Headache Medicine 2021, 12(4):346-348 p-ISSN 2178-7468, e-ISSN 2763-6178

346

ASAA

DOI: 10.48208/HeadacheMed.2021.59

Headache Medicine

Neuroimaging

Chronic subdural hematoma that developed after a diagnostic

lumbar puncture: headache worsens with bilateral compression

of jugular veins (Queckenstedt’s maneuver)

Marcelo Moraes Valença¹ , Luiz Severo Bem Junior¹ , Ana Cristina Veiga da Silva¹ ,

Ubiratan Alves Viturino da Silva¹ , Marcelo Andrade Valença¹ ,

Alberto Henrique Torres Trindade da Silva² , Déborah Emmily de Carvalho² ,

Henry Martins Soares Fortes² , Martina Falcão Valença³ , Luciana Patrízia Alves de Andrade-Valença¹

¹Federal University of Pernambuco, Recife, Pernambuco, Brazil

²University of Pernambuco, Recife, Pernambuco, Brazil

³International Neuroscience Institute-Hannover, Germany

An MRI image of the skull is shown in Figure 1. The image is consistent with the presence of

a chronic subdural hematoma on the right. This is a case of a 40-year-old man who, a month

earlier, underwent a lumbar puncture with CSF withdrawal to investigate a headache. The CSF

was considered normal. After lumbar puncture, he continued to have headaches for days, but

with a change in the pattern: it got worse when he sat or walked. The headache continued and

became continuous, worsening with Valsalva maneuvers (e.g., coughing, physical exertion). The

patient had suffering facies on physical examination and, even lying down, he had severe pain.

The pain worsened when the jugular veins were manually compressed by pressure on the neck

(Queckenstedt’s maneuver). On examination of the fundus of the eye, incipient papilla edema

was observed. It was then decided that the patient underwent an urgent magnetic resonance

imaging of the skull.

When the jugular veins undergo bilateral compression in the neck (Queckenstedt’s maneuver),

there is a reduction in blood volume of cephalic origin that goes to the heart. As a result, there

is an increase in the intracranial venous pressure and a consequent increase in intracranial pres-

sure. Increased venous pressure due to compression of the jugular veins increases this already

high intracranial pressure with greater severity and, consequently, the headache intensity. High

intracranial hypertension is the cause of headache suffering in this patient. There is most likely

intracranial hypertension in a patient with an extensive subdural hematoma with a deviation

of the midline structures, as is the case of our patient. In a study of 84 patients with a chronic

unilateral subdural hematoma, the hematoma volume was 176 ± 48 ml.

The mean maximum

midline displacement was 12.5 ± 3.7 mm in this group.

In terms of historical curiosity, Naffziger described a similar maneuver in examining a patient with

sciatic pain, when compression of the jugular veins causes pain or dysesthesia in the affected

limb (Naffziger test or sign).

Chronic subdural hematoma is a neurological disease that occurs more frequently in the elderly,

mainly with a history of alcoholism (with blood dyscrasia due to liver dysfunction) and the use

of anticoagulant/antiplatelet drugs.

2-3

In this age group, there is encephalic involution with an

increase in the subarachnoid space; this explains why there is no headache in many patients with

chronic subdural hematoma of this age group, with more frequent cognitive or focal decits (e.g.,

motor decit). Parkinsonism, although rare, has been associated with chronic subdural hematoma.

Marcelo Moraes Valença

mmvalenca@yahoo.com.br

Submited: March 26, 2022

Accepted: March 27, 2022

Edited by:

Juliana Ramos Andrade

347

ASAA

Valença MM, Bem Junior LS, Silva ACV, Silva UAV, Valença MA, Silva AHTT, Carvalho DE, Fortes HMS, Valença MF, Andrade-Valença LPA

Chronic subdural hematoma that developed after a diagnostic lumbar puncture: headache worsens with bilateral compression of jugular veins (Queckenstedt’s

maneuver)

Our patient is a young adult without brain atrophy, and

the headache was predominant and severe.

In most cases, there are reports of head trauma, often

mild, that occurred 1-3 months before diagnosis. There

are reports of chronic subdural hematoma arising after

lumbar puncture, diagnosis, or spinal anesthesia.

Gener-

ally, before the diagnosis of intracranial hematoma, these

In Figure 2 can be seen the chronic subdural hematoma

drainage through a burr hole and exit through the orice

with high pressure of hematic material typically dark in col-

or like petroleum. After drainage, the headache improved.

Figure 2. Chronic subdural hematoma drainage through a

burr hole and exit through the orice with high pressure of

hematic material typically dark in color like petroleum.

patients presented a clinical picture typical of post-dural

puncture headache.

5-6

In some patients, the cause is un-

known (idiopathic etiology).

Treatment is most often surgical.

A conservative ap-

proach can be adopted, especially in small-volume he-

matomas.

Recently, an endovascular procedure with the

middle meningeal artery occlusion has been performed.

2,7

Figure 1. A, coronal view on MRI of the skull showing a supratentorial subdural hematoma with features of chronicity and devia-

tion of midline structures. B, MRI transverse view showing the typical image of a right supratentorial chronic subdural hematoma.

348

ASAA

Valença MM, Bem Junior LS, Silva ACV, Silva UAV, Valença MA, Silva AHTT, Carvalho DE, Fortes HMS, Valença MF, Andrade-Valença LPA

Chronic subdural hematoma that developed after a diagnostic lumbar puncture: headache worsens with bilateral compression of jugular veins (Queckenstedt’s

maneuver)

Funding: This study did not receive any funding.

Conflict of interest: There is no conict of interest to de-

clare.

Authors Contribution: The authors contributed equally to the

writing of the manuscript.

Marcelo Moraes Valença

https://orcid.org/0000-0003-0678-3782

Luiz Severo Bem Junior

https://orcid.org/0000-0002-0835-5995

Ana Cristina Veiga da Silva

https://orcid.org/0000-0002-1149-4427

Ubiratan Alves Viturino da Silva

https://orcid.org/0000-0002-7715-8258

Marcelo Andrade Valença

https://orcid.org/0000-0002-0824-0928

Alberto Henrique Torres Trindade da Silva

https://orcid.org/0000-0003-2356-4426

Déborah Emmily de Carvalho

https://orcid.org/0000-0002-8068-3598

Henry Martins Soares Fortes

https://orcid.org/ 0000-0003-3963-9058

Martina Falcão Valença

https://orcid.org/0000-0002-4085-3118

Luciana Patrízia Alves de Andrade-Valença

https://orcid.org/0000-0002-3487-0325

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