Neurocritical Care

, Volume 12, Issue 1, pp 83–87 | Cite as

Intracranial Venous Thrombosis After Placement of a Lumbar Drain

Practical Pearl



Lumbar drains are frequently used in clinical neuroscience and are often managed in the neurointensive care unit. Complications are generally rare, and intracranial venous thrombosis (IVT) and infarction has not been reported.


We report the case of a 45-year-old woman who developed a cerebrospinal fluid (CSF) leak after spinal surgery. Fifteen hours after placement of a lumbar drain she developed pure alexia and color agnosia caused by left lateral sinus thrombosis with hemorrhagic infarction in the posterior inferior left temporal lobe. We review the literature on the association of IVT with injury to the spinal dura, and we propose a mechanism whereby the lumbar drain may facilitate its development.


We found 29 cases in which spinal dural injury was followed by IVT. The association is not coincidental, because nearly all cases were associated with post-dural puncture headache, which occurs in only a minority of cases of dural puncture. Injury to the spinal dura alters the distribution of craniospinal elasticity causing profound intracranial CSF hypotension on assuming the erect posture. This causes acute dilation of cerebral veins resulting in both orthostatic headache and venous stasis. We propose that placement of the lumbar drain and elevation of the head of the bed aggravated intracranial CSF hypotension and facilitated IVT.


When a lumbar drain is placed for treatment of a spinal CSF leak, the patient should remain flat in bed. Any patient with post-dural injury headache that intensifies after an initial plateau, persists for longer than a week, or loses its orthostatic character should be evaluated for intracranial sinus or venous thrombosis.


Lumbar spinal fluid drainage Intracranial sinus thrombosis Spinal puncture Post-dural puncture headache Pure alexia and color agnosia without hemianopsia 



This work was supported by a grant from the Monica Lester Family Trust.


  1. 1.
    Michenfelder JD, Gronert GA, Rehder K. Neuroanesthesia. Anesthesiology. 1969;30:65–100.CrossRefPubMedGoogle Scholar
  2. 2.
    Graf CJ, Gross CE, Beck DW. Complications of spinal drainage in the management of cerebrospinal fluid fistula. J Neurosurg. 1981;54:392–5.CrossRefPubMedGoogle Scholar
  3. 3.
    Houle PJ, Vender JR, Fountas K, McDonnell D, Fick JR, Robinson J. Pump-regulated lumbar subarachnoid drainage. Neurosurgery. 2000;46:929–32.CrossRefPubMedGoogle Scholar
  4. 4.
    Haan J, Thomeer R. Predictive value of temporary external lumbar drainage in normal pressure hydrocephalus. Neurosurgery. 1988;22:388–91.CrossRefPubMedGoogle Scholar
  5. 5.
    Grady RE, Horlocker TT, Brown RD, Maxson PM, Schroeder DR. Neurologic complications after placement of cerebrospinal fluid drainage catheters and needles in anesthetized patients: implications for regional anesthesia. Anesth Analg. 1999;88:388–92.CrossRefPubMedGoogle Scholar
  6. 6.
    Bloch J, Regli L. Brain stem and cerebellar dysfunction after lumbar spinal fluid drainage: case report. J Neurol Neurosurg Psychiatry. 2003;74:992–4.CrossRefPubMedGoogle Scholar
  7. 7.
    Snow RS, Kuhel W, Martin SB. Prolonged lumbar drainage after the resection of tumors of the skull base: a cautionary note. Neurosurgery. 1991;28:880–3.CrossRefPubMedGoogle Scholar
  8. 8.
    Aidi S, Chaunu M, Biousse V, Bousser M. Changing pattern of headache pointing to cerebral venous thrombosis after lumbar puncture and intravenous high-dose steroids. Headache. 1999;39:559–64.CrossRefPubMedGoogle Scholar
  9. 9.
    Albucher JF, Vuillemin-Azaïs C, Manelfe C, Clanet M, Guiraud-Chaumeil B, Chollet F. Cerebral thrombophlebitis in three patients with probable multiple sclerosis. Cerebrovasc Dis. 1999;9:298–303.CrossRefPubMedGoogle Scholar
  10. 10.
    Benzon HT, Iqbal M, Tallman MS, Boehlke L, Russell EJ. Superior sagittal sinus thrombosis in a patient with postdural puncture headache. Reg Anesth Pain Med. 2003;28:64–7.PubMedGoogle Scholar
  11. 11.
    Bienfait HP, Gijtenbeck JMM, van den Bent MJ, de Bruin HG, Voogt PJ, Pillay M. Cerebral venous and sinus thrombosis with cerebrospinal fluid circulation block after the first methotrexate administration by lumbar puncture. Neuroradiology. 2002;44:929–32.CrossRefPubMedGoogle Scholar
  12. 12.
    Ergan M, Hansen von Büneau F, Courthéoux P, Viader F, Prouzeau S, Marcelli C. Thrombose veineuse cérébrale après injection intra-thécale de glucocorticoïdes. Revue du Rhumatisme (Ed. francaise). 1997;64:595–8.Google Scholar
  13. 13.
    Gewirtz EC, Costin M, Marx GF. Cortical vein thrombosis may mimic postdural puncture headache. Reg Anesth. 1987;12:188–90.Google Scholar
  14. 14.
    Gunal DI, Afsar N, Tuncer N, Aktan S. A case of multiple sclerosis with cerebral venous thrombosis: the role of lumbar puncture and high-dose steroids. Eur Neurol. 2002;47:57–8.CrossRefPubMedGoogle Scholar
  15. 15.
    Maurelli M, Bergamaschi R, Candeloro E, Todeschini A, Micieli G. Cerebral venous thrombosis and demyelinating diseases: report of a case in a clinically isolated syndrome suggestive of multiple sclerosis onset and review of the literature. Mult Scler. 2005;11:242–4.CrossRefPubMedGoogle Scholar
  16. 16.
    Milhaud D, Heroum C, Charif M, Saulnier P, Pages M, Blard JM. Dural puncture and corticotherapy as risks factors for cerebral venous sinus thrombosis. Eur J Neurol. 2000;7:123–4.CrossRefPubMedGoogle Scholar
  17. 17.
    Mouraux A, Gille M, Dorban S, Peetters A. Cortical venous thrombosis after lumbar puncture. J Neurol. 2002;249:1313–5.CrossRefPubMedGoogle Scholar
  18. 18.
    Städler C, Vuadens P, Dewarrat A, Janzer R, Uske A, Bogousslavsky J. Thrombose veineuse cérébrale après ponction lombaire et stéroïdes intraveineux chez deux patients souffrant d’une sclérose en plaques. Rev Neurol (Paris). 2000;156:155–9.Google Scholar
  19. 19.
    Borum SE, Naul LG, McLeskey CH. Postpartum dural venous sinus thrombosis after postdural puncture headache and epidural blood patch. Anesthesiology. 1997;86:487–90.CrossRefPubMedGoogle Scholar
  20. 20.
    Hubbert CH. Dural puncture headache suspected, cortical vein thrombosis diagnosed. Anesth Analg. 1987;66:283–6.CrossRefGoogle Scholar
  21. 21.
    Ravindran RS, Zandstra GC. Postpartum headache following regional anesthesia; a symptom of cerebral venous thrombosis. Can J Anaesth. 1989;36:705–7.CrossRefPubMedGoogle Scholar
  22. 22.
    Wilder-Smith E, Kothbauer-Margreiter I, Lämmie B, Sturzenegger M, Ozdoba C, Hauser SP. Dural puncture and activated protein C resistance: risk factors for cerebral venous sinus thrombosis. J Neurol Neurosurg Psychiatry. 1997;63:351–6.CrossRefPubMedGoogle Scholar
  23. 23.
    Schou J, Scherb M. Postoperative sagittal sinus thrombosis after spinal anesthesia. Anesth Analg. 1986;65:541–2.CrossRefPubMedGoogle Scholar
  24. 24.
    Brugeilles H, Penisson-Besnier I, Pasco A, Oillic P, Lejeune P, Mercier P. Cerebral venous thrombosis after myelography with iopamidol. Neuroradiology. 1996;38:534–6.CrossRefPubMedGoogle Scholar
  25. 25.
    Hartley RW, Jackson A, Cooke RS. Dural venous sinus thrombosis following myelography: demonstration by magnetic resonance imaging. Br J Radiol. 1992;65:1134–6.CrossRefPubMedGoogle Scholar
  26. 26.
    Fishman RA. Cerebrospinal fluid in diseases of the nervous system. 2nd ed. Philadelphia: W.B. Saunders Company; 1992.Google Scholar
  27. 27.
    Levine D, Rapalino O. The pathophysiology of lumbar puncture headache. J Neurol Sci. 2001;192:1–8.CrossRefPubMedGoogle Scholar
  28. 28.
    Canhäo P, Batista P, Falcäo F. Lumbar puncture and dural sinus thrombosis—a causal or casual association? Cerebrovasc Dis. 2005;19:53–6.CrossRefPubMedGoogle Scholar
  29. 29.
    Atkinson EA, Fairburn B, Heathfield KWG. Intracranial venous thrombosis as a complication of oral contraception. Lancet. 1970;1:914–8.CrossRefPubMedGoogle Scholar
  30. 30.
    Bloemenkamp KWM, Rosendaal FR, Helmerhorst FM. Enhancement by factor V Leiden mutation of risk of deep-vein thrombosis associated with oral contraceptives containing a third generation progestagen. Lancet. 1995;346:1593–6.CrossRefPubMedGoogle Scholar
  31. 31.
    La Brocca A, Terzolo M, Pia A, Paccotti P, De Giuli P, Angeli A. Recurrent thromboembolism as a hallmark of Cushing’s syndrome. J Endocrinol Invest. 1997;20:211–4.PubMedGoogle Scholar
  32. 32.
    Maxwell SRJ, Moots RJ, Kendall MJ. Corticosteroids: do they damage the cardiovascular system? Postgrad Med J. 1994;70:863–70.CrossRefPubMedGoogle Scholar

Copyright information

© Humana Press Inc. 2009

Authors and Affiliations

  1. 1.Department of Neurology, RIRM-311New York University School of MedicineNew YorkUSA

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