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Acute Bilateral Intracranial Subdural Hematomas following accidental dural puncture, intrathecal catheter,and two epidural blood patches; a case report
Abstract Number: F5D-9
Abstract Type: Case Report/Case Series
This case report describes a rare but serious complication of neuraxial anesthesia, intracranial subdural hematoma.
Neuraxial analgesia is the most widely used practice for labor analgesia. A rare but serious complication after dural puncture is intracranial subdural hematoma (1). With the loss of cerebrospinal fluid (CSF), the caudal shift of the brain can result in tearing of the bridging veins resulting in a subdural hematoma. We present a case of an accidental dural puncture, postdural puncture headache (PDPH) and subsequent subdural hematoma.
A 22 years female, G3P2012 presented for a trial of labor after one previous cesarean section. Her BMI was 37. She had chronic hypertension with superimposed preeclampsia. A combined spinal epidural (CSE) was performed using loss of resistance to saline and the epidural space was located at 6cm. After a spinal dose of fentanyl 25 microgram (mcg) was given, the epidural catheter was threaded and on aspiration free Cerebrospinal fluid (CSF) flow was noted. With an accidental dural puncture, it was decided to maintain the intrathecal catheter and with infusion of bupivacaine 0.1% and fentanyl 2 mcg/mL at 2 ml/hr. Two days later the patient complained of a postural headache and was diagnosed with postdural puncture headache (PDPH). Subsequently an epidural blood patch (EBP) was performed by injecting with 20 ml of sterile blood successfully. The patient’s headache was relieved and she was discharged from the hospital later that evening. However, on postpartum day 5 the patient's severe headache recurred with similar postural symptoms as her initial headache. She was readmitted to the hospital and a second EBP was performed the same day. This time she reported relief at that time but only for ten hours after which her headache recurred with similar symptoms. At that point a neurology consultation and an MRI were obtained. MRI findings revealed bilateral small intracranial subdural hematomas. Conservative management was recommended and the patient was discharged and instructed to return with development of any neurologic symptoms and a follow up MRI in 6 to 8 weeks. Patient returned at 6 weeks and reported complete resolution of the symptoms.
Subdural hematoma is a rare but serious complication of dural puncture, and has been reported with epidural and spinal anesthesia and diagnostic lumbar punctures(1). PDPH is the first symptom in the vast majority of these cases(1). Changes in the characteristics of a PDPH or no appreciable relief and/or recurrence after a second EBP should alert the health care provider of other more serious intracranial pathology.
1) Cuypers V, Van de Velde M, Devroe S. Intracranial subdural haematoma following neuraxial anaesthesia in the obstetric population: a literature review with analysis of 56 reported cases. Int J Obstet Anesth 2016; 25: 58-65.