A Case Report of Inadvertent Intrathecal Insertion of Central Venous Catheter

This report describes an unusual complication during attempted central venous catheterization. Using the carotid arterial pulsation as landmark, right internal jugular venipuncture was done with 14G needle with free aspiration of venous blood. Because it was impossible to insert the catheter though the needle, a guidewire was used to assist the catheter placement. The guidewire was inserted with a little resistance, and the catheter was inserted over the guidewire without difficulty. After removal of the guidewire, we found the catheter tip was in the intrathecal space, confirmed by aspiration of cerebrospinal fluid. We speculate that the needle tip was in the vertebral vein, and the guidewire penetrated the venous wall and the dura into the intrathecal space. After the operation, the patient complained pain in right neck and upper extremity. Although the symptom was fully recovered within two weeks, we must acknowledge the possibility of permanent neurological complications. The misplacement occurred because of erroneous judgement of anatomical landmarks. To avoid this complication, when difficulty of puncture or insertion of catheter is exist, we should confirm the anatomical landmarks again by palpating the carotid artery or by ultrasound imaging.