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Management of subdural hygroma after accidental dural puncture
Abstract Number: S5D-5
Abstract Type: Case Report/Case Series
A 39yo G1P0 with a history of obesity and asthma presented to labor and delivery in spontaneous labor. At the onset of active labor the patient requested a labor epidural. Epidural placed with moderate difficulty and three attempts. Many hours later, fetal heart tracing became nonreassuring with multiple variable and late decelerations with minimal variability and she was scheduled to undergo urgent cesarean section. Noted on interview with the patient was a large inguinal area of pain that had never become comfortable with the epidural. After discussion with the team the labor epidural was to be replaced with a combined spinal epidural for the procedure in the lateral position to facilitate monitoring during placement. With touhy insertion, some slow blood-tinged fluid returned. The anesthesia team assumed a possible accidental dural puncture and administered 1.6mL of 0.75% bupivacaine with dextrose and threaded a catheter. After several minutes in the supine position the sensory and motor block was inadequate for surgery and we subsequently converted to general anesthesia. On postoperative day 2, the patient noted positional frontal headache without any visual changes or tinnitus. She underwent ultrasound guided epidural blood patch with improvement in symptoms and was discharged. On postoperative day 4 she returned to the emergency room with similar symptoms of a postural headache significantly worse when sitting up. She underwent a head CT and was found to have bilateral subdural hygromas. She underwent additional epidural blood patch after neurosurgical consultation with improvement in her symptoms. Subdural hygroma is a rare complication of accidental dural puncture that is poorly described in anesthesiology literature and more commonly recognized as a neurosurgical complication of ventriculo-peritoneal shunt that sometimes requires surgical intervention. It should be considered in patients with resistant headaches as an alternative cause of headache after neuraxial anesthesia.
Verdú, M. T., Alonso, B., Burguillos, S., & Martínez-Lage, J. F. (1999). Postpartum Subdural Hygroma after Epidural Analgesia. Anesthesiology,91(3), 867.