up to 40% of women experiencing headaches in the first week after delivery (4). These postpartum headaches may be caused by multiple non-anesthesia-related factors, including stress, tension, hypoglycemia, and caffeine withdrawal. More severe headaches have been attributed to severe hypertension, cerebral hemorrhage, cortical vein thrombosis, cerebral tumor, and sinusitis (5). Neuraxial anesthesia has also been implicated as an etiologic factor for severe postpartum headaches. Headaches after neuraxial anesthesia have been attributed not only to PDPH, but also to meningitis and pneumocephalus (6,7).
One of the classic features of PDPH is the relationship of the headache to posture. This positional component is considered to be pathognomonic for PDPH. Other symptoms include throbbing pain in the frontal or occipital regions, neck pain, or auditory and visual complaints. This patient had many of these features. Risk factors for PDPH include female sex, young-adult age, and pregnancy, all of which were seen in this patient. In this case, however, the patient experienced a positional headache after spinal anesthesia that appeared to be related to incidental intracranial pathology. Neurocysticercosis is caused by an infection of the human CNS with the parasite T. solium (the pork tapeworm) and is now recognized as a common cause of neurological disease in both developing countries and North America. In the United States, neurocysticercosis is primarily seen in the immigrant population, mostly from Latin America. On the basis of serological studies, it is estimated that 1000 new cases are diagnosed each year (8). The pathogenesis and clinical manifestations vary with the active or inactive infective state, site of infection, and accompanying host response (9). The most common clinical presentation of neurocysticercosis is seizures, which may be focal, focal with secondary generalization, or generalized (10). Headaches are common in parenchymal, ventricular, and cisternal neurocysticercosis. They can be hemicranial or bilateral and are often confused with migraine or tension headaches. Such presentation may be the initial sign of increased intracranial pressure (ICP). Other symptoms and signs of increased ICP may also be present, including nausea and vomiting, altered mental status, visual disturbances, or dizziness (11,12). Increased ICP is usually as a result of obstructive hydrocephalus caused by cysticercosis organisms blocking CSF flow within the ventricular system. Treatment depends on the location of the disease and its presentation. Occasionally, surgery is indicated when there is evidence of CSF outflow obstruction or a "mass" effect (13).
Our patient, who had radiologic evidence of hydrocephalus, was successfully treated with an antiparasitic drug. Although it is possible that some of her symptoms were due to the spinal anesthetic and subsequent loss of CSF (e.g., PDPH), the fact that her symptoms responded so well to antiparasitic drugs suggests that the neurocysticercosis was her principal pathology. However, it may be that the alteration in CSF dynamics hastened the onset of hydrocephalus and, thus, worsened her symptoms (14).
In summary, we report a case of a positional headache, occurring five days after an uneventful spinal anesthetic, initially presumed to be due to PDPH but eventually diagnosed as neurocysticercosis. Since the introduction of spinal anesthesia, headache or neurological symptoms that follow have been immediately attributed to the anesthetic. Vandam and Dripps (15), in their landmark 1954 review, state that "it is not scientific thinking always to attribute to the anesthetic a neurological complaint arising in a patient who has had spinal anesthesia." This case exemplifies the concept that neurological sequelae after spinal anesthesia are not always attributable to the anesthetic and illustrates the importance of taking a careful history and neurologic examination before performing an epidural blood patch.
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References
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- Vandam LD, Dripps RD. Long-term follow-up of patients who received 10,098 spinal anesthetics. JAMA 1954; 156: 1486–91.
Accepted for publication April 1, 2003.
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Abstract
Introduction
