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THORACIC SUBDURAL HEMATOMA AND INTRACRANIAL SUBARACHNOID HEMORRHAGE AFTER PLACEMENT OF LUMBAR EPIDURAL CATHETER
Abstract Number: F-66
Abstract Type: Case Report/Case Series
Subdural hematoma (SDH) and subarachnoid hemorrhage (SAH) are ominous complications of neuraxial techniques that can mimic meningitis, epidural hematoma or epidural abscess. [1,2] We present a case of concomitant SDH and SAH after placement of a labor epidural and suggest a diagnostic algorithm (Figure).
A 33 year-old G3P1 in labor requested epidural analgesia. History revealed no neurologic, musculoskeletal or hematologic disease; physical exam was notable for BMI of 40. Epidural placement required three attempts: 1) possible dural puncture, 2) catheter threaded but immediately removed due to sterility concerns, and 3) successful placement. The catheter functioned well during labor, and the patient had an uncomplicated vaginal delivery. Postpartum (PP), she was initially stable.
PP Day (PPD) 2
The patient developed back pain at the T8 level, radiating to the occiput and sacrum, most severe with weight-bearing or ambulation. There was no neck stiffness, headache, photophobia, vision change, tinnitus or neurologic deficits. Brain and spine MRI revealed trace blood ventral to the spinal cord at T12, a subdural hematoma extending from T5-L2 with ventral cord displacement but no compression, and trace intracranial blood in the lateral ventricles. Neurology was consulted. In absence of cord compression, surgical intervention was deemed unnecessary.
The patient developed hypertension, headache, nausea and photophobia. Preeclampsia workup was negative, and MRI was unchanged. The patient became febrile to 102°F with leukocytosis, but no motor or sensory deficits. She exhibited meningismus and bilateral abducens nerve palsies, and remained febrile despite empiric antibiotic treatment and negative cultures. A diagnostic lumbar puncture (LP) was considered, but avoided given concern for infection and potential for intrathecal spread. With no evidence of infection or preeclampsia, the patient’s pain, hypertension, fever and leukocytosis were attributed to inflammation after SAH.
The patient was afebrile, pain-free and ambulating, but continued antihypertensive therapy.
This case illustrates the diagnostic challenge of differentiating between meningitis, SAH and SDH. While diagnosing meningitis relies on LP, the presence of epidural blood and possibility of epidural or systemic infection is a relative contraindication to LP.
1. Kreppel D et. al. Neurosurg Rev 2003
2. Reihsaus E et. al. Neurosurg Rev 2000