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Atypical post-dural puncture headache complicated by a sub-dural hematoma in an unidentified dural puncture
Abstract Number: F-30
Abstract Type: Case Report/Case Series
Introduction: Patients with atypical presentation of post dural puncture headache (PDPH) can be difficult to diagnose, especially in the context of unidentified dural puncture. Subdural hematoma (SDH) is a rare but significant morbidity from dural puncture. This case describes a post-partum patient with PDPH, without evidence of accidental dural puncture, complicated by SDH requiring blood patch for treatment.
Case: A 33 year old G3P1011 was admitted at 38w5d in spontaneous labor. An epidural catheter was placed at L2-3 without difficulty when the patient requested analgesia at 2cm cervical dilation. Loss of resistance was at 3cm and the catheter was secured at 7.5cm. She was dosed with 3mg 1.5% lidocaine with epinephrine and 10 ml 0.125% bupivacaine. A T7 sensory level was maintained with a dilute bupivacaine/fentanyl infusion. Five hours later a viable infant was born vaginally without complication.
On PPD0, 9 hours after epidural placement, she complained of a headache. The headache improved overnight with acetaminophen, but worsened the next morning with standing. The anesthesia team evaluated the patient on PPD1 for headache and neck pain of pain scale 5/10 when supine and 8/10 when standing. The headache was located left-sided frontal/temporal and additional symptoms included nausea and vomiting. On PPD2 she noted a worsening headache with standing that now resolved when she was supine. She was offered a blood patch and declined. She was given butalbital/caffeine, 1mg IV cosyntropin, and acetaminophen. She was discharged on PPD3 feeling slightly improved.
She returned PPD5 with severe headache, nausea, vomiting, and hearing difficulty. A brain MRI was performed which showed a 3mm left sub-acute SDH and a very small likely right SDH with intracranial hypotension. Neurosurgery was consulted and recommended an epidural blood patch. She underwent an epidural blood patch at L3-4 with 20mL of autologous blood. One hour after the procedure her symptoms including headache, neck pain, and hearing difficulties were improved. She was discharged on HD3 in improved condition.
Discussion: Post dural puncture headache is the most common major complication after neuraxial procedures. These headaches are often initially treated conservatively with analgesics and bed rest. The most effective treatment for a post dural puncture headache, however, is a blood patch(1). Undetected accidental dural punctures account for a small percentage of PDPH. However, they may delay diagnosis and treatment of headache from an ADP. The incidence of a SDH from a dural puncture is unknown, but is a serious complication. The leakage of CSF lowers intracranial pressure, which can result in a caudal pull on the meninges and spinal cord(2). In cases of SDH, the bridging veins are stretched due to the caudal pull of the meninges and may lead to a tear at the weakest point.
1. Davies et al. BJA. 2001.720-723.
2. Zeidan et al. IJOA, 15(1):51-58. Jan2006