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///2018 Abstract Details
2018 Abstract Details2019-08-02T15:57:01-05:00

Subdural Hematomas in Parturients Receiving Epidurals for Cesarean Section

Abstract Number: F5D-2
Abstract Type: Case Report/Case Series

Anirban Kanjilal MD1 ; Daniel Garcia MD, PhD2; Jing Song MD3; Yelena Spitzer MD4

Neuraxial anesthesia is the primary technique in the care of obstetric patients, with post-dural puncture headache (PDPH) being the most feared complication. While PDPH is normally benign, there is a risk of subdural hematoma (SDH). Here, we present two cases of SDH following accidental dural puncture. A 32-year-old female presented for an elective repeat cesarean delivery (CD). Spinal anesthetic was challenging, so epidural placement was performed with difficulty after several attempts with no clear indication of dural puncture. The delivery was uneventful and the patient was discharged home on post-operative day (POD) 3. The patient presented to the ER on POD 12 complaining of severe occipital headache with radiation to the frontal area. In the ER her blood pressure was 166/94 mmHg and she had proteinuria, suggesting post-partum pre-eclampsia. Initially, the patient stated her headache started on POD1, but resolved, and recurred on POD 10. Subsequently, she described the headache as positional. Given the atypical presentation for PDPH, neurology was consulted and CT and MRI were obtained. Imagining showed a 6-7 mm left sided SDH with some mass effect. A neurosurgical consult was obtained. A repeat CT scan showed stable SDH. The option of doing an epidural blood patch (EBP) for possible PDPH was discussed with neurosurgery and on POD 13, the patient received a successful EBP. The headache, however, persisted after EBP. A repeat CT scan on POD 14 was unchanged and the patient was discharged home. Repeat imaging one month later showed resolution of the SDH and the patient was symptom free. A healthy 34-year-old female underwent epidural placement for trial of labor after cesarean (TOLAC), which was complicated by accidental dural puncture. The patient proceeded to CD with the in-situ epidural. A few hours post-operatively, the patient complained of a constant, non-positional headache. The patient failed conservative management with fioricet. Although the headache was not positional in nature, an EBP was performed on POD 2 due to the headache occurring in the setting of a known dural puncture. The next day (POD 3), the headache persisted but "felt different". On POD 4, patient reported a stable headache with fioricet and was discharged home. On POD 6, patient presented to the ED with severe bitemporal headache that worsened with movement and ambulation as well as dizziness, neck pain and blurred vision. A head CT demonstrated bilateral SDH. The patient was admitted on POD 7. The patient's headache was positional and a second EBP was performed, with instantaneous headache relief. Epidurals are generally safe and complications such as PDPH are not considered fatal. Subdural hematomas can occur after dural puncture secondary to intracranial hypotension causing cerebral sagging and shearing of the bridging veins. It is important for anesthesiologists to keep SDH in their differential diagnosis when evaluating a headache after epidural anesthesia.

SOAP 2018