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WHAT A HEADACHE… A CASE OF SUBDURAL HEMATOMA AFTER NEURAXIAL ANESTHESIA FOR LABOR AND TUBAL LIGATION
Abstract Number: T 41
Abstract Type: Case Report/Case Series
The differential diagnosis of headache in the peripartum population include tension headache, migraine, preeclampsia or eclampsia, post dural puncture headache (PDPH), cortical vein thrombosis, meningitis, sub arachnoid hemorrhage, subdural hemorrhage(SDH), cerebral infarction and space occupying lesions such as tumors. PDPH is the most common complication of spinal and epidural anesthesia. Intracranial SDH is rare, but could be a lethal complication that can occur after neuraxial anesthesia.(1)
A healthy 25 year old G2P1001 presented at 41 weeks gestation for a scheduled induction of labor and subsequently requested epidural analgesia. The L4–L5 epidural space was accessed using a 17-gauge Tuohy-Weiss needle in the usual sterile fashion with no complications. The patient underwent a vacuum assisted vaginal delivery with good analgesia. Two hours post delivery the patient complained of non-positional headache inconsistent with PDPH and was managed conservatively with fluid, Acetaminophen, Butalbital and Caffeine. On post partum day one she stated improvement of the headache and presented for tubal ligation. Spinal Anesthesia was attempted but the patient was found to have inadequate analgesia so the decision was made to convert to ketamine anesthesia. On post partum day two she reported a 10/10 postural headache with diplopia that did not respond to oral pain medications; a sphenopalatine ganglion block was performed with some improvement. Six days later the patient presented in the emergency department with worsening headache. A CT head was done which showed a small SDH that was managed conservatively.
Given the absence of a frank wet tap in this patient it is possible that a CSF leak occurred secondary to an inadvertent dural puncture during placement of the labor epidural or secondary to the spinal for the post partum tubal ligation. Intracranial SDH formation has been reported after a dural tear with persistent leakage of CSF(2), However the exact pathophysiological mechanism is not known. The leakage of CSF from the dural hole causes reduction in CSF volume, which first lowers the intraspinal pressure and second the CSF pressure which may result in a caudally directed movement of the spinal cord and brain, this in turn pulls and tears the bridging vessels, and a SDH results. Postpartum headache can be relatively benign; alternatively it can be a sign of significant pathology and should be evaluated promptly. This case exemplifies that a headache not consistent with a PDPH may be a premonitory sign of a more serious neurological sequalae and therefore should not be underestimated. Furthermore, this case highlights the need for caution prior to performing a spinal especially in a patient with a headache after a previous neuraxial block.
(1)Vaughan,D,J et al.(2000) Br J Anaesth 2000: 84: 518-520
(2)Sköldefors,EK et al.(1998) Eur J Obstet Gynecol 81: 119–21