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Subdural hematoma and TIA after CSE
Abstract Number: F-02
Abstract Type: Case Report/Case Series
Case: A 37 year old G2P1001 at 38 weeks had an uneventful combined spinal-epidural for labor with normal vaginal delivery. On postoperative day (POD) 2, the patient complained of a severe frontal headache, worse when sitting with associated neck stiffness, not responding to conservative management. Pain service performed an epidural blood patch under fluoroscopy at L3/L4, with mild improvement of the symptoms and pain score going from 10 to 6. She was discharged home on POD 3 with Fioricet’s prescription. The patient presented to the ER on POD 6 with worsening headache and neck stiffness. The headache was again described as positional, frontal, non-radiating, without any nausea, vomiting or fever. Examination of the back was non-tender, there was no focal neurological deficits and no signs of erythema, infection or bleeding at either of the epidural sites. Head CT revealed disproportionately enlarged ventricular, sulcal and cisternal spaces with dilated frontal CSF spaces. She was admitted for monitoring of presumed intracranial hypotension secondary to wet tap and CSF leak. Neurology recommended a second blood patch for intracranial hypotension treatment. Due to the ineffectiveness of the first epidural blood patch, the pain service recommended conservative management and monitoring. A MRI was obtained on POD 7 for persistent headache and revealed subdural fluid collections adjacent to the right and left cerebral hemispheres and in the cerebellar hemispheres bilaterally likely chronic subdural hematomas secondary to intracranial hypotension. A second epidural blood patch was then performed that day by the pain service under fluoroscopy with moderately headache’s improvement. POD 11, the patient’s sister-in-law revealed that the patient had had episodes of visual disturbances, word finding difficulties, upper extremity left-sided weakness, and severe headaches in both this pregnancy and previous pregnancy, prior to delivery. Those symptoms had not been reported before, bringing a new light to the case. She also mentioned multiple episodes of severe posterior headache, radiating to the front 1-2 times/month. At this point, the diagnosis of TIA episodes was suspected. POD 12, the stroke team were emergently called bedside as the patient had slurred speech, left arm paresthesia and weakness. MRI/MRA brain and neck revealed stable bilateral subdural collections with no other acute findings and TIA was suspected. POD 14, the patient was discharged home with resolved headache and no neurological deficits.
Discussion: While the risk of post dural puncture headaches is 2-3% after CSE, subdural hematoma is extraordinarily rare with only a few cases reported. The true incidence is unknown as most PDPH are treated conservatively or with EBP without imaging. This case is complicated by a history of TIA with headaches. We describe both common and rare complications of a CSE in a parturient and reveals the importance of a multi disciplinary team.