Volume 32, No.3, 2023
Pictorial Neurological Disease
Hemorrhagic shock due to retroperitoneal hemorrhage: a rare complication of lumbar puncture

Ruiz de Santaquiteria-Torres  Valentin,  1 , Arriero-Fernandez  Noemi,  1 , Gil-Abadia  Lucia,  2 , Rubio-Arroyo  Maria del Mar,  3 , Eguileor-Marin  Ziortza,  1 , Copa-Morales  Jose Pablo,  1 , Estrella-Alonso  Alfonso,  1 , Silva-Obregón  Jose Alberto,  1, 4 , Marian-Crespo  Carlos,  1 , 
1 Intensive Care Unit. University Hospital of Guadalajara. Guadalajara. Spain
2 Radiology Department. University Hospital of Guadalajara. Guadalajara Spain
3 Obstetrics and Gynecology Department. University Hospital of Guadalajara. Guadalajara. Spain
4 Research Institute Idi-Paz. PBM Group. Madrid. Spain
Corresponding Author:

Valentín Ruiz de   Santaquiteria Torres

keywords: Lumbar puncture, Hemorrhagic shock, Retroperitoneal hemorrhage

Lumbar puncture is a routine procedure frequently done in hospitalized patients. This tecnique is not free from complications. Here we bring a case of active bleeding from a lumbar arterie after a lumbar puncture that leads to hemorrhagic shock and retroperitoneal hematoma. Furthermore, we focus on developing non-surgical alternatives to cease active bleeding.

A 70-year-old female with a past medical history significant for diabetes, ischemic stroke without sequelae, hypothyroidism, and atrial fibrillation anticoagulated with acenocoumarol was admitted to Neurology hospitalization to be studied about a case of delirium with agitation and hallucinations.

A lumbar puncture (LP) was planned to be done after 36 hours of interruption of acenocoumarol and the start of low molecular weight heparin. A 20 gauge conventional needle was used and 4 attempts were needed, having placed the patient in left decubitus. The first two tries with midline technique and the rest with left paramedian approach through L3-L4 space. A hematic liquid opening followed by a clear fluid ending was achieved.

In the following hours, she felt intense hypogastralgia, followed by hypotension and a four-point drop in hemoglobin value. The intensive Care Unit was called and an ABCD approach was performed including Focused Assessment with Sonography in Trauma (FAST), finding hemorrhagic shock stigma: drowsiness, hypotension, tachycardia and intraperitoneal fluid, as well as mass effect signs. We started resuscitation with a total amount of 3000 milliliters of crystalloids, six-packed red blood cells, 400 milliliters of fresh frozen plasma, a gram of tranexamic acid, and a gram of calcium chloride, with the necessity of noradrenaline.

Meanwhile, a contrast-enhanced abdominopelvic CT was performed and showed a retroperitoneal hematoma with mass effect and active bleeding from the third right lumbar artery (probably due to an oblique left paramedian LP approach). Finally, the bleeding was stopped with the embolization of the artery referred to with four coils placed by the Interventional Radiology team.