A CASE OF INTRACRANIAL EPIDURAL HEMATOMA IN A PATIENT RECEIVING NEURAXIAL LABOR ANESTHESIA
Abstract Number: T-08
Abstract Type: Case Report/Case Series
Neurologic complications due to inadvertent dural puncture, including intracranial hemorrhage, are well described. Disruption of the bridging veins due to intracranial hypotension may result in a subdural hematoma. Intracranial epidural hematomas (EDH) however have not been a reported complication of inadvertent dural puncture. We report a case of a healthy parturient who following an uncomplicated labor with combined spinal-epidural (CSE) suffered an intracranial EDH, requiring decompressive craniotomy.
A 34 year old G3P0020 at 41 weeks gestation presented to labor and delivery for a post-dates induction. Her medical history was significant for obesity and recurrent syphilis. An uncomplicated CSE was placed prior to delivery. On postpartum day (PPD) 0, she developed a postural right-sided headache, without cranial nerve symptoms. This was managed conservatively with intravenous hydration and caffeine. On PPD 1 an epidural blood patch was performed, resulting in moderate relief of her headache. On PPD 2, the headache returned; however, it was now left sided, with associated photophobia. An MRI revealed a right temporal-parietal EDH and a smaller right holo-hemispheric subdural hematoma with a resultant midline shift. CT angiography did not reveal definitive intracranial vascular malformation and initial coagulation studies were within normal limits. Following emergent neurosurgical consultation, a decompressive craniotomy was performed.
Intracranial epidural hematomas are most commonly arterial in origin, and occur after trauma. Rarely traumatic EDH may be secondary to dural AV fistula; however, the most likely culprit is damage to the middle meningeal artery. There is one case report of intracranial EDH after spinal anesthesia for retained placenta, however it was discovered after epileptic seizure and was most likely traumatic. Non-traumatic etiologies of acute EDH include infection, coagulopathy, dural vascular malformations, and hemorrhagic tumors. Our patient was initially treated for postdural puncture headache; careful history taking disclosed subtle changes in her headache characteristics including laterality and cranial nerve involvement prompting imaging. This case emphasizes the importance of meticulous history and utilization of imaging when postpartum headache is not consistent with classical presentation of PDPH as there may be catastrophic etiologies that if undetected may be fatal.