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Table of Contents    
LETTER TO EDITOR
Year : 2012  |  Volume : 60  |  Issue : 4  |  Page : 446-447

Acute urine retention caused by lumbosacral sedimentation of subarachnoid hemorrhage in a patient with a ruptured internal carotid artery aneurysm


1 Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
2 Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan

Date of Web Publication6-Sep-2012

Correspondence Address:
Shih-Wei Hsu
Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.100736

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How to cite this article:
Su TM, Yang KY, Kuo YL, Hsu SW. Acute urine retention caused by lumbosacral sedimentation of subarachnoid hemorrhage in a patient with a ruptured internal carotid artery aneurysm. Neurol India 2012;60:446-7

How to cite this URL:
Su TM, Yang KY, Kuo YL, Hsu SW. Acute urine retention caused by lumbosacral sedimentation of subarachnoid hemorrhage in a patient with a ruptured internal carotid artery aneurysm. Neurol India [serial online] 2012 [cited 2021 May 6];60:446-7. Available from: https://www.neurologyindia.com/text.asp?2012/60/4/446/100736


Sir,

The term "lumbar sedimentation sign" to describe the phenomenon of layering of altered blood products within the cerebrospinal fluid space at the lumbosacral junction on spinal magnetic resonance imaging (MRI) has been reported recently in patients with subarachnoid hemorrhage (SAH). [1] However, no clinical manifestations correlating with lumbar sedimentation of SAH has been reported. We present a case with aneurysmal SAH who presented with acute urine retention due to sedimentation of subarachnoid blood products in the lumbosacral thecal space.

A 63-year-old female experienced sudden-onset explosive headache while bathing. Examination in the emergency room showed Glasgow Coma Scale score of E4V4M6. Cranial computerized tomography (CT) scan demonstrated diffuse SAH. Cerebral angiography revealed a saccular aneurysm arising at the junction of left internal carotid artery and posterior communicating artery. The aneurysm was successfully occluded with detachable coils. Six days after the ictus, she noted intermittent low back pain with radiation to both legs with no sphincter disturbance. Two days later, she complained of voiding difficulty and saddle tingling sensation. Urine analysis revealed no evidence of infection, and urine culture showed no growth of organisms. A spinal MRI disclosed an apparent fluid-fluid level in the dependent portion of the lumbosacral thecal sac [Figure 1] and [Figure 2]. Sedimentation of blood products originating from the intracranial SAH was considered. Repeated spinal MRI was obtained with the patient in Trendelenburg position for more than 30 minutes. The layering pattern in the thecal sac became blurring and almost vanished on axial images [Figure 3]. Two hours after the second MRI examination, she experienced severe headache and vomited twice. Repeated brain CT scan revealed no evidence of bleed. She received intermittent catheterization and medical treatment. With conservative treatment, her voiding problem improved gradually, and she returned home ten days later with mild low back pain. The patient recovered completely at 3-month follow-up.
Figure 1: Sagittal magnetic resonance imaging study on T1-weighted (a) and T2-weighted (b) images show an apparent fluid-fluid level (arrow) in the lumbosacral thecal sac. The signal intensities reveal the sedimentary blood products in the most dependent portion of the thecal sac

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Figure 2: Axial magnetic resonance imaging study at the level of L5/S1 show the apparent fluid-fluid level (arrow) caused by the sedimentary blood products on T1-weighted image (a) and T2-weighted image (b)

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Figure 3: Magnetic resonance imaging study immediately after the patient had changed her position for more than 30 minutes. The mid sagittal T1-weighted image (a) shows blurring of the previous fluid-fluid level (arrow). The axial images at the level of L5/S1 on T1- weighted image (b) and T2-weighted image (c) show nearly complete disappearance of the fluid-fluid level

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The possible etiology of acute urine retention in this patient is an interesting issue. Side effects from medication were excluded because no drug with anticholinergic effect was used. No evidence of urinary tract infection was established by laboratory studies. Spinal arachnoiditis after SAH was a rare sequel that could cause acute urine retention. [2],[3] However, the onset of presenting symptoms is late and the prognosis is poor in most reported cases. [2],[3] In this case, the onset of presenting symptoms was much earlier and the neurological deficits recovered well with conservative treatment. According to the time course of the presenting symptoms (back pain, then acute urine retention after resuming activity), we thought the cause of acute urine retention was more likely resulting from the effect of chemical irritation caused by the sedimentation of hemorrhagic products in the lumbosacral subarachnoid space after resuming activity. The appropriate management for such cases remains an unknown issue. According to the experiences of previous reports that spinal subarachnoid hematoma occurred after lumbar puncture, [4],[5],[6] the management strategy depends on the clinical manifestations. However, our patient is different from the cases with spinal subarachnoid hematoma after lumbar puncture, because the presenting symptoms/signs are more likely resulting from the effect of chemical irritation caused by the hemorrhagic products in the subarachnoid space, not the mass effect caused by sedimentation of subarachnoid blood products. We think surgical intervention is not indicated for this kind of case because the sedimentary blood products do not cause mass effect. Lumbar puncture may be beneficial by removing the hemorrhagic blood products, thus reducing the irritating effect. Postural drainage by Trendelenburg position to dilute the sedimentary blood products may be another treatment option.

 
  References Top

1.Crossley RA, Raza A, Adams WM. The lumbar sedimentation sign: spinal MRI findings in patients with subarachnoid haemorrhage with no demonstrable intracranial aneurysm. Br J Radiol 2011;84:279-81.  Back to cited text no. 1
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2.Kok AJ, Verhagen WI, Bartels RH, van Dijk R, Prick MJ. Spinal arachnoiditis following subarachnoid haemorrhage: Report of two cases and review of the literature. Acta Neurochir (Wien) 2000;142:795-9.  Back to cited text no. 2
[PUBMED]    
3.Thines L, Khalil C, Fichten A, Lejeune JP. Spinal arachnoid cyst related to a nonaneurysmal perimesencephalic subarachnoid hemorrhage: Case report. Neurosurgery 2005;57:E817.  Back to cited text no. 3
[PUBMED]    
4.Karakosta A, Kyrallidou A, Chapsa C, Pouliou A. Acute spinal subarachnoid haematoma following spinal anesthesia treated conservatively: Case report. Eur J Anaesthesiol 2011;28:388-90.  Back to cited text no. 4
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5.Pai SB, Krishna KN, Chandrashekar S. Post lumbar puncture spinal subarachnoid hematoma causing paraplegia: A short report. Neurol India 2002;50:93-4.  Back to cited text no. 5
    
6.Park JH, Shin KM, Hong SJ, Kim IS, Nam SK. Subacute spinal subarachnoid hematoma after spinal anesthesia that causes mild neurologic deterioration. Anesthesiology 2007;107:846-8.  Back to cited text no. 6
[PUBMED]    


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