Abstract

RODRIGUEZ-NAVARRO, M.A. et al. Recurrent postdural puncture headache in a woman with undiagnosed Chiari I malformation. Rev. Soc. Esp. Dolor [online]. 2009, vol.16, n.2, pp.97-100. ISSN 1134-8046.

Objective: To identify the risk of neurological complications of spinal anesthesia in patients with preexisting Chiari I malformation and to differentiate this entity from "acquired Chiari I malformation", caused by intracranial hypotension. These two entities can be difficult to distinguish radiologically. Case report: After undergoing dural puncture for epidural analgesia during delivery, a 37-year-old woman developed recurrent postdural puncture headache (PDPH). Cerebral magnetic resonance imaging (MRI) revealed Chiari I malformation (displacement of the cerebellar tonsils into the foramen magnum) and diffuse dural gadolinium enhancement. The patient had experienced chronic headaches exacerbated by Valsalva's maneuver before receiving epidural analgesia but had not reported these symptoms. She was treated with analgesics, caffeine and corticosteroids, which resolved the symptoms. After 6 months of follow-up, a second MRI scan revealed the persistence of the anatomical alterations characteristic of Chiari I malformation but without meningeal alterations. Discussion: After dural puncture, "intracranial hypotension syndrome" can occur, caused by alteration of cerebrospinal fluid (CSF) flow and pressure between the cranial and spinal compartments. Continuous CSF leak through the puncture site would cause a negative pressure gradient that would "push" the cerebellar tonsils toward the foramen magnum. Is the pressure change more marked in patients with prior alterations, such as Chiari malformation? Is the previous malformation the cause of the recurrent headache, despite treatment? Conclusion: Thorough clinical evaluation is required before spinal anesthesia is administered since severe neurological complications can occur in patients with undiagnosed Chiari malformations.

Keywords : Hindbrain herniation; Chiari I deformity; Spinal anesthesia complications; Postdural puncture headache.

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