title: Contrast mimicking a subarachnoid hemorrhage after lumbar percutaneous epidural neuroplasty: a case report.
abstract: BACKGROUND
  Subarachnoid hemorrhage is one of the most feared acute neurologic events. Accurate diagnosis of subarachnoid hemorrhage is essential, and computed tomography of the brain is the first diagnostic imaging study. However, in rare circumstances, a similar appearance may occur in the absence of blood in the subarachnoid space. The contrast enhancement of subarachnoid space is a rare complication after lumbar percutaneous epidural neuroplasty, with, to the best of our knowledge, no previous report in the literature.
  
  
  METHODS
  A 42-year-old Korean male patient, who underwent a spinal operation five years previously at the level of L4 to S1, visited our clinic with persistent and aggravating low back pain. An imaging study revealed the focal and diffuse disc protrusion at the level of L4/5 and L5/S1. The clinician decided to perform a lumbar percutaneous epidural neuroplasty. During the procedure, dural adhesion was suspected at the previously operated level, and the neuroplasty catheter was malpositioned into the intradural space on the first attempt. After the catheter was repositioned, the scheduled epidural neuroplasty was completed. Our patient had no definite abnormal neurological signs. But, after a day, our patient complained of severe headache with sustained high blood pressure without neurological disorientation. Computed tomography of his brain showed a subarachnoid hemorrhage-like appearance with intracranial air. Sequential angiography, subtractional magnetic resonance imaging and examination of the cerebrospinal fluid revealed no abnormalities. Follow-up computed tomography after one day revealed no definite intracranial hemorrhage, and our patient was discharged with improved low back pain without neurological deficit.
  
  
  CONCLUSIONS
  We report a rare case of contrast mimicking a subarachnoid hemorrhage after lumbar percutaneous epidural neuroplasty. The physician should keep in mind a rare case like this, and the supine position with head elevation is necessary to avoid a similar complication after lumbar percutaneous epidural neuroplasty.
authors.affiliation: Department of Neurosurgery, Guro Teun Teun Hospital, 1126-34, Guro 3-dong, Guro-gu, Seoul 152-880, Republic of Korea. jivago91@hanmail.net.
authors.forename: Chang Hyun
authors.initials: CH
authors.lastname: Oh
authors.forename: Seong Dae
authors.initials: SD
authors.lastname: An
authors.forename: Seung Hyun
authors.initials: SH
authors.lastname: Choi
authors.forename: Gyu Yeul
authors.initials: GY
authors.lastname: Ji
references.citation: Neuroimaging Clin N Am. 1997 Nov;7(4):693-708
references.pmid: 9336494
references.citation: Can J Neurol Sci. 1999 Feb;26(1):57-9
references.pmid: 10068810
references.citation: AJNR Am J Neuroradiol. 2003 Feb;24(2):254-6
references.pmid: 12591643
references.citation: Neurocrit Care. 2004;1(3):371-4
references.pmid: 16174937
references.citation: Invest Radiol. 1980 Nov-Dec;15(6 Suppl):S260-3
references.pmid: 7203932
references.citation: J Comput Assist Tomogr. 1994 Jan-Feb;18(1):126-8
references.pmid: 8282861
references.citation: Can Assoc Radiol J. 1986 Dec;37(4):243-7
references.pmid: 2950107
references.citation: Invest Radiol. 1980 Nov-Dec;15(6):507-10
references.pmid: 7203906
references.citation: AJR Am J Roentgenol. 1998 Feb;170(2):503-5
references.pmid: 9456974
references.citation: Pain Physician. 2004 Apr;7(2):177-86
references.pmid: 16868590
references.citation: J Forensic Sci. 2002 Mar;47(2):360-5
references.pmid: 11908608
references.citation: Radiology. 1980 Feb;134(2):421-5
references.pmid: 7352222
references.citation: J Neurol Neurosurg Psychiatry. 2003 Aug;74(8):1131-2
references.pmid: 12876252
references.citation: Radiology. 1982 Mar;142(3):673-6
references.pmid: 7063682