Subdural Hematoma After Lumbar Puncture in Patients with Coagulation Disorders: A Case Report and Pathogenetic Implications

Introduction

Lumbar puncture (LP) is a relatively safe examination, commonly used for diagnosis using cerebrospinal fluid, measuring intracranial pressure, and cerebrospinal fluid dynamics [1]. However, complications occur in some cases, including infection, intracranial epidural hematoma, and low cranial pressure syndrome [2]. Improper LP operation can cause spinal nerve root damage and induce spinal cord injury, especially when anticoagulants are used, which significantly increases the risk of bleeding [3]. Cerebral venous sinus thrombosis (CVST) is a special type of cerebrovascular disease treated in neurology, commonly seen in children and young adults [4,5]. Oral anticoagulant therapy should be administered as early as possible in the acute phase [6]. However, in most cases, differential diagnosis of sinus thrombosis from other neurological diseases is required, or to evaluate the severity of the patient, so a lumbar puncture is needed at the same time to obtain cerebrospinal fluid. Therefore, such patients face the risks described above.

We report a case of lumbar subdural hematoma after a lumbar puncture in a patient with a CVST, and finally, the hematoma was treated. Video 1 provides a video clip recorded during the emergency neurospinal microsurgery for removing the hematoma. This case of subdural hematoma following LP in a CVST patient is important due to its rarity, as very few previous cases have reported before, and it has clinical implications. As a teaching case, the reasons for the failure of lumbar puncture and the occurrence of adverse events are inferred. How to avoid this factor in future clinical behavior is discussed, as well as exploring alternative diagnostic methods or developing guidelines for safer LP procedures in anticoagulated patients.

Case Report

A 15-year-old girl with CVST and intracranial hypertension underwent decompressive therapy, anticoagulation, and an LP. The initial symptoms included suddenly losing consciousness and falling to the ground, landing on the back of the head, and about 10 seconds later regaining consciousness, without any other symptoms such as nausea or vomiting. It was not treated at that time. Three days later, the headache worsened and was accompanied by vomiting. Imaging examination indicated thromboses in the superior sagittal sinus, rectus sinus, a large cerebral vein, right transverse sinus, sigmoid sinus and bilateral superficial veins of the frontal and parietal lobes. Mannitol and diuresis were routinely administered to reduce intracranial pressure. Subcutaneous injection of enoxaparin sodium was given for anticoagulation. The initial pressure of the lumbar puncture in the outer hospital was 350–360 mmH2O, and it was colorless and turbid. Later, she was transferred to Xuanwu Hospital. To evaluate her intracranial hypertension, she underwent lumbar puncture in the emergency neurology department. A total of 3 tests were conducted due to changes in vomiting. The cerebrospinal fluid pressures were 350 mmH2O (May 6th), 170 mmH2O (May 11th), and 270 mmH2O (May 17th). Appropriate amounts of cerebrospinal fluid were collected for examination (specific quantity unknown). Traumatic No. 9 lumbar puncture needles were used. After LP (May 18th), she had headache and lumbosacral and lower-extremity pain, with preserved motor function. After differentiation from diseases such as myelitis and spinal vascular malformations, the medical history, physical examination, and MRI revealed lumbar subdural hematomas, prompting urgent evacuation of the intraspinal hematoma (Figure 1). Microscopic video revealed a distended dural sac with elevated tension. There were 3 stitches visible in the dorsal dural membrane. Upon dural incision, a subdural hematoma was observed with compression of the cauda equina. After hematoma evacuation, ventral dural stitches were aligned with their dorsal counterparts (Figure 2).

Discussion

Lumbar puncture is the primary modality for cerebrospinal fluid acquisition and is critical for diagnosing diverse neurological conditions. Minor bleeding manifests as the presence of red blood cells in the cerebrospinal fluid, while subdural hematoma is a rare complication [7]. This case is noteworthy because it involves the uncommon complication of a subdural hematoma following a lumbar puncture in a patient with CVST, particularly in light of the patient’s anticoagulation therapy. We emphasize both the rarity and clinical significance of this complication, as well as its implications for clinical practice.

For patients with CVST, subcutaneous injection of low-molecular-weight heparin (LMWH) is the preferred treatment, and direct oral anticoagulants are not the first choice. Changes in cerebrospinal fluid dynamics can cause subdural hematoma after lumbar puncture. Leakage of cerebrospinal fluid after LP can lead to a sudden drop in intracranial pressure, causing the dura mater to separate from the arachnoid membrane and pull the pontine vein, resulting in rupture and bleeding. Meanwhile, the patient has coagulation dysfunction and is prone to bleeding after puncture injury to the blood vessel. Surgical factors such as repeated punctures, use of invasive coarse needles, or overly deep needle insertion can increase the risk of vascular injury.

This case is unique because of the rare occurrence of subdural hematoma following lumbar puncture in a patient with CVST. Bodilsen et al reported that the incidence of spinal cord hematoma after lumbar puncture was 0.20% in patients without coagulopathy and 0.23% in patients with coagulopathy [8, 9]. Central neuraxial blocks have procedural similarities with lumbar punctures. In 2009, the Royal College of Anaesthetists conducted a national survey of the major complications of spinal block anesthesia and found 8 cases of spinal canal hematoma in more than 700 000 procedures, with anticoagulant use in 7, but only 1 patient had a complete recovery of neurological function [10,11]. Therefore, although the relative incidence of hemorrhagic complications is low, their consequences are often severe, and the incidence of such cases should not be underestimated in neurology centers.

This article presents reasons for the failure of lumbar puncture and the occurrence of adverse events through an intraoperative video, and we discuss how to avoid this factor. Our patient underwent lumbar puncture 3 times, and 2 needles penetrated the dura of the spinal canal. Based on anatomical structure, we speculate that during the lumbar puncture the ventral dura was punctured, and the anterior vertebral venous plexus was pierced. In addition, the patient had cranial hypertension. A large amount of cerebrospinal fluid was rapidly released, resulting in negative pressure in the spinal canal, and a large volume of blood was aspirated into the dural sac. Her CVST combined with anticoagulation made the bleed leading to hematoma.

Domingues et al proposed guidelines for lumbar puncture in anticoagulated patients, emphasizing the need to assess drug pharmacology, thrombotic risk, and the urgency of CSF analysis. Tailored decision-making and clear communication between the treating physician and the one performing the lumbar puncture are crucial for risk mitigation [12]. If necessary, temporarily discontinuing anticoagulants or antiplatelet drugs should be considered. The operation needs to be standardized: fine needles are selected, and multiple punctures are avoided. After the operation, the patient lies flat for 4–6 hours. A lumbar puncture can be delayed if the risk of thrombosis is high. Alternative examination methods or other imaging techniques may need to be considered to assess the status of the nervous system to avoid the risks from unnecessary punctures and associated complications.

Subdural hematoma presents with lumbosacral pain and neurological symptoms such as decreased muscle strength, decreased sensation, and urinary incontinence [13]. Imaging indications suggest spinal cord compression or ineffective conservative treatment as surgical indications. Xu et al correctly pointed out that neuroimaging is the standard method for diagnosing spinal cord hematoma [14], which helps medical residents and fellows in early identification of whether emergency surgery is needed to reduce neurological damage. If neurosurgery determines that emergency surgery to remove the hematoma is required, it should be done as soon as possible. This suggests that we may have missed some patients with asymptomatic subdural hematoma.

Conclusions

In summary, this observation supports the pathogenesis of postoperative bleeding following lumbar puncture of patients with anticoagulation therapies and highlights its significance for clinical education and training. The necessity of lumbar puncture should be carefully assessed in patients undergoing anticoagulant therapy for venous sinus thrombosis, especially those with high intracranial pressure. Evaluation of anticoagulation status and considering alternative diagnostic methods to avoid high risks are needed. Future studies are needed to develop guidelines aimed at minimizing complications during the procedure, such as developing safer lumbar puncture techniques or evaluating alternative diagnostic tools for anticoagulated patients, thereby safeguarding patients’ neurological function and quality of life.