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Wendy C. Ziai, MD; Agnieszka A. Ardelt, MD, PhD; Rafael H. Llinas, MD

Arch Neurol. 2006;63:1643-1646.

Background  Cervical epidural steroid injection treatment of radicular pain has become a common procedure.

Objectives  To describe the clinical, radiologic, and autopsy findings of a 41-year-old patient treated with methylprednisolone acetate cervical epidural steroid injection, who developed a fatal hemorrhagic brainstem infarction and to discuss the possible mechanisms involved.

Design  Case report.

Setting  Pain management center and tertiary care hospital.

Results  Immediately following a seemingly uncomplicated epidural steroid injection at C5-6, the patient developed progressive symptoms of extensive brainstem and thalamic infarction (documented by magnetic resonance imaging and autopsy) with hemorrhagic conversion and hydrocephalus. Hemorrhage within the adventitia of the left vertebral artery, but no dissection, was found at the C5 vertebral level at necropsy.

Conclusions  This case report shows the possibility of serious intracranial pathology resulting from cervical epidural steroid injection despite use of fluoroscopic guidance. Vascular spasm distant to the site of injection is a possible mechanism.

Author Affiliations: Divisions of Neurosciences Critical Care (Drs Ziai and Ardelt), and Cerebrovascular Disease (Dr Llinas), Department of Neurology (Drs Ziai, Ardelt, and Llinas), Johns Hopkins University School of Medicine, Baltimore, Md.

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