Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
Journal of Obstrectic Anaesthesia and Critical Care
Search articles
Home Print this page Email this page Small font size Default font size Increase font size Users Online: 109

 Table of Contents  
Year : 2014  |  Volume : 4  |  Issue : 1  |  Page : 45-47

Intracranial subdural hematoma after spinal anesthesia for cesarean section: Case report and review of literature

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 Publication20-May-2014

Correspondence Address:
Uma Srivastava
Department of Anaesthesia and Critical Care, S. N. Medical College, Agra,Uttar Pradesh - 282 003
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2249-4472.132826

Rights and Permissions

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 2023 Mar 27];4:45-7. Available from: https://www.joacc.com/text.asp?2014/4/1/45/132826

  Introduction Top

Intracranial subdural hematoma (SDH) is an exceptionally unusual complication of dural puncture, either intentional for diagnostic, therapeutic or anesthetic indication [1],[2],[3],[4] or accidental during epidural insertion. [4],[5],[6] 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 [7] or death. [8],[9]

  Case report Top

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.
Figure 1: Subdural fronto-parieto-occipital haematoma right side

Click here to view

  Discussion Top

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. [10],[11],[12],[13],[14]

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. [1],[4],[15] 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. [1] Downward displacement of brain stretches these vessels further and results in tearing of walls and extravasation of blood and formation of haematoma. [1],[4],[15] Because bridging veins have thinner walls in subdural space compared with subarachnoid space, [16] hemorrhages are mostly subdural [1],[8],[17] and may present acutely, sub acutely or chronically.

As the primary pathophysiologic mechanism of PDPH and SDH is thought to be the same, [1],[16] the PDPH must be treated promptly because prolonged, unresolved and untreated PDPH may lead to hemorrhage in subdural space. [1],[12],[18],[19] 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. [6] Change in character of headache from postural to non-postural may be the warning sign of SDH. [1],[14],[16] 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, [1],[9],[14],[17] and other patients with pre-existing neurological disease, cerebral atrophy, receiving anti-coagulant drugs, with multiple dural punctures, [7],[14] puncture with cutting spinal needle of more than 25 G or by epidural needle [5],[6] 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. [18] It is possible that venous congestion during pregnancy makes bridging veins more prone to rupture. [1]

Differential diagnosis of severe postpartum headache in association with the dural puncture [9],[17],[18] 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.

  References Top

1.Zeidan A, Farhat O, Maaliki H, Baraka A. Does postdural puncture headache left untreated lead to subdural hematoma? Case report and review of the literature. Int J Obstet Anesth 2006;15:50-8.  Back to cited text no. 1
2.Suess O, Stendel R, Baur S, Schilling A, Brock M. Intracranial haemorrhage following lumbar myelography: Case report and review of the literature. Neuroradiology 2000;42:211-4.  Back to cited text no. 2
3.De Tommaso O, Caporuscio A, Tagariello V. Neurological complications following central neuraxial blocks: Are there predictive factors? Eur J Anaesthesiol 2002;19:705-16.  Back to cited text no. 3
4.Reina MA, López A, Benito-León J, Pulido P, María F. Intracranial and spinal subdural hematoma: A rare complication of epidural and subarachnoid anesthesia. Rev Esp Anestesiol Reanim 2004;51:28-39.  Back to cited text no. 4
5.Davies JM, Murphy A, Smith M, O'Sullivan G. Subdural haematoma after dural puncture headache treated by epidural blood patch. Br J Anaesth 2001;86:720-3.  Back to cited text no. 5
6.Vaughan DJ, Stirrup CA, Robinson PN. Cranial subdural haematoma associated with dural puncture in labour. Br J Anaesth 2000;84:518-20.  Back to cited text no. 6
7.Rocchi R, Lombardi C, Marradi I, Di Paolo M, Cerase A. Intracranial and intraspinal hemorrhage following spinal anesthesia. Neurol Sci 2009;30:393-6.  Back to cited text no. 7
8.Cantais E, Behnamou D, Petit D, Palmier B. Acute subdural hematoma following spinal anesthesia with a very small spinal needle. Anesthesiology 2000;93:1354-6.  Back to cited text no. 8
9.Yildirim GB, Colakoglu S, Atakan TY, Büyükkirli H. Intracranial subdural hematoma after spinal anesthesia. Int J Obstet Anesth 2005;14:159-62.  Back to cited text no. 9
10.Lay CL, Campbell JK, Mokri B. Low cerebrospinal fluid pressure headache. In: Goodsby PJ, Silberstein SD, editors. Boston: Butterworth-Heinemann; 1997. p. 355-67.  Back to cited text no. 10
11.Turnbull DK, Shepherd DB. Post-dural puncture headache: Pathogenesis, prevention and treatment. Br J Anaesth 2003;91:718-29.  Back to cited text no. 11
12.Mokri B. Headaches caused by decreased intracranial pressure: Diagnosis and management. Curr Opin Neurol 2003;16:319-26.  Back to cited text no. 12
13.Lybecker H, Djernes M, Schmidt JF. Postdural puncture headache (PDPH): Onset, duration, severity, and associated symptoms. An analysis of 75 consecutive patients with PDPH. Acta Anaesthesiol Scand 1995;39:605-12.  Back to cited text no. 13
14.Amorim JA, Remígio DS, Damázio Filho O, de Barros MA, Carvalho VN, Valença MM. Intracranial subdural hematoma post-spinal anesthesia: Report of two cases and review of 33 cases in the literature. Rev Bras Anestesiol 2010;60:620-9, 344-9.  Back to cited text no. 14
15.Eggert SM, Eggers KA. Subarachnoid haemorrhage following spinal anaesthesia in an obstetric patient. Br J Anaesth 2001;86:442-4.  Back to cited text no. 15
16.Yamashima T, Friede RL. Why do bridging veins rupture into the virtual subdural space? J Neurol Neurosurg Psychiatry 1984;47:121-7.  Back to cited text no. 16
17.Dawley B, Hendrix A. Intracranial subdural hematoma after spinal anesthesia in a parturient. Obstet Gynecol 2009;113:570-3.  Back to cited text no. 17
18.Bisinotto FM, Dezena RA, Fabri DC, Abud TM, Canno LH. Intracranial subdural hematoma: A rare complication following spinal anesthesia: Case report. Rev Bras Anestesiol 2012;62:88-95.  Back to cited text no. 18
19.Nakanuno R, Kawamoto M, Yuge O. Intracranial subdural hematoma following dural puncture. Masui 2007;56:395-403.  Back to cited text no. 19


  [Figure 1]

This article has been cited by
1 Sub-Dural Haematoma After Accidental Dural Puncture During Labour Epidural Analgesia
Gisha V Mathew,Khalil Shibli,Noureddine Korichi,Venkatesh B Thippeswamy
Cureus. 2021;
[Pubmed] | [DOI]
2 Effect of intrathecal fentanyl on the incidence, severity, and duration of postdural puncture headache in parturients undergoing caesarean section: A randomised controlled trial
WegdanA Ali,Moćmen Mohammed,AhmedR Abdelraheim
Indian Journal of Anaesthesia. 2020; 64(11): 965
[Pubmed] | [DOI]
3 Prevenir atelectasia em cirurgia robótica
Ozkan Onal,Emine Aslanlar,Seza Apiliogullari,Omer Faruk Erkocak,Jale Bengi Celik
Brazilian Journal of Anesthesiology. 2016;
[Pubmed] | [DOI]
4 Post-spinal hyperacute subdural hematoma
Ozkan Onal,Emine Aslanlar,Seza Apiliogullari,Omer Faruk Erkocak,Jale Bengi Celik
Brazilian Journal of Anesthesiology (English Edition). 2016;
[Pubmed] | [DOI]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)  

  In this article
Case report
Article Figures

 Article Access Statistics
    PDF Downloaded704    
    Comments [Add]    
    Cited by others 4    

Recommend this journal