British Journal of Radiology (2005) 78, 767-769
© 2005 British Institute of Radiology
doi: 10.1259/bjr/16733207
Portal and systemic venous gas in a patient after lumbar puncture
D Karaosmano
lu, MD,
S Ö Oktar, MD,
M Araç, MD and
G Erba
, MD
Gazi University, School of Medicine, Department of Radiology, 06510, Beevler-Ankara, Turkey
Correspondence: Dr Devrim Karaosmanolu, Gazi Üniversitesi T
p Fakültesi, Radyoloji Anabilim Dal, 06510, Beevler, Ankara-Turkey
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Abstract
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The presence of portal and systemic venous gas is traditionally regarded as an ominous radiological sign indicating a grave prognosis. With advances in imaging technology, the incidence of its detection has increased along with its association with clinically benign disorders. We present a young patient with systemic and portal venous gas after traumatic lumbar puncture.
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Introduction
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Portomesenteric gas has historically been thought a rare condition often associated with mesenteric ischaemia and bowel necrosis. However, a variety of other clinical causes have also been reported [1]. Systemic venous gas, on the other hand, is generally an iatrogenic problem that can be associated with serious medical problems and has a grave prognosis. To our knowledge, only five cases of concurrent portal and systemic venous gas have been reported in the literature, each suggesting a different mechanism of passage between systemic and portal systems [2, 3]. We present ultrasound (US) and CT findings of a young patient with portal and systemic venous gas, presumed to be secondary to traumatic lumbar puncture.
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Case report
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A 19-year-old male patient presented to the emergency department with a severe headache. Physical examination, including a neurological examination, was unremarkable. His medical history, vital signs and laboratory findings were also normal. Emergency CT examination of the head with and without intravenous contrast material performed to rule out subarachnoid haemorrhage or any other neoplastic or inflammatory processes was normal. A lumbar puncture was performed following CT examination to exclude meningitis. The procedure was traumatic; three passes were necessary to obtain enough cerebrospinal fluid (CSF) for bacteriological and serological analysis. Analysis of the CSF revealed no bacteria, and the biochemical and cytological analysis were also normal. 3 h after lumbar puncture, the patient reported mild pain in the abdomen. US examination revealed widespread intravenous gas in the portal vein and its branches, the inferior vena cava and the iliac veins (Figure 1a
). The superior mesenteric artery and vein were patent on Doppler US examination. Patchy areas of hyperechogenicity thought to be consistent with accumulation of gas in the liver parenchyma were also observed (Figure 1b). A CT study with intravenous and oral contrast performed 2 h after the US, showed gas in the extradural space at the L4 level and gas in venous vascular structures of the liver (Figure 2). The air bubbles in the lumen of the inferior vena cava and main portal vein observed at the US examination were not detected at the time of the CT study.
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Figure 1. 19-year-old male with gas in portal and systemic venous system. (a) Grey scale ultrasound reveals gas bubbles in the right main portal vein demonstrating the string of pearls sign. (b) Ultrasound images show the hyperechogenic appearance of the liver parenchyma due to gas bubbles in the peripheral venous structures (short arrows). Also note air bubbles in the lumen of inferior vena cava and hepatic veins.
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Figure 2. (a) Helical CT scan shows gas bubbles in the spinal canal (straight arrow). (b) Helical CT scan shows gas bubbles in the peripheral venous structures of the liver (arrowheads). (c) Helical CT scan obtained at the level of the porta hepatis shows gas in the left main portal vein (straight arrow).
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His headache responded to non-opioid analgesia and his abdominal pain also subsided. Extensive radiological evaluation of the other intra-abdominal organs of the patient revealed no abnormality. An US examination performed 15 min after the CT revealed similar findings to the initial US examination. Follow up US and CT examinations 4 days after the patient's admission showed complete disappearance of the widespread intravenous gas. The patient was discharged 7 days after his admission. 4 months after discharge, the patient remained symptom free and repeat US examination was normal.
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Discussion
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Portal venous gas was previously thought to be associated with serious and sometimes mortal medical conditions such as pneumatosis intestinalis and bowel infarction. More recently with the appearance of new imaging modalities, the recognition of portal venous gas has substantially increased. Early reports of portal venous gas described a very high mortality rate, whereas recent studies have reported mortality rates as low as 29% [4]. This decrease in mortality rates is not only due to the appearance of more effective and improved therapy, but also due to increased detection by the new and more sensitive imaging modalities. Intestinal obstruction, Crohn's disease, ulcerative colitis, perforated gastric ulcer, diverticulitis, caustic ingestion, suppurative cholangitis, blunt abdominal trauma, abdominal abscesses and iatrogenic causes such as gastric dilatation, barium enema examination and liver transplantation are among the wide spectrum of non-ischaemic diseases that have been reported to have caused portal venous gas [5–8].
Systemic venous gas has been associated with decompression sickness, iatrogenic causes and penetrating trauma [6]. The combination of portal and systemic venous gas is a rare condition. To date only five cases have been reported. Presumed possible mechanisms in these patients were fulminant sepsis due to gas forming organisms, necrotizing enterocolitis with a patent ductus venosus, portosystemic shunt in pneumatosis intestinalis, bowel or portosystemic fistula secondary to previous operations and portal obstruction secondary to gas bubbles in cystic fibrosis [2, 3]. To our knowledge, systemic venous gas due to lumbar puncture has not been reported.
Portomesenteric and systemic venous gas can be diagnosed by US and CT, both having high sensitivity for detection of intravascular gas. On US, intravascular gas can be easily identified in the lumen of the vessel as small mobile echogenic foci or a series of gas bubbles resembling a "string of pearls" moving in the direction of blood flow. Distinguishing gas from other particulate material is not a major concern for experienced medical staff accustomed to US. Gas can be distinguished by its echo characteristics and, in real time, by a velocity greater than that expected for blood within the vessel [6]. On CT, gas in the portal vein is seen as tubular lucencies branching from the porta hepatis to the periphery of the liver. Centrifugal flow of blood in the portal vein results in accumulation of gas in the liver periphery. This is an important finding in differentiating gas in the portal vein from pneumobilia since the bile flow is centripetal, and gas in the biliary system tends to collect near the liver hilum and usually does not extend to within 2 cm of the liver capsule. US may be limited by overlying bowel gas and operator skill. However, in our case US was superior to CT, with patchy areas of parenchymal gas accumulation within the liver only detected on US.
Lumbar puncture is a common medical procedure, with a recognized morbidity. The majority of the complications are minor and respond to conservative treatment. Our implication of portosystemic venous gas is likely to have occurred from air entry into the epidural veins from one of the several attempts at lumbar puncture. Air could then pass into the portosystemic circulation via the paravertebral venous system. The vertebral venous plexus, or Batson's venous plexus, is a paraspinal venous system composing of a network of veins that are longitudinally orientated. It has abundant and complex interconnections with pelvic venous structures, femoral and iliac veins, and the inferior and superior vena cava [9]. Unlike the other veins of the body, the veins of the vertebral venous plexus have no valves and are not protected against variations of abdominal or thoracic pressures.
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Conclusion
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The medical history, clinical progress, age, and absence of history of endovascular instrumentation has led us to consider a cause and effect between lumbar puncture, and the radiological appearance of gas in the portal and systemic venous system. The anastomosis between Batson's plexus, the portal system and systemic veins may be the explanation of the widespread venous gas seen in our case.
Received for publication July 26, 2004.
Revision received January 4, 2005.
Accepted for publication March 15, 2005.
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References
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Abstract
Introduction
