Education: Images in Anesthesiology
AN 80-yr-old man underwent hybrid thoracoabdominal aortic aneurysm repair using open and endovascular techniques. He had a cerebrospinal fluid (CSF) drain placed before the procedure for spinal cord protection by means of decreasing CSF pressure and promoting perfusion. It was removed on postoperative day 2, but replaced on postoperative day 3 because of lower extremity weakness. During both placements skin disinfection was achieved with povidone/iodine. Wide sterile fields were used and operators wore sterile gloves, hats, and masks.
The CSF drain remained in place until the seventh postoperative day because as the lower extremity weakness recurred with trials of clamping. The patient became febrile to 102.7°F. He developed mental status changes and computed tomography of the head was obtained emergently. This revealed layering thick fluid in the occipital horns bilaterally with increased periventricular white matter hypoattenuation, indicating meningitis with pus in the ventricles. CSF analysis revealed abundant polynuclear cells and few gram-negative rods. The culture grew Klebsiella pneumoniae
. The spinal drain was removed, and the patient was treated with broad- spectrum antibiotics. He slowly recovered and was eventually discharged to a rehabilitation facility with residual proximal leg weakness suggestive of mild anterior cord ischemia syndrome.
Placement of CSF drains has been shown to decrease the incidence of paralysis after thoracoabdominal aneurysm repair.1
Serious complications associated with CSF drains include intracranial hemorrhage2
and retained catheter fragments.3
Meningitis is a very rare complication of lumbar drains placed for spinal cord protection during aortic aneurysm repair.3
Longer duration of drainage and repeated procedures might increase meningitis risk. This case demonstrates that meningitis should be considered in patients with CSF drains placed for spinal cord protection that develop fever and altered mental status.
1. Coselli JS, Lemaire S, Köksoy C, Schmittling ZC, Curling PE: Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: Results of a randomized clinical trial. J Vasc Surg 2002; 35:631–9
2. Wynn MM, Mell MW, Tefera G, Hoch JR, Acher C: Complications of spinal fluid drainage in thoracoabdominal aortic aneurysm repair: A report of 486 patients treated from 1987 to 2008. J Vasc Surg 2009; 49:29–34, discussion 34–5
3. Cheung AT, Pochettino A, Guvakov DV, Weiss SJ, Shanmugan S, Bavaria JE: Safety of lumbar drains in thoracic aortic operations performed with extracorporeal circulation. Ann Thorac Surg 2003; 76:1190–7, discussion 1196–7
© 2011 American Society of Anesthesiologists, Inc.