Intraventricular hemorrhage after acupuncture

Abstract

Acupuncture is a traditional treatment method that has been extensively used for centuries in a number of Asian countries for pain control as well as for treatment of various diseases. Acupuncture has been known to be a safe procedure with little side effects, but at times serious complications such as infection, pneumothorax, central or peripheral nerve injury and cardiac injury may occur. Cases of cerebral hemorrhage by acupuncture are rare with few being reported. A 32-year-old woman presented with a headache that occurred after acupuncture at posterior neck. We diagnosed her symptoms initially as peripheral nerve irritation by acupuncture and administered analgesic only. However, the final diagnosis was turned up to be intraventricular hemorrhage. The authors emphasize that acupuncturists and emergency physicians should know that acupuncture can lead to intracranial hemorrhage as a serious complication and this should be considered in all causes of headache for diagnosis without prejudice.

Introduction

Acupuncture is a traditional method of treatment that has been extensively used for centuries in a number of Asian countries, including Korea, Japan, and China for pain control as well as for treatment of various diseases. Acupuncture has been known to be a fairly safe procedure with little side effects, but at times serious adverse events such as infection, pneumothorax, injury of either the central or peripheral nervous system, and cardiac injury may occur.^1–3 We are reporting a case of intraventricular hemorrhage (IVH) as rare complication after acupuncture.

Case

A 32-year-old woman presented with a headache that occurred 4 h ago. She experienced posterior neck pain for past several months and had received acupuncture in a local oriental clinic. But her pain did not improve and she received acupuncture with a needle longer than usual. She told us that she felt severe headache as well as posterior neck pain soon after the acupuncture.

She first went home and had waited 2 h for symptoms to improve. However, her headache did not improve and was getting worsened. It was accompanied by nausea and vomiting. The vital signs were as follows: blood pressure of 120/80 mmHg, heart rate of 84 beats per minute, respiratory rate of 20 breaths per minute and body temperature of 36.5°C. She was alert.

On neurologic examination, pupil was isocoric and light reflex prompt. Motor and sensory in all extremities was normal and no specific neurologic abnormality. However, she had severe anxiety symptoms that did not allow for more detailed neurologic examination. All laboratory data performed were within normal limits.

We initially thought her symptoms were due to irritation of peripheral nerves by acupuncture, so we administered analgesics and waited for symptoms to improve. However, the pain was progressively worse. Vertical nystagmus was observed. Immediately, we performed computed tomography (CT) and magnetic resonance imaging (MRI) of brain subsequently. Brain CT and MRI showed IVH from the base of the fourth ventricle extending to the inferior horns of lateral ventricles through the third ventricle with obstructive hydrocephalus (Figure 1). There was also hemorrhage in the cisterna magna (Figure 2).

Figure 1.

CT shows intraventricular hemorrhage with obstructive hydrocephalus.

Figure 2.

MRI (T1 TSE SAG) shows intraventricular hemorrhage and hemorrhage in the cisterna magna.

We consulted the neurosurgeon. An external ventricular drain (EVD) was placed, and the patient underwent transfemoral cerebral angiography (TFCA). TFCA showed that stagnant contrast was noted around the left C2 radicular artery without any evidence of arterio-venous (AV) shunting flow or pseudoaneurysm (Figure 3).

Figure 3.

TFCA shows contrast stagnation around the left C2 radicular artery (black arrow) without any evidence of AV shunting flow or pseudoaneurysm.

After placing the EVD, she became alert but she still complained of headache and diplopia up to 29th day of admission. Repeated brain CT revealed hydrocephalus worsen. A ventriculo-peritoneal shunt was inserted. Afterwards, there were no any signs of neurological decline. On day 64, she was discharged without any neurological sequelae.

Discussion

Cases of cerebral hemorrhage due to acupuncture are rare with few reported. In a systemic review by Xu et al., ¹ among 294 cases with serious complications due to acupuncture, there were three cases of cerebral hemorrhage. In patients who developed complications of cerebral hemorrhage, symptoms such as headache, nausea and vomiting developed rapidly after acupuncture, requiring hospital care from several hours up to 3 days post acupuncture.^2–4 In this case, the patient came to the ER 4 h after receiving acupuncture despite a severe headache.

In the cases from Tsukazaki et al. ² and Choo et al., ⁴ both patients received acupuncture in an area named “feng fu”, which approximates the foramen magnum and lies below the external occipital protuberance. Heo et al. ³ also reported a case of cerebral hemorrhage after the patient had received acupuncture in the posterior neck and even Murata et al. ⁵ have reported that cerebral hemorrhage had occurred while receiving acupuncture between C(Cervical spine)1 and C2. Even in our case, the patient had received acupuncture between C1 and C2, which was not the first, but rather had received acupuncture several times in the same area, and at the time of the visit, the patient reported that she received acupuncture a little deeper with a longer needle.

Cases of cerebral hemorrhage associated with acupuncture were found to have various complications such as subarachnoid hemorrhage, subdural hematoma, epidural hematoma, or cerebellar hemorrhage. Heo et al. ³ reported findings of hemorrhage in the cerebellum, and Choo et al. ⁴ observed the findings of the IVH. In the case of Tsukazaki et al., ² although the CT was reported as normal, signs of hemorrhage were demonstrated on cerebrospinal fluid, and after performing the MRI, he was confirmed to have had subarachnoid hemorrhage.

In our case, we presume that the IVH had occurred as a result of direct trauma of the Left C2 radicular artery due to acupuncture. And we delayed in the diagnosis as the headache was considered to be due to nerve irritation rather than potential cerebral hemorrhage associated with acupuncture.

We emphasize that acupuncturists and emergency physicians should know that acupuncture can lead to intracranial hemorrhage as a serious complication and that should be considered in all causes of headache for diagnosis without prejudice.