IATROGENIC PNEUMOCEPHALUS AFTER LAPAROSCOPIC RENAL BIOPSY

Abstract

A 31-year-old black woman was referred to our department for biopsy for chronic renal insufficiency. The patient had a medical history significant for right middle cerebral artery stroke secondary to antiphospholipid antibody and severe nephrotic syndromes, and required chronic anticoagulation therapy with warfarin. As previous attempts at renal biopsy under computerized tomography (CT) guidance were nondiagnostic, laparoscopic renal biopsy was recommended. Warfarin was discontinued 5 days before the procedure and the patient was admitted to the hospital preoperatively for intravenous heparin anticoagulation. Heparin therapy was discontinued at midnight on the day of surgery. The procedure was performed with the patient under general anesthesia, and placed in the left lateral decubitous position and flexed at the waist. A retroperitoneal approach through the right flank was used. A 10 mm. trocar was placed off the tip of the right 12th rib, and 2, 5 mm. trocars were positioned inferiorly and slightly posterior to this in a subcostal orientation. The right kidney was readily identified with limited dissection. Several substantial renal biopsy specimens were obtained with a laparoscopic cup biopsy forcep under direct vision. In the recovery room the patient complained of severe headache and right lower extremity numbness with paralysis. Head CT demonstrated pneumocephalus (see figure). There was no evidence of an acute intracranial hemorrhage. The patient did not demonstrate any acute mental status changes. Anticoagulation was resumed 24 hours postoperatively and symptoms were treated medically. Repeat head CT 4 days later revealed near resolution of the pneumocephalus. Right lower extremity paralysis gradually improved with aggressive physical therapy and was thought to be secondary to a right lumbosacral plexopathy sustained during positioning at the time of the procedure. Biopsy specimens identified stage 1 to 2 membranous nephropathy associated with mild mesangial proliferation, mild renal atrophy and tubulointerstitial nephritis.