|Year : 2014 | Volume
| Issue : 1 | Page : 45-47
Intracranial subdural hematoma after spinal anesthesia for cesarean section: Case report and review of literature
Uma Srivastava1, Archna Agrawal2, Amrita Gupta2, Yogita Dwivedi2, Sathiyanarayanan Pilendran3, Vinay Shukla3
1 Professor, Department of Anaesthesia and Critical Care, S. N. Medical College, Agra, Uttar Pradesh, India
2 Lecturer, Department of Anaesthesia and Critical Care, S. N. Medical College, Agra, Uttar Pradesh, India
3 PG Student, Department of Anaesthesia and Critical Care, S. N. Medical College, Agra, Uttar Pradesh, India
|Date of Web Publication||20-May-2014|
Department of Anaesthesia and Critical Care, S. N. Medical College, Agra,Uttar Pradesh - 282 003
Source of Support: None, Conflict of Interest: None
Subdural hematoma (SDH) is a rare but serious complication of spinal anesthesia. We report a case of intracranial SDH in a patient developing 11 days after spinal anesthesia for cesarean section. The patient complained of headache on the 2nd post-operative day that was relieved by analgesics, bed rest and hydration. Later she presented with severe headache, vomiting, dizziness, dysarthria, irritability and somnolence. Diagnosis of the left sided SDH was confirmed radiologically and treated surgically. The patient recovered completely. The report highlights the need of considering the possibility of SDH in patients when postdural puncture headache is prolonged or recurs after a headache free period with neurological symptoms.
Keywords: Cesarean section, postdural puncture headache, spinal anaesthesia, subdural hematoma
|How to cite this article:|
Srivastava U, Agrawal A, Gupta A, Dwivedi Y, Pilendran S, Shukla V. Intracranial subdural hematoma after spinal anesthesia for cesarean section: Case report and review of literature. J Obstet Anaesth Crit Care 2014;4:45-7
|How to cite this URL:|
Srivastava U, Agrawal A, Gupta A, Dwivedi Y, Pilendran S, Shukla V. Intracranial subdural hematoma after spinal anesthesia for cesarean section: Case report and review of literature. J Obstet Anaesth Crit Care [serial online] 2014 [cited 2020 Feb 28];4:45-7. Available from: http://www.joacc.com/text.asp?2014/4/1/45/132826
| Introduction|| |
Intracranial subdural hematoma (SDH) is an exceptionally unusual complication of dural puncture, either intentional for diagnostic, therapeutic or anesthetic indication ,,, or accidental during epidural insertion. ,, It often presents as postdural puncture headache (PDPH) with varied neurological symptoms. Failure to differentiate between the two and delay in diagnosis and treatment of hematoma can cause neurological deficit  or death. ,
| Case report|| |
The present case is about a 29-year-old primigravida underwent elective cesarean section under spinal anesthesia in a local nursing home 11 days back. She had received routine ante-natal care and the pregnancy was uncomplicated. Her medical history was unremarkable. She had no history of trauma, any neurological or coagulation disorder, had no previous anesthesia or surgery and was not receiving any medication except iron and calcium. Her blood biochemistry was within normal range. As per her records from the nursing home where she underwent caesarean section, spinal anesthesia was given in a sitting position at L3-4 level by 25 G Quincke needle with 12 mg of hyperbaric bupivacaine. Dural puncture was successful at the first attempt and was atraumatic. A female baby (birth weight 3.7 kg) was delivered with APGAR score of 6 at 1 min and 9 at 5 min. Intra-operative period was not fruitful.
On the 1 st post-operative day she complained of generalized headache particularly severe in occipital region which aggravated on sitting and was associated with one episode of vomiting. a tentative diagnosis of PDPH was made by the obstetrician and the anesthesiologist and accordingly she was prescribed intravenous fluids, analgesics (paracitamol) and rest in bed. The headache improved and she was discharged home on 4 th day with advice to take analgesics, caffeinated drinks and bed rest. The headache recurred on 6 th day and increased in severity over the next 3-4 days and was only partially relieved by analgesics and lying down. She was referred to the neuro surgical unit or our institution on the 11 th day with severe, incapacitating and a throbbing headache along with the complaints of extreme irritability, drowsiness, vertigo, dysarthria and repeated vomiting.
On admission her Glasgow coma scale was 13/15, she was drowsy (responding to deep painful stimuli), incoherent, irritable, had unclear speech and was afebrile. Arterial pressure was 140/95, heart rate was 71/min, regular, pupil size was changing frequently with normal reaction (normal size of semi dilated). An urgent magnetic resonanace imaging (MRI) of the head was advised by the neurosurgeon. Meanwhile blood chemistry and other laboratory investigations were done and were within normal range.
MRI revealed subacute SDH in right temporo fronto-parietal region with pressure effect and 8 mm midline shift [Figure 1]. She underwent urgent craniotomy with evacuation of haematoma. The patient's condition improved and was discharged home on 7 th day with no headache or any other symptom. Cerebral angiography done later did not reveal any associated arterio-venous malformation or aneurysm.
| Discussion|| |
Subarachnoid block is frequently used for anesthesia purpose and PDPH is the most common complication but SDH is extremely rare. Both are postulated to be caused by cerebrospinal fluid (CSF) leak through dural hole and present as headache with or without neurological symptoms. ,,,,
SDH is presumed to occur due to reduced intracranial pressure following CSF loss, causing sudden downward shift of brain leading to rupture of fragile bridging veins. ,, Bridging veins are short veins that pass directly from cortical surface of brain to dural sinuses. Between these two points, these veins have a straight course and lack tortuousity to allow any possible displacement of brain.  Downward displacement of brain stretches these vessels further and results in tearing of walls and extravasation of blood and formation of haematoma. ,, Because bridging veins have thinner walls in subdural space compared with subarachnoid space,  hemorrhages are mostly subdural ,, and may present acutely, sub acutely or chronically.
As the primary pathophysiologic mechanism of PDPH and SDH is thought to be the same, , the PDPH must be treated promptly because prolonged, unresolved and untreated PDPH may lead to hemorrhage in subdural space. ,,, SDH formation causes rise in intracranial pressure and patient presents with headache which is more severe, persists even on lying down and is usually accompanied with variable neurological symptoms such as, vertigo, diplopia, motor deficit, altered consciousness, convulsions, cranial nerve palsy etc.  Change in character of headache from postural to non-postural may be the warning sign of SDH. ,, SDH may be managed conservatively or surgically depending upon the size and patients symptoms and prognosis is good if diagnosed and managed timely.
Exact etio-pathological factors for SDH are not known but few predisposing factors enhance the possibility and contribute to the pathogenesis of SDH. Obstetric patients, ,,, and other patients with pre-existing neurological disease, cerebral atrophy, receiving anti-coagulant drugs, with multiple dural punctures, , puncture with cutting spinal needle of more than 25 G or by epidural needle , are more prone. Susceptibility of obstetric population to PDPH may be attributed to the difference in elastically of dura, younger age and gender based difference in cranial morphology. Physiological changes of pregnancy, dehydration, postpartum diuresis and early ambulation are few of the other contributing factors.  It is possible that venous congestion during pregnancy makes bridging veins more prone to rupture. 
Differential diagnosis of severe postpartum headache in association with the dural puncture ,, includes PDPH, pre-eclampsia, migraine, meningitis, drug induced headache and intracranial pathology. In our patient, there was no evidence of pre-eclampsia or coagulopathy. Exact cause of haematoma in our patient is difficult to ascertain. Intracranial hypotension due to continuous CSF loss seems to be the most likely cause of SDH formation.
Although SDH is an uncommon complication of spinal anaesthesia, the potential for this serious problem should alert the clinicians to have a high level of suspicion especially when PDPH is prolonged or has changed its character from postural to non-postural or reappeared with neurological symptoms. We recommend that the patients who receive central neuraxial block should be instructed at the time of discharge from hospital to inform if neurological symptoms appear or headache recurred.
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