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Subdural Hematomas and Posterior Reversible Encephalopathy Syndrome Associated with Unrecognized Unintentional Dural Puncture In a Preeclamptic Patient
Abstract Number: SUN-05
Abstract Type: Case Report/Case Series
A healthy 23 year-old G1P0 parturient presented in labor at term. Combined spinal-epidural (CSE) labor analgesia was attempted. After multiple failed attempts to obtain cerebrospinal fluid, the CSE was abandoned and an epidural catheter was placed, which functioned well. The patient became hypertensive and proteinuric and was diagnosed with preeclampsia without severe features.
On postpartum day (PPD) 1 she complained of a mild postural headache. On PPD 2 she became nauseous, vomited, and developed a severe positional headache. She was offered an epidural blood patch (EBP) but opted for conservative management and was discharged on PPD 3 with a positional headache. On PPD 5 she presented to the anesthesia team complaining of a severe non-positional headache with photophobia accompanied by a BP of 174/102. The anesthesia team consulted their obstetric colleagues who diagnosed preeclampsia with severe features and started Mg and labetalol. An MRI was obtained due to the severity and non-positional nature of the headache. It demonstrated increased FLAIR and T2 signals in the basal ganglia consistent with posterior reversible encephalopathy syndrome (PRES), displacement of the pons and cerebral tonsils suggesting intracranial hypotension, and bilateral subdural hematomas (SDH). She was transferred to the neuro-ICU, given nicardipine by infusion for BP control for PRES and received an EBP to stabilize her SDH. Her headache resolved, her SDH remained stable, and the patient was discharged on hospital day 8.
The differential diagnosis of postpartum headache is broad and encompasses obstetric and anesthetic complications. Our patient’s headache was a result of unrecognized unintentional dural puncture (UDP) leading to intracranial hypotension and SDH, as well as PRES. Up to 35% of UDPs may be unrecognized (1) highlighting the need for close follow up after neuraxial anesthesia. SDH after dural puncture is rare and thought to be secondary to decreased ICP with traction-induced tears in bridging veins (2). A change in the character of headache should raise the possibility of SDH (2). EBP allows for restoration of normal ICP, ameliorating the headache and, in the rare instances in which it occurs, stabilizing SDH. In addition to developing SDH, our patient developed PRES, which is well-described in association with preeclampsia, and results from impaired cerebral autoregulation with vascular leakage and vasogenic edema (3). It presents as encephalopathy, with or without headache, visual disturbances, and seizures. Given that PRES has also been associated with UDP (4), it is possible that preeclamptics with UDP may be at increased risk for PRES. Our case highlights rare but serious complications of neuraxial procedures and preeclampsia and highlights the need for thorough investigation and prompt treatment of severe postpartum headaches.
1.Sprigge: Anaesthesia 2008
2.Zeidan: IJOA 2006
3.Fischer: J Neurol 2017
4.Hammad: CRiNM 2015