Postpartum subdural haematoma following spinal anaesthesia

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1 Postpartum subdural haematoma following spinal anaesthesia Hadab A Mohamed, MD Associate Professor of Anaesthesia, Faculty of Medicine, University of Khartoum, Sudan استار يشاسك تقسى انتخذ ش كه ح انطة خايعح انخشط و- انس دا د. ذاب اؼ ذ ؽ ذ ان ستخهص : ز ا روش ٣ ش ٣ ر ا تا صق ؼذ ز ؼا ر ٠ ض ٣ ق د اؿ ٠ ذؽد غثوح اال ا عاك ٤ ؼذشد ال شاذ ٤ ػوة اظشائ ؼ ٤ ح الد ه ٤ صش ٣ ذؽد ا رخذ ٣ ش ا صل ٠. ذش ا ا ش ٣ عر ٤ ؼذ ز صذاع اصات شاط ا شاض ذؤد ض ٣ ادج ع ٤ ح ا ذ ا ذ اس ػواه ٤ ش ذؤد ا ٠ ر ي. ا ا د ا لؽ صاخ ا ؼ ٤ ت اك ٤ ا كؽ صاخ ع ٤ ح ا ذ غث ٤ ؼ ٤. ا ؽا ح اال ٠ ا د غ ٤ ذ ؼا ك ٠ ا صا ٤ ح ا ؼشش ٣ ػ ش ا ؼعشخ الظشاء ػ ٤ ح الد ه ٤ صش ٣ ثش ع ذؽد ا رخذ ٣ ش ا صل ٠ ا ز هذ اظش ك ٠ ظغ ا ع ط تاعرؼ ا ؼو ح تز ظ ش واط 25 ادخ د ػ ٠ ا غر ات ٤ ا لوشاخ ا وط ٤ ا صا صح ا شاتؼ. تؼذ ا وعاء شالشح ا ٣ ا ا ؼ ٤ اشر د ا ش ٣ ع صذاع هذس ا ٣ عاػلاخ خشم اال ا عاك ٤ ا غثة إظشاء ا رخذ ٣ ش ا صل ٠ هذ اعرعاتد ا ش ٣ ع عائ ا ؼالض ا رؽلظ ٠ ش اخشظد ض ا ك ٠ ا ٤ ا خا ظ ؼ ٤ ػ ٠ ا ذرؼاغ ٠ ؼث ب ك راس ٣ عاد ؼ ٤ تا ض. ا ا صذاع ٣ شرذ ؼ ٤ ا ٣ ض اؼ ٤ ا ا غ ا ا غرح ا ٣ ا ا ر ٠ هعر ا ا ش ٣ ع ت ض ا. ذذ س غر ػ ٠ ا ش ٣ ع ك ٠ ا ٤ ا صا ٠ ػشش تؼذ ا ؼ ٤ صاسخ ذ رات ا ظاخ ا صشع ا اعرذػ ٠ و ا طث ٤ ة اخرصاص ٠ ك ٠ ا خ االػصاب ا ز غ ة اظشاء أشؼ وطؼ ٤ شأط. شلد االشؼ ػ ظ د ض ٣ ق تعا ث ٠ ا شأط ذؽد اال ا عاك ٤ أعرشدخ ا ش ٣ ع ظ ٤ غ ظائل ا ا ؼصث ٤ تؼذ اظشاء ظشاؼ اظؽ رلش ٣ ؾ ا ض ٣ ق. ا ش ٣ ع ا صا ٤ ا د ا شأج ؼا ك ٠ ا صا ٤ ح ا صالش ٤ ا ؼ ش ؼعشخ الظشاء ػ ٤ ح الد ه ٤ صش ٣ ثش ع ذؽد ا رخذ ٣ ش ا صل ٠ ا ز هذ اظش ا ٣ عا ك ٠ ظغ ا ع ط تاعرؼ ا ؼو ح تز ظ ش واط 23 ادخ د ػ ٠ ا غر ات ٤ ا لوشاخ ا وط ٤ ا صا صح ا شاتؼ. أؼغد ا ش ٣ ع ت لظ اػشاض عاتور ا صذاع شات ؼذ ز اػشاض ػصث ٤ ك ٠ ا ٤ ا ؽاد ا ؼشش ٣ تؼذ ا ؼ ٤ ح ا و ٤ صش ٣ لظ ا رشخ ٤ ص ػ ذ ا ذ اظشاء ص س اشؼ وطؼ ٤ شأط. اعرشدخ ا ش ٣ ع ا ظائل ا ا ؼصث ٤ غاتور ا تؼذ اظشاء ػ ٤ رلش ٣ ؾ ا ضف ا شأط. ا ؼذز ك ٠ ا ؽا ر ٤ ظ ع ا غشد ٣ ثشص ا ز ٣ ٣ اسع ػ ٤ ح تز ا ظ ش تأ ا صذاع غر ش تؼذ ا ثز سؿ إػطاء ا ؼالض ا رؽلظ ٠ ٣ عة أ ٣ ؤخذ ت ظذ ٣ ػ ٠ ا ػال ذش ٤ ش ت ظ د ض ٣ ق تا خ. Summary This review describes the occurrence of intracranial subdural haematoma in two parturients following caesarean section under spinal anaesthesia. Both patients had no previous history of headache, head trauma, coagulopathy or anticoagulant therapy. The preoperative laboratory investigations, including coagulation screening were normal for both patients. The study candidates were 22 and 32 years old parturients, scheduled for elective caesarean section under spinal anaesthesia in the sitting position, using a 25 and 23 gauge needles respectively. Both candidates complained of postpartum headache, which was suggestive of post-dural puncture headache that Corresponding author Hadab A Mohamed hadab99@hotmail.com responded initially to conservative management. Patients were discharged home on diclofenac sodium tablets and oral antibiotics. At home, the headache was on and off which was followed later by neurological presentations. The brain CT scan of both patients revealed bilateral subdural haematomas. Full neurological functions were regained following urgent surgical evacuation of haematomas. This should highlight the fact that any sort of persistent headache following a lumbar puncture, which is resistant to conventional management, should be regarded as an ominous sign of intracranial haematoma. Keywords: Caesarean section, spinal anaesthesia, subdural haematoma Introduction Postdural puncture headache (PDPH) is a very unpleasant complication after spinal anaesthesia, diagnostic lumbar puncture, 101

myelography and sometimes after diagnostic or therapeutic sympathetic blocks (1). Postdural puncture headache usually appears 24 to 48 hours after dural puncture, and rarely after 7 days (2).

2 myelography and sometimes after diagnostic or therapeutic sympathetic blocks (1). Postdural puncture headache usually appears 24 to 48 hours after dural puncture, and rarely after 7 days (2). Most headaches last less than a week and 95% of them resolve within 6 weeks (2). Persistent headache for more than that, despite conservative therapy, should raise the suspicion of intracranial complication. This is a report of two parturients, who developed bilateral subdural haematoma following spinal anaesthesia that was complicated by postdural puncture headache. Case presentation Case 1 A 22 years old primigravida, at 38 weeks gestational age, was scheduled for elective caesarean section under spinal anaesthesia because of cephalopelvic disproportion. She had no previous history of headache, head trauma, coagulopathy or anticoagulant therapy. Preoperative laboratory tests, including coagulation screening, were normal on admission. On arrival to the operation suite, the patient received a preload of one litre normal saline, 10 minutes before spinal anaesthesia. Spinal anaesthesia was performed in the sitting position, using a 25-gauge spinal needle inserted at the level of L3/4 interspace. Two ml of 0.5% hyperbaric bupivacaine was injected in the subarachnoid space, after obtaining free flow of clear cerebrospinal fluid at the third attempt for lumber puncture. The patient was then put immediately supine with left lateral uterine tilt. Sensory level height was found to be at T6. Anaesthesia and surgery went uneventful and the patient was transferred to the recovery room. In the third postoperative day, the patient experienced severe nausea and headache. Her headache was frontal and was more intense when the patient assumed the sitting position. Considering that it was a postdural puncture headache, complete bed rest, hydration and nonsteroidal anti-inflammatory drug (NSAID) were ordered by the obstetrician. The patient was discharged home on the 5 th postoperative day when headache became mild. Her headache persisted at home and she went to seek an internist opinion, who prescribed another NSAID. The headache was on and off, but it was not related to posture as before. On the 12 th postoperative day her level of consciousness started to deteriorate and she started to develop epileptic seizures. She was then referred by her internist to a neurologist, who requested a brain CT scan (Fig 1), Fig 1: Brain CT scan showing bilateral subdural haematoma, 12 days following spinal anaesthesia which revealed bilateral subdural haematomas. An urgent evacuation of haematoma was done and the patient spent an overnight in a high dependency unit which was followed by full neurological recovery two days later. Case 2 The second patient was a 32 years old parturient, at 37 weeks gestation, who was scheduled for elective caesarean section as she had a history of previous two caesarean deliveries. The patient had no history of head trauma, coagulopathy or anticoagulant medications and her preoperative laboratory tests, including coagulation screening, were all normal. The procedure was performed under spinal anaesthesia in the sitting position, using 23 gauge spinal needle inserted at L3- L4 interspace and was successful following five attempts. Twenty-four hours after 102

3 surgery, the patient developed severe frontal headache when sitting. Putting in mind the possibility of post-dural puncture headache, she was advised by her obstetrician to have complete bed rest, generous hydration and NSAID. Her headache became less and she was discharged home on the 4 th postoperative day. At home, and throughout the first 16 days following discharge, her headache was on and off, with variable response to NSAID. In the morning of the 21st postoperative day the patient was discovered fitting in her room and was transferred to the casualty. After basic resuscitation, a brain MRI (Fig 2): Fig 2: Brain MRI showing bilateral subdural haematoma 21 days following spinal anaesthesia was performed and revealed a huge bilateral subdural haematoma. Full neurological functions were retained two days after an urgent evacuation of haematoma. Discussion Post-dural puncture headache and, rarely, cranial subdural haematoma, with some common characteristics are potential complications following spinal anaesthesia, epidural anaesthesia or myelography (1,2,3,4). Following these procedures, any breach in the dura, may result in a post-dural puncture headache. Post-dural puncture headache is typically frontal or occipital and may extend to the neck. It is associated with head-up posture, nausea and photophobia. It is believed that it results from continuous CSF leak to the epidural space and reduction in intracranial pressure. This drainage of CSF causes caudal displacement of intracranial structures, resulting in increased traction on pain-sensitive dura, sinuses and blood vessels (4,5). An intracranial subdural haematoma may then result from this traction that may cause rupture of bridging epidural veins (4,6). Factors that may increase the risk of post-dural puncture headache and the development of subdural haematoma after spinal anaesthesia include young age, female sex, parturients, use of large-bore spinal needles, multiple injection attempts, patients with alcohol abuse, and patients taking anticoagulants (7). Elderly and those with cortical atrophy may also present a predisposition to spontaneous subdural haematoma (7). In most cases, post-dural puncture headache is relieved with conservative treatment that involves recumbent positioning, generous hydration, analgesics and caffeine. However, if the headache persists, it should be considered as a warning sign of intracranial haematoma. Such haematoma may increase intracranial pressure, changing the typical characteristic presentation of post-dural puncture headache and may be associated with neurological manifestations, such as convulsions, altered level of consciousness and lateralizing signs. Brain CT scan or MRI is diagnostic and is usually reliable. However, an intracranial haematoma which is 7-21 days old may have the same radiological density as the brain, so MRI or CT scan with contrast may be more reliable (8). 103

4 According to the literature, the incidence of intracranial subdural haematoma, following dural puncture, ranges between 1/500,000 and 1/1,000,000 (9,10). Most patients with post-dural puncture headache are treated conservatively without further investigations; therefore, the true incidence of subdural haematoma after spinal anaesthesia may be greater than the published case reports suggest. When post-dural puncture headache develops, change in the characteristic pattern of headache should be considered as a warning signs of intracranial haemorrhage. In the cases discussed in this review, the diagnosis was delayed because of premature discharge from the hospital, self-medication at home and underestimating the role of the anaesthetist in early diagnosis and management. Although there are no absolute measures to prevent the occurrence of PDPH, the anaesthetist should take all possible precautions to lessen its incidence by adopting meticulous neuraxial technique and proper selection of instruments. The differential diagnosis of PDPH is broad and includes other possible causes of headache (11), e.g. pregnancy induced hypertension, so it is essential to establish a differential diagnosis as early as possible to prevent serious and lifethreatening complications such as those seen in subjects of this review. An early collaboration between obstetrician and anaesthetist is mandatory to decide the most appropriate management option. The anaesthetist should be actively involved in the diagnosis and management of postoperative complications, especially those suspected to be directly related to anaesthesia. The presence of an intracranial haemorrhage or haematoma should be ruled out if an epidural blood patching is to be performed. Persistent post-dural puncture headache or change in its character may be accompanied with new neurological event, so close observation of the patients neurological evolution seems to be mandatory following any neuraxial block. Proper neuraxial technique, high index of suspicion and proper management of postdural headache are helpful measures to lessen the incidence of subdural haematoma following spinal anaesthesia. In addition to conservative management that should be allowed for 24 hours, early epidural blood patching is very effective and should be encouraged. Epidural blood patching involves injecting ml of the patients own blood into the epidural space at the level of dural puncture to stop further leakage of cerebrospinal fluid by induction of coagulation at the site of dural breach. An early CT scan should be done following failure of conservative management because if an epidural blood patch is performed in the presence of intracranial haematoma, a rebound intracranial hypertension and neurological deterioration can result (12). Detection of small subdural haematomas (<10mm) with midline shift less than 5mm, is not an indication for surgical evacuation and may be managed conservatively (12). As a conclusion, proper technique of neuraxial block and early diagnosis and management of post-dural puncture headache may reduce the incidence of intracranial haematomas. Persistence of post-dural puncture headache, or change in its characteristic presentation despite conservative management should raise the suspicion of intracranial haematoma. Early detection of this complication, either with brain CT scan or MRI, will determine the next line of management. An early epidural blood patching should be considered if post-dural puncture headache persists for more than 24 hours following conservative management, provided that an intracranial haematoma has been excluded. 104

5 Subdural haematoma Hadab Mohamed References 1. Mehrdad Moradi, Shoaleh Shami, Fariba Farhadifar, Karim Nesseri. Cerebral subdural haematoma following spinal anaesthesia: report of two cases. Case Reports in Medicine 2012:2012:1-4. doi: / 2012/ Lehman LJ, Hacobian A, De Sio M. Successful use of epidural blood patch for post-dural puncture headache following lumbar sympathetic block. Reg Anesth 1996;21(4): Velarde CA, Zuniga RE, Leon RF, Abram SE. Cranial nerve palsy and intracranial subdural hematoma following implantation of intrathecal drug delivery device. Reg Anasth Pain Med 2000;25: Acharya R, Chhabra SS, Ratra M, Sehgal AD. Cranial subdural haematoma after spinal anesthesia. Br J Anesth 2001;86: Acharya R. Chronic subdural haematoma complicating spinal anaesthesia. Neurological Sciences 2005 Feb;25(6): Baldwin LN, Galizia EJ. Bilateral subdural haematomas: a rare diagnostic dilemma following spinal anesthesia. Anesth Inten Care 1993;2: Karaman S, Demir F, Günüşen İ. Subdural haematoma following spinal anesthesia for cesarean section. Ege Tıp Dergisi/ Ege Journal of Medicine 2011;50(4): Bjarnhall M, Ekseth K, Bostrom S, Vegfors M. Intracranial subdural haematoma: a rare complication following spinal anesthesia. Acta Anaesth Scand 1996;40: Cantais E, Behnamou D, Petit D, Palmier B. Acute subdural hematoma following spinal anesthesia with a very small spinal needle. Anesthesiology 2000;93: Blake DW, Donnan G, Jensen D. Intracranial subdural haematoma after spinal anesthesia. Anesth Inten Care 1987;15: Bezov D, Lipton RB, Ashina, S. Postdural puncture headache: part I diagnosis, epidemiology, etiology, and pathophysiology. Headache: The Journal of Head and Face Pain 2010;50: doi: /j x 12. Horlocker TT, McGregor DG, Matsushige DK, Schroeder DR, Besse JA. A retrospective review of 4767 consecutive spinal anesthetics: central nervous system complications. Perioperative Outcomes Group. Anesth Analg 1997;84:

Case Report Cerebral Subdural Hematoma Following Spinal Anesthesia: Report of Two Cases

Case Reports in Medicine Volume 2012, Article ID 352028, 4 pages doi:10.1155/2012/352028 Case Report Cerebral Subdural Hematoma Following Spinal Anesthesia: Report of Two Cases Mehrdad Moradi, 1 Shoaleh