title: Brainstem stroke following uncomplicated cervical epidural steroid injection.
abstract: BACKGROUND
  Cervical epidural steroid injection treatment of radicular pain has become a common procedure.
  
  
  OBJECTIVE
  To describe the clinical, radiologic, and autopsy findings of a 41-year-old patient treated with methylprednisolone acetate cervical epidural steroid injection, who developed a fatal hemorrhagic brainstem infarction and to discuss the possible mechanisms involved.
  
  
  METHODS
  Case report.
  
  
  METHODS
  Pain management center and tertiary care hospital.
  
  
  RESULTS
  Immediately following a seemingly uncomplicated epidural steroid injection at C5-6, the patient developed progressive symptoms of extensive brainstem and thalamic infarction (documented by magnetic resonance imaging and autopsy) with hemorrhagic conversion and hydrocephalus. Hemorrhage within the adventitia of the left vertebral artery, but no dissection, was found at the C5 vertebral level at necropsy.
  
  
  CONCLUSIONS
  This case report shows the possibility of serious intracranial pathology resulting from cervical epidural steroid injection despite use of fluoroscopic guidance. Vascular spasm distant to the site of injection is a possible mechanism.
authors.affiliation: Divisions of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA. weziai@jhmi.edu
authors.forename: Wendy C
authors.initials: WC
authors.lastname: Ziai
authors.forename: Agnieszka A
authors.initials: AA
authors.lastname: Ardelt
authors.forename: Rafael H
authors.initials: RH
authors.lastname: Llinas
mesh_terms: D000328:Adult; D000893:Anti-Inflammatory Agents / Q000009:adverse effects*; D020526:Brain Stem Infarctions / Q000139:chemically induced* / Q000473:pathology; D002574:Cervical Vertebrae / Q000187:drug effects; D006801:Humans; D007268:Injections, Epidural / Q000379:methods; D018810:Magnetic Resonance Angiography / Q000379:methods; D008279:Magnetic Resonance Imaging / Q000379:methods; D008297:Male; D008775:Methylprednisolone / Q000009:adverse effects / Q000031:analogs & derivatives*; D000077555:Methylprednisolone Acetate; D010146:Pain / Q000188:drug therapy
chemical_list: D000893:Anti-Inflammatory Agents; D000077555:Methylprednisolone Acetate; D008775:Methylprednisolone