Bilateral interhemispheric subdural hematoma after inadvertent lumbar puncture in a parturient

Abstract

Purpose Interhemispheric subdural hematomas (ISH) are rare in adults and occur most often after cranial trauma. We describe a parturient who developed bilateral acute ISH after inadvertent dural puncture associated with placement of an epidural catheter for labour analgesia. We discuss the features, pathophysiology, and management of this type of subdural hematoma. Clinical features A 38-yr-old woman requested epidural analgesia for relief of labour pain. An inadvertent dural puncture occurred during placement of a 17G Tuohy needle. After labour and delivery, the patient developed symptoms of a postdural puncture headache, which responded only partially to an epidural blood patch. The patient's headache subsequently became less positiondependent and was associated with episodes of sharp pain radiating down her legs and paresthesias on the left side of her body. A computed tomography (CT) scan showed right frontal and left parietal acute ISH without an intracranial mass effect. The patient was monitored in the intensive care unit and treated conservatively because of the relatively small size of the ISH and the absence of progressive neurological deficits on serial examinations. Daily CT scans showed gradual decreases in the size of the ISH concomitant with improvement of the headache. Conclusions Rupture of bridging veins between the cerebral cortex and the superior sagittal sinus is the usual mechanism by which ISH occur. Nearly one-quarter of patients with ISH do not survive, although those with smaller hematomas have a better outcome. If the hematoma is \ 1 cm in thickness, a conservative approach to ISH is recommended in the absence of mental status changes, seizure activity, or focal deficits, but with larger ISH or evidence of progressive neurological deterioration, surgical evacuation is most often required to prevent mortality. RésuméObjectif Les he´matomes sous-duraux inter-he´misphe´riques (ISH) sont rares chez l'adulte et surviennent le plus souvent apre`s un traumatisme craˆnien. Nous de´crivons le cas d'une parturiente qui a pre´sente´un he´matome sous-dural aigu bilate´ral apre`s ponction durale accidentelle en rapport avec la mise en place d'un cathe´ter pe´ridural pour analge´sie au cours du travail. Nous discutons les caracte´ristiques, la physiopathologie et la prise en charge de ce type d'he´matome sous-dural. Caractéristiques cliniques Une femme aˆge´e de 38 ans a demande´a`be´ne´ficier d'une analge´sie pe´ridurale pendant le travail. Il y a eu une ponction accidentelle de la dure-me`re pendant la mise en place d'une aiguille de Tuohy 17G. Apre`s le travail et l'accouchement, la patiente a pre´sente´des symptômes de ce´phale´e post ponction dure-me´rienne qui n'ont re´pondu que partiellement a`un colmatage sanguin (blood patch) pe´ridural. La ce´phale´e de la patiente est devenue ensuite moins lie´e à la position, mais elle a e´te´associe´e à des e´pisodes de douleurs aigues

Intracranial Subdural Hematoma after Spinal Anesthesia for Cesarean Section

“…Most reported acute cases develop within the first 2 days [1–3, 7, 9, 10] and our patient's case history was typically an acute event: a severe and persistent nonpostural headache, unresponsive to analgesics, with symptoms of acute neurological deterioration, suggesting a sudden increase of intracranial pressure.…”

Prophylactic vs therapeutic blood patch for obstetric patients with accidental dural puncture – a randomised controlled trial

“…The headache can be incapacitating and may be accompanied by diplopia, tinnitus, hypoacusis, photophobia, nausea, dizziness, nuchal rigidity and myalgia. Additional complications reported include cranial nerve palsies and subdural haematoma . An otherwise successful and satisfactory birth experience may be marred as a result, leading to significant dissatisfaction with the anaesthesia experience , litigation , prolonged hospital stay and sequelae including chronic headache .…”

Intracranial Subdural Hematoma Versus Postdural Puncture Headache Following Epidural Anesthesia: A Case Report

“…These include female gender, history of similar previous episodes, history of chronic headache, obstetric patients like our patient who underwent labor induction for IUFD, size and shape of the needle (particularly large needles leading to excessive CSF leakage), low body mass index (BMI), dehydration, and experience of the operator [ 2 , 15 ]. There are numerous predisposing factors that specifically influence the development of intracranial subdural hematoma following induction of epidural anesthesia including coagulation abnormalities, anticoagulation agents, excessive alcohol consumption, and cerebral atrophy [ 2 , 8 , 9 ].…”

“…It is employed in a variety of procedures, most importantly, during childbirth in obstetric patients [1]. However, it is associated with several complications which can be very significant clinically such as intracranial subdural hematoma [2][3][4][5][6][7][8][9][10][11]. Many patients with subdural hematoma following epidural block can be mistakenly diagnosed with postdural puncture headache (PDPH).…”