Brainstem stroke following uncomplicated cervical epidural steroid injection.
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.
Ziai
Wendy C
WC
Divisions of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA. weziai@jhmi.edu
Ardelt
Agnieszka A
AA
Llinas
Rafael H
RH
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
D000893:Anti-Inflammatory Agents; D000077555:Methylprednisolone Acetate; D008775:Methylprednisolone