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

Abstract

Headache is a relatively common complaint following dural puncture whether it is diagnostic (lumbar puncture) or unintentional (e.g., after epidural anesthesia). Although postdural puncture headache (PDPH) turns out to be the culprit in many cases, other serious etiologies should be ruled out such as postepidural intracranial subdural hematoma (PEISH). PEISH is usually overlooked because it is relatively rare and due to other frequent causes of headache (e.g., tension headache, migraine, and PDPH) being the main consideration. PEISH can be easily misdiagnosed as PDPH because of similar clinical manifestations. Herein, we report a case of this rare complication and demonstrate the major differences between PDPH and PEISH. This 27-year-old woman with intrauterine fetal death of dizygotic twins complained of severe headache immediately following receiving epidural anesthesia for labor induction. The patient was initially diagnosed with PDPH, and a blood patch was placed which provided complete resolution of the headache only for two days. Computed tomography of the brain revealed a small subdural hematoma over the left frontal convexity. Conservative management with close monitoring was recommended in this case due to the small size of the hematoma and absence of intracranial mass effect. An early follow-up CT scan showed complete and spontaneous resolution of the hematoma. In patients with recurrence or change in the pattern of the headache, persistence of headache despite treatment, and presence of neurological dysfunction following epidural anesthesia, suspicion of intracranial etiology must be raised. Therefore, knowledge of this condition and differentiating it from PDPH is necessary to avoid misdiagnosis and futile attempts of treatment.

The Delayed Presentation of Bilateral Subdural Hematoma Secondary to Epidural Anesthesia for Elective Vaginal Delivery: A Case Report and Review of the Literature

“…As such, the potential enduring or life-threatening consequences that might have transpired due to the failure to identify SDH through medical imaging remain a matter of uncertainty. Some cases have reported full recovery with conservative measures [ 5 ]. The management of SDH depends mainly on its thickness, midline shifting, and neurological findings.…”

“…Cerebrospinal fluid (CSF) leakage through dural puncture causes a reduction in intracranial pressure, leading to the stretching of the bridging veins and pain centers within the brain [ 4 ]. Alarming signs that may help differentiate common PDPH from other possible differential diagnoses include persistent headaches not responding to conservative management or postural changes, and the presence of symptoms of neurological dysfunction [ 5 ]. Subdural hemorrhage (SDH) forms due to blood accumulation under the dura mater.…”

Post Dural Puncture Subdural Hematoma: A Rare Iatrogenic Complication of Neuraxial Anesthesia

“…Low body mass index, the experience of the operator, and the shape and size of the needle are a few of the factors that influence the risk of PPDH and PPDsH [ 5 ]. Although conservative measures like strict bed rest, oral or IV analgesia, caffeine, and IV hydration may help relieve symptoms, for both etiologies, EBP has been proven to be the most efficacious treatment modality [ 3 , 6 ]. If symptoms improve with EBP, studies have shown resolution of even thick sub-dural hematomas on their own [ 7 ].…”

Intracranial Subdural Hematoma: A Rare Complication Following Spinal Anesthesia for C/S Surgery

“…Subdural hematoma is caused by head trauma, coagulation issues, certain medications, iatrogenic causes, dehydration, and lumbar puncture [4][5][6][7]. When short-term anesthetic is required for surgical procedures, epidural anesthesia is preferred [2].…”

“…It has been reported that the incidence of cerebral subdural hematoma after lumbar puncture is about 1:500,000 and 1:1,000.000 [6]. This uncommon consequence, which is rarely reported in the medical literature, is a life-threatening illness for which early identification and treatment are crucial [4][5][6][7]. In this case, we present an extremely rare complication of subdural hematoma in a patient who underwent a cesarean section with spinal anesthesia, had no risk factors for bleeding in the postpartum months, and presented to the emergency department with a headache that did not respond to analgesic treatment and with very superficial neurological deficits.…”