TOP 10 CITED PAPER 2006-2008 INTERNATIONAl … · puncture headache complicated by subdural hematoma following spinal or epidural anesthesia. ... ,thesizeofthehematoma,severityofsymptoms,de-

481 M.E.J. ANESTH 20 (4), 2010

Editorial

TOP 10 CITED PAPER 2006-2008 INTERNATIONAl JOuRNAl Of

ObSTETRIC ANESTHESIA

On behalf of the Editorial board of the Middle East Journal of Anesthesiology (MEJA), I would like to congratulate Drs. A. Zeidan, O. farhat, H. Maaliki, and Dr. A. baraka from the Departments of Anesthesiology and Neurosurgery, Sahel General Hospital, and the Department of Anesthesiology of the American university of beirut, beirut, lebanon for ranking their paper entitled “Does postdural puncture headache left untreated lead to subdural hematoma?”* which was published in the “International Journal of Obstetric Anesthesia”, Volume 15, Issue 1, 2006, pages 50-58” among the top 10 cited reports between 2006 and 2008. Also, I sincerely thank the Editorial board of the International Journal of Obstetric Anesthesia for awarding certificates of recognition to the authors of the paper, and for permitting the MEJA to republish the report.

The paper reports a 39-year-old pregnant woman who developed cranial subdural hematoma following spinal anesthesia for Cesarean section using a 26 gauge spinal needle with an atraumatic bevel. In addition, the paper reviews the literature on 46 patients who developed a postdural puncture headache complicated by subdural hematoma following spinal or epidural anesthesia.

The report concluded that postdural puncture headache left untreated may be complicated by the development of subdural hematoma. Also, patients developing a postdural puncture headache unrelieved by conservative measures, as well as the change from postdural to non-postdural headache, require careful follow-up for early recognition and management of possible subdural hematoma.

Anis baraka, MD,fRCA(Hon) Emeritus Editor-in-Chief MEJA Department of Anesthesiology American university of beirut

* Reprinted with permission from International Journal of Obstetric Anesthesia.

ANIS bARAkA482

M.E.J. ANESTH 20 (4), 2010

483TOP 10 CITED PAPER 2006-2008 INTERNATIONAl JOuRNAl Of ObSTETRIC ANESTHESIA

CASE REPORT AND REVIEW

Does postdural puncture headache left untreated lead tosubdural hematoma? Case report and review of the literature

A. Zeidan, O. Farhat, H. Maaliki, A. BarakaDepartments of Anesthesiology and Neurosurgery, Sahel General Hospital, and Department of Anesthesiology,American University of Beirut Medical Center, Beirut, Lebanon

SUMMARY. The patient was a 39-year-old pregnant woman who was scheduled for cesarean section. Spinal anes-thesia was induced using a 26-gauge needle with an atraumatic bevel. Postoperatively, the patient developed cranialsubdural hematoma manifesting as severe non-postural headache, associated with right eye tearing, fifth cranial nervepalsy and left hemiparesis. The diagnosis was confirmed by computed tomography scan. The patient was managed bycareful neurological follow-up associated with conservative treatment and recovered fully after 12 weeks. Our reportreviews the literature on 46 patients who developed a postdural puncture headache complicated by subdural hema-toma following spinal or epidural anesthesia. It is possible that postdural puncture headache left untreated may becomplicated by the development of subdural hematoma. Patients developing a postdural puncture headache unre-lieved by conservative measures, as well as the change from postural to non-postural, require careful follow-upfor early diagnosis and management of possible subdural hematoma.� 2005 Elsevier Ltd. All rights reserved.

Keywords: Subdural hematoma; Dural puncture; Spinal, epidural; Anesthesia; Parturient

INTRODUCTION

Spinal anesthesia can be followed by postdural punctureheadache (PDPH), and even cerebral hemorrhage.1–4

This report describes the occurrence of cerebral subduralhemorrhage in a 39-year-old patient undergoing cesar-ean section under spinal anesthesia, and reviews the lit-erature of 46 patients who developed subduralhematoma following spinal and epidural anesthesia.

CASE REPORT

A 39-year-old woman, gravida 5 para 4 (three normaldeliveries and one uneventful cesarean section under

general anesthesia) was scheduled for elective cesareansection under spinal anesthesia. She had no history oftrauma, headache or coagulation abnormalities. Preoper-ative laboratory blood tests, including platelet count,prothrombin time and activated prothromboplastin time,were normal. The patient received no anticoagulants.Before spinal anesthesia, lactated Ringer’s solution1500 mL was administered. With the patient in the sit-ting position, spinal anesthesia was performed at theL3-4 interspace using a 26-gauge needle with an atrau-matic bevel (Atraucan�, B-Braun, Germany). Subarach-noid puncture was successful on the first attempt and0.5% plain bupivacaine 12 mg was administered, whichled to a sensory block up to T6. The intraoperativecourse was uneventful except for a decrease in systolicblood pressure from 143 to 110 mmHg, which was trea-ted with i.v. ephedrine 10 mg; the systolic blood pres-sure remained >110 mmHg throughout the remainderof the operative period.Three days postoperatively, the patient experienced a

mild occipital headache, which was assumed to be aPDPH because it was more intense in the sitting posi-tion. Over the next two days, the headache improvedrapidly following hydration and bed rest. The patientwas discharged on the fifth postoperative day. On post-operative day six, the patient suffered from headache

International Journal of Obstetric Anesthesia (2006) 15, 50–58� 2005 Elsevier Ltd. All rights reserved.doi:10.1016/j.ijoa.2005.07.001

Accepted June 2005

A. Zeidan MD, Staff anesthesiologist, Sahel General Hospital,O. Farhat MD, Staff neurosurgiologist, Sahel General Hospital,H. Maaliki MD, Staff anesthesiologist, Sahel General Hospital,A. Baraka MD, FRCA, Professor and Chairman, Department ofAnesthesiology, American University of Beirut Medical Center;Beirut, Lebanon.

Correspondence to: Anis Baraka MD FRCA, Professor & Chairman,Department of Anesthesiology, American University of Beirut MedicalCenter, Beirut, Lebanon.E-mail: [email protected]

50

ANIS bARAkA484

associated with right eye tearing and fifth nerve palsy.On the 15th day, the patient developed diplopia and se-vere right orbital pain. On the 30th day she came tothe hospital when she developed a mild left hemibodyweakness. Neurological examination demonstrated mildupper and lower left limb weakness, non-postural severeheadache and right eye pain associated with the disap-pearance of the diplopia and fifth nerve palsy. A com-puted tomography (CT) scan on the day of admissionto the hospital revealed a 1.8-cm thick chronic cerebralsubdural hematoma (>2 weeks old) overlying the rightfronto-parietal lobe causing compression of the underly-ing brain and obliteration of the sulci (Fig. 1).The patient was admitted to the department of neuro-

surgery and surgical versus conservative managementwas discussed with the patient. She refused the surgicaloption, and accordingly close regular follow-up of neu-rological symptoms (lower left limb weakness, head-ache, and right eye pain), was chosen. The patientshowed a marked clinical improvement. Eleven dayslater, a follow-up CT scan showed good resolution ofthe hematoma (Fig. 2). Cerebral angiography throughthe right femoral artery did not reveal an associatedaneurysm or arteriovenous malformation. The patientwas discharged on the 12th day and recovered fully 12weeks after dural puncture.

DISCUSSION

Postdural puncture headache is the most frequent majorcomplication after spinal anesthesia. In the majority ofcases the symptoms subside within a few days whentreated with analgesics and bed rest. Intracranial sub-

dural hematoma is rare, but could be a lethal complica-tion that can occur after epidural or spinal anesthesia, aswell as following myelography.1–3 The same mechanismhas been postulated for both PDPH and subdural hema-toma.4 The leakage of cerebrospinal fluid (CSF) fromthe dural hole causes reduction in CSF volume, whichlowers first the intraspinal pressure, and more danger-ously, the intracranial pressure. This alteration in cere-brospinal dynamics results in a caudally-directedmovement of the spinal cord and brain, which in turnstretches the pain-sensitive structures, dura, cranialnerves and bridging veins.Cerebral veins empty into dural sinuses that are

adherent to the inner table of the skull. These veins formshort trunks passing directly from the brain to the duramater. Between these two points, bridging veins take astraight course with no tortuosity to allow for any possi-ble displacement of the brain. The thinnest parts of thebridging veins’ walls are in the subdural space and thethickest are in the subarachnoid portion. This impliesthat bridging veins are more fragile in the subdural por-tion than in the subarachnoid space.5 Anteroposterioracceleration or deceleration and/or traction exerted onthe bridging veins, may cause a rupture at their weakestpoint in the subdural space. Cerebral atrophy and lowCSF pressure (low CSF volume) will accentuate thismechanism.Following spinal anesthesia, a dural fistula can re-

main open for many weeks, and the volume of CSF lostmay be over 200 mL per day, which can exceed normalCSF production.6 In these circumstances, the rupture of

Fig. 1 Cranial CT scan 30 days after spinal anesthesia showing right-sided subdural hematoma.

Fig. 2 Cranial CT scan 41 days after spinal anesthesia showingdecreasing size of subdural hematoma.

Postdural puncture subdural hematoma 51

M.E.J. ANESTH 20 (4), 2010


a subdural vein is certainly conceivable. Research onweakness of the dura and abnormalities of connectivetissue, particularly abnormality of fibrillin and elastin,is gaining momentum as one of the etiological factorsfor delayed healing of a dural tear.7 The incidence ofPDPH is reduced following dural puncture using a smallneedle (26-gauge spinal). In contrast, PDPH occurs in upto 80% of parturients who experience inadvertent duralpuncture with a large bore needle.8 Nevertheless, theuse of a 26-gauge spinal needle in our patient was com-plicated by PDPH and subsequent subdural hematoma.Thus, once PDPH develops, it should be treated as suchirrespective of needle size.The concurrence of neurological symptoms with

PDPH does not mean certainty of the formation of intra-cranial hemorrhage. Continuous loss of CSF leads tointracranial hypotension. Intracranial hypotension is anincreasingly recognized neurologic syndrome character-ized by postural headache that occurs or worsens shortlyafter assuming the upright position and disappears or im-proves after resuming the recumbent position. Addi-tional symptoms may include neck pain, nausea,emesis, interscapular pain, photophobia, diplopia, dizzi-ness, change in hearing, visual blurring, cranial nervepalsies and radicular upper extremity symptoms.7 Theoccurrence of subdural hematoma increases the intracra-nial pressure which can be associated with non-posturalheadache, convulsions, hemiplegia, disorientation andmore serious neurological symptoms. Differentiation be-tween the neurological symptoms of intracranial hypo-tension and subdural hematoma can be difficult. Achange in headache characteristics from postural tonon-postural should be a warning sign. CT scan of theskull usually gives the correct diagnosis. However, intra-cranial hematoma 7–21 days old may have the sameradiological density as the brain, so magnetic resonanceimaging (MRI) or CT scan with contrast may be morereliable.1

The delayed diagnosis, in many cases, implies thatsubdural hematoma wasn’t taken into consideration asa complication of spinal anesthesia. In our case, therewas a major delay between the onset of symptoms anddiagnosis. The patient considered the prolonged postop-erative headache as a benign complication of spinalanesthesia and she didn’t consult us until the appearanceof the hemiparesis. Our patient developed an intracranialhypotension syndrome (eye tearing and fifth nervepalsy) on the sixth postoperative day. The time of forma-tion of the subdural hematoma, although unknown, wasmost probably on the second or third week after duralpuncture. We concur that intracranial hypotension syn-drome might be a prodrome of subdural hematoma afterdural puncture.Cerebral atrophy, dehydration, anticoagulant, arterio-

venous malformations and excessive CSF leakage (mul-

tiple dural puncture, large dural hole) are thought to becontributing factors in the pathogenesis of subduralhematoma. In our patient, the angiography of cerebralvessels revealed no associated aneurysm or arteriove-nous abnormalities. Furthermore, our patient receivedno anticoagulants.Review of the literature disclosed 25 cases of sub-

dural hematoma following spinal anesthesia (Table1).1,4,9–31 Among these 25 cases, the age of patients ran-ged between 20 to 88 years. The earliest diagnosis ofsubdural hematoma was six hours after spinal anesthesiaand the latest was 29 weeks. Subdural hematoma afterspinal anesthesia occurred most frequently on the leftside of the brain (13 cases were left-sided, six right-sided, four bilateral and two were intracerebral). Thelargest spinal needle used was 19 gauge and the narrow-est one was a 27-gauge Whitacre needle. Three cases ofmultiple puncture were noted. Surgery was performed in20 of these 25 patients, and was followed by postopera-tive mortality of four patients. Mortality was not relatedto the age of the patient or the size of the spinal needleused.Also, review of the literature disclosed 21 cases of

subdural hematoma after unintentional dural puncturefollowing epidural anesthesia (Table 2),2,10,12,32–49 themost recent being reported by Kayacan et al.49 Nineteenof these 21 cases were obstetric patients. The earliestdiagnosis of subdural hematoma was two days after epi-dural anesthesia and the latest was 20 weeks. Almosthalf of the patients developed bilateral subdural hema-toma (11 cases were bilateral, six left-sided and fourright-sided). Surgery was performed in 15 of these 21patients and two died. In both groups, (spinal and epidu-ral), the size of the hematoma, severity of symptoms, de-layed diagnosis and/or interventions did not apparentlyaffect mortality rate.It is possible that parturients are at high risk of devel-

oping post dural puncture headache.50–53 The increasedincidence of post-dural puncture headache in parturientsmay be attributed to numerous factors including peripar-tum dehydration, which could reduce the production ofCSF, postpartum diuresis, abrupt release of intra-abdom-inal pressure and venacaval compression at delivery,which reduces epidural venous pressures. Maternal bear-ing-down efforts that could increase CSF leakagethrough the dural hole could also be a factor, as wellas early ambulation, anxiety about delivery and hormon-ally-induced ligamentous changes.54 In addition, it iswidely believed that pregnancy increases the risk ofstroke; reports showed that the incidence of intracerebralhemorrhage is increased in the six weeks after deliv-ery.55 Furthermore, there was an association betweenpost-partum hemorrhagic stroke and cesarean deliv-ery.56,57 It seems that venous congestion during preg-nancy can make bridging veins more susceptible to

52 International Journal of Obstetric Anesthesia

ANIS bARAkA486

Tab

le1.

Reportedcasesof

subd

ural

hematom

aafterspinal

anesthesia

References

Age/Sex

Diagnosistime/PDP/Methods/

Localizationofhematoma

Predisposing

factors

Procedure

Needlesizefor

spinalanesthesia

Warningsign

Treatment/Outcome

Welch9

69/M

48days,clinical

diagnosis:Bilat.SDH

None

Retropubicprostatectomy

22-G

Frontalheadache,diplopia

andconfusion

Surgical/death

Pavlin10

37/M

6days,angiography:rightSDH

Multiplepuncture

attemptswith22-G

Perirectalabscess

25-G

Coma

Surgical/neurological

deficit

Mantia11

27/F

5days,CTscan:rightSDH

Pregnancy?

Normaldelivery

26-G

Lefthemiplegiaandaphasia

Medical/neurological

deficit?

Newrick12

67/M

10days,CTscan:leftSDH

None

Inguinalherniorraphy

22-G

Disorientationandgeneral

hyperreflexia

Surgical/death

Miyazaki13

33/F


Pregnancy?

Cesareansection

21-G

Severeheadache,vomiting

andconfusion

Surgical/recovered

Rudehill14

70/M


None


22-G

Severeheadache,vomiting,

confusionanddrowsiness

Surgical/recovered

Jonsson15

63/M

On12thdayscanwasnormal,

29daysbyangiography:leftSDH

None


24-G

Rightorbitpain,dysphasia

andrightarmweakness

Surgical/recovered

Giamundo16

50/M


None


?Severeheadache,memory

deficitandconfusion

Surgical/recovered

Blake17

67/M

3weeks,CTscan:leftSDH

Multiplepuncture

attempts

TURP

25-G

Rightfrontalpain,confusion

andclumsygait

Surgical/recovered

Beal18

67/M


None

TURP

22-GQuincke

Coma

Surgical/death

Macon4

68/M

2weeks;CTscan:leftSDH

Multiplepuncture

Inguinal

herniorraphy

25-GQuincke

NPH,leftorbitpainandleft

hemicranialpain

Surgical/recovered

Ortiz19

63/F


Anticoagulants

Vaginalhysterectomy

22-G

Severeheadache,left

hemiparesisandphotophobia

Surgical/?

VandeKelft20

68/M

30days;CTscan:rightSDH

Previousdural

puncture

with22-G

onemonthago

Urethraldilatation

22-G

NPH,confusionanddizziness

Surgical/recovered

Baldwin21

71/M

29weeks,CTscan:Bilat.SDH

None

TURP

22-G

Headache,vomitingand

personalitychanges

Surgical/recovered

Bj�rnhall1

71/M


None

Cystoscopy

22-GQuincke

NPHandvomiting

Surgical/recovered

Akpek22

31/F

14days;MRI:Bilat.SDH,

basalgangliaand

thalamushemorrhage

Pregnancy?

Cesareansection

22-G

Absentmindedness;

drowsinessand

righthemiparesis

Surgical/recovered

Cantais23

42/M


Anticoagulants

Achillestendonrepair

27-GWhitacre

SeverefrontalNPH,

vomitingandcoma

Surgical/death

Acharya24

20/M

1week,MRI:rightSDH

None

Appendectomy

23-GQuincke

SevereNPH,vomiting

Medical/recovered

Eggert25

29/F

1day,CTscan:leftSDH

Pregnancy?

Removalof

retainedplacenta

24-GSprotte

Fronto-occipitalNPH,

photophobiaandvomiting

Medical/recovered

(con

tinuedon

next

page)


M.E.J. ANESTH 20 (4), 2010


rupture. Also, sudden increases in venous pressure ofthese dilated veins by coughing, stressing or abdominalcompression during labor and delivery (Valsalva maneu-ver) can lead to an augmentation of tension, especially atthe subdural portion of bridging veins.5

The true incidence of subdural hematoma after duralpuncture is unknown. In most cases, non postural head-ache and vomiting are the warning signs. In addition,changes in headache characteristics (intractable head-ache associated with retro-orbital and frontal pains) wereobserved in most cases. Most patients with headachesare probably treated without further investigation.Therefore, the true incidence of subdural hematomaafter spinal anesthesia may be greater than the publishedcase reports suggest. Suess et al. found that headachelasting >5 days was the chief complaint in 17 reportedcases of intracranial hemorrhage after myelography.3

The management of subdural hematoma is either con-servative or surgical. Small hematomas often resolvespontaneously. Early blood patching may decrease therisk of subdural bleeding by preventing a fall in CSFvolume and subsequent intracranial hypotension. Rey-nolds and Salvin recommend that “headache after duralpuncture with a large needle should be treated promptlywith an epidural blood patch.”58 However, when epidu-ral blood patch is performed in the presence of intracra-nial hemorrhage, rebound intracranial hypertension andneurological deterioration can result.14,47

The practice of administering a prophylactic epiduralblood patch to obstetric patients after inadvertent duralpuncture with an epidural needle has been controversial.When a large dural hole is known to exist and a func-tioning epidural catheter is in place, a prophylactic epi-dural blood patch through the catheter might be tried.Some authors have suggested that prophylactic epiduralblood patch may reduce the incidence of subsequentPDPH to 5%–21%.59–61 However, Scavone et al.62

showed recently that prophylactic epidural blood patchafter inadvertent dural puncture in parturients did not de-crease the incidence of PDPH to the magnitude pre-dicted; the length and severity of PDPH symptoms,however, were decreased. Loeser et al.63 have shownthat therapeutic epidural blood patch is not as effectivewhen performed within the first 24–48 h after duralpuncture. Also, Safa-Tisseront et al.64 showed recentlythat the percentage of failure of epidural blood patchwas significantly increased when epidural blood patchwas performed within three days after dural puncture.Epidural blood patch essentially has two effects.

The immediate effect is simply related to volumereplacement by compression of the dura that will re-store CSF pressure and relieve the headache. Thesecond latent effect is related to sealing of a duradefect. The time interval between these two effectsvaries considerably. Beards et al.65 demonstrated noT

able

1.continued

References

Age/Sex



Predisposing

factors

Procedure

Needlesizefor

spinalanesthesia

Warningsign

Treatment/Outcome

Sharma26

28/F

6h,CTscan:right

intracerebralhematoma

Pregnancy?

Cesareansection

24-G

Severeheadache,

vomitingandlefthemiparesis

Surgical/neurological

deficit?

Wells27

59/M

2days,CTscan:

leftintracranialhemorrhage

Cerebralaneurysms

Prostatesurgery

27-GWhitacre

NPH

andconfusion

Surgical/recovered

Kelsaka28

38/M


None

Inguinalherniorrhaphy

22-GQuincke

SeverefrontalNPH

Surgical/recovered

Slowinski29

38/F

6weeks,M

RI:bilat.SDH

None

Saphenousveinligation

25-GQuincke

NPH,diplopiaandbilateral

abducentnervepalsy

Surgical/recovered

Alilou30

41/F


None

Tuballigation

19-G

Severeheadache,sixnerve

palsyanddiplopia

Surgical/recovered

Tan31

88/F


Brainatrophy

Rightfemoralherniorraphy

25-GQuincke

Confusionanddrowsiness

Surgical/recovered

Ourcase

39/F


Pregnancy?

Cesareansection

26-GAtraucan

NPH

andlefthemiparesis

Medical/recovered

SDH:subduralhematoma;NPH:non-posturalheadache;PDP:post-duralpuncture.


ANIS bARAkA488

11. Mantia A M. Clinical report of the occurrence of an intracerebralhemorrhage following post-lumbar puncture headache.Anesthesiology 1981; 55: 684–685.

12. Newrick P, Read D. Subdural haematoma as a complication ofspinal anaesthetic. Br Med J 1982; 285: 341–342.

13. Miyazaki S, Fukushima H, Kamata K, Ishii S. Chronic subduralhematoma after lumbar-subarachnoid analgesia for a cesareansection. Surg Neurol 1983; 19: 459–460.

14. Rudehill A, Gordon E, Rahn T. Subdural haematoma. A rare butlife-threatening complication after spinal anaesthesia. ActaAnaesthesiol Scand 1983; 27: 376–377.

15. Jonsson L O, Einarsson P, Olsson G L. Subdural haematoma andspinal anaesthesia. A case report and an incidence study.Anaesthesia 1983; 38: 144–146.

16. Giamundo A, Benvenuti D, Lavano A, D’Andrea F. Chronicsubdural haematoma after spinal anaesthesia. Case report.J Neurosurg Sci 1985; 29: 153–155.

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18. Beal J L, Royer J M, Freysz M, Poli L, Wilkening M. Acuteintracranial subdural hematoma of arterial origin after spinalanesthesia. Ann Fr Anesth Reanim 1989; 8: 143–145.

19. Ortiz M, Aliaga L, Baturell C, Preciado M J, Aguilar J, Vidal F.Intracranial subdural haematoma - a rare complication after spinalanaesthesia. Eur J Anaesthesiol 1991; 8: 245–248.

20. Van de Kelft E, De la Porte C, Meese G, Adriaensen H.Intracranial subdural hematoma after spinal anesthesia. ActaAnaesthesiol Belg 1991; 42: 177–180.

21. Baldwin L N, Galizia E J. Bilateral subdural haematomas: a rarediagnostic dilemma following spinal anaesthesia. AnaesthIntensive Care 1993; 21: 120–121.

22. Akpek E A, Karaaslan D, Erol E, Caner H, Kayhan Z. Chronicsubdural haematoma following caesarean section underspinal anaesthesia. Anaesth Intensive Care 1999; 27:206–208.

23. Cantais E, Behnamou D, Petit D, Palmier B. Acute subduralhematoma following spinal anesthesia with a very small spinalneedle. Anesthesiology 2000; 93: 1354–1356.

24. Acharya R, Chhabra S S, Ratra M, Sehgal A D. Cranial subduralhaematoma after spinal anaesthesia. Br J Anaesth 2001; 86:893–895.

25. Eggert S M, Eggers K A. Subarachnoid haemorrhage followingspinal anaesthesia in an obstetric patient. Br J Anaesth 2001; 86:442–444.

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29. Slowinski J, Szydlik W, Sanetra A, Kaminska I, Mrowka R.Bilateral chronic subdural hematomas with neurologic symptomscomplicating spinal anesthesia. Reg Anesth Pain Med 2003; 28:347–350.

30. Alilou M, Halelfadl S, Caidi A, Kabbaj S, Ismaili H, Maazouzi W.Cranial subdural haematoma following spinal anaesthesia. Ann FrAnesth Reanim 2003; 22: 560–561.

31. Tan S T, Hung C T. Acute-on-chronic subdural haematoma: a rarecomplication after spinal anaesthesia. Hong Kong Med J 2003; 9:384–386.

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33. Edelman J D, Wingard D W. Subdural hematomas after lumbardural puncture. Anesthesiology 1980; 52: 166–167.

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35. Deglaire B, Duverger P, Muckensturm B, Maissin F, DesbordesJ M. Acute intracranial subdural hematoma after accidental dural

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37. Wyble S W, Bayhi D, Webre D, Viswanathan S. Bilateral subduralhematomas after dural puncture: delayed diagnosis after falsenegative computed tomography scan without contrast. Reg Anesth1992; 17: 52–53.

38. Campbell D A, Varma T R. Chronic subdural haematomafollowing epidural anaesthesia, presenting as puerperal psychosis.Br J Obstet Gynaecol 1993; 100: 782–7844.

39. Thons M, Neveling D, Hatzmann W. Intracerebral subduralhematoma after delivery with peridural catheter anesthesia. ZGeburtshilfe Perinatol 1993; 197: 235–237.

40. Garcia-Sanchez M J, Prieto-Cuellar M, Sanchez-Carrion J M,Galdo-Abadin J R, Martin-Linares J M, Horcajadas-Almansa A.Chronic subdural hematoma secondary to an accidental duralpuncture during lumbar epidural anesthesia. Rev Esp AnestesiolReanim 1996; 43: 327–329.

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43. Diemunsch P, Balabaud V P, Petiau C, et al. Bilateral subduralhematoma following epidural anesthesia. Can J Anaesth 1998; 45:328–331.

44. Davies J M, Murphy A, Smith M, O’Sullivan G. Subduralhaematoma after dural puncture headache treated by epiduralblood patch. Br J Anaesth 2001; 86: 720–723.

45. Ferrari L, De Sevin F, Vigue J P, Granry J C, Preckel M P.Intracranial subdural hematoma after obstetric dural puncture. AnnFr Anesth Reanim 2001; 20: 563–566.

46. Ezri T, Abouleish E, Lee C, Evron S. Intracranial subduralhematoma following dural puncture in a parturient with HELLPsyndrome. Can J Anaesth 2002; 49: 820–823.

47. Kardash K, Morrow F, Beique F. Seizures after epidural bloodpatch with undiagnosed subdural hematoma. Reg Anesth Pain Med2002; 27: 433–436.

48. Nolte C H, Lehmann T N. Postpartum headache resulting frombilateral chronic subdural hematoma after dural puncture. Am JEmerg Med 2004; 22: 241–242.

49. Kayacan N, Arici G, Karsli B, Erman M. Acute subduralhaematoma after accidental dural puncture during epiduralanaesthesia. Int J Obstet Anesth 2004; 13: 47–49.

50. Barash P, Cullen B, Stoelting R. Clinical Anesthesia. 4thed. Philadelphia: Lippincott Williams & Wilkins, 2001:1152.

51. Angle P, Thompson D, Halpern S, Wilson D B. Second stagepushing correlates with headache after unintentional duralpuncture in parturients. Can J Anaesth 1999; 46: 861: 861–866.

52. Vandam L D, Dripps R D. Long-term follow-up of patients whoreceived 10,098 spinal anesthetics; syndrome of decreasedintracranial pressure (headache and ocular and auditorydifficulties). JAMA 1956; 161: 586–591.

53. Loo C C, Dahlgren G, Irestedt L. Neurological complicationsin obstetric regional anaesthesia. Int J Obstet Anesth 2000; 9:99–124.

54. Ravindran R S, Viegas O J, Tasch M D, Cline P J, Deaton R L,Brown T R. Bearing down at the time of delivery and the incidenceof spinal headache in parturients. Anesth Analg 1981; 60:524–526.

55. Sharshar T, Lamy C, Mas J L. Incidence and causes of strokesassociated with pregnancy and puerperium. Stroke 1995; 26:930–936.

56. Witlin A G, Mattar F, Sibai B M. Postpartum stroke: Atwenty-year experience. Am J Obstet Gynecol 2000; 183:83–88.

57. Lanska D J, Kryscio R J. Risk factors for peripartum andpostpartum stroke and intracranial venous thrombosis. Stroke2000; 31: 1274–1282.


M.E.J. ANESTH 20 (4), 2010


Tab

le2.

Reportedcasesof

subd

ural

hematom

aafterepidural

anesthesia

References

Age/Sex



Predisposingfactors

Procedure

Needleandsize

Warningsign

Treatment/

Outcome

Jack32

29/F

28days,angiography:

bilatSDH

Pregnancy?Preeclampsia?

Normaldelivery

Tuohy?-GNo

obviousdural

puncture?

Headache;disorientation

andmuscleweakness

Surgical/recovered

Pavlin10

23/F

8days,angiography:

bilatSDH

Pregnancy?

Normaldelivery

Crawford18-G

Headache;dysarthria

andrightvisionloss

Surgical/recovered

Edelman33

27/F

40days,autopsy:bilatSDH

Pregnancy?

Normaldelivery

Tuohy16-G

Apneaandcardiacarrest

Death

Reinhold34

36/F


Pregnancy?

Normaldelivery

Tuohy18-G

Headache;blurredvision;

dysphasiaandmemorydeficit

Surgical/recovered

Newrick12

29/F

4weeks,angiography:

bilatSDH

Pregnancy?

Normaldelivery

Tuohy18-G

Headache;drowsiness,

visionlossandright

limbweakness

Surgical/permanent

visualdefect

Deglaire35

70/M

2days,CTscan:

rightSDH.

Anticoagulants

TUR-P

Tuohy17-G

Coma

Surgical/death

Scott36

(?)

Someweeks?-CT

scan:bilatSDH

Pregnancy?

Normaldelivery

Tuohy?-G

Prolongedsevereheadache

Surgical/recovered

Wyble37

15/F

On17thdayCTscannormal;

19daysCTscan:bilatSDH

Pregnancy?

Normaldelivery

Tuohy17-G

NPH,blurredvision,

vomiting.Thenconfusion

andparesisafterbloodpatch

Surgical/recovered

Campbell38

21/F

6weeks,CTscan:bilatSDH

Pregnancy?

Cesarean-section

Tuohy16-G?

Noobvious

duralpuncture?

Persistentheadache,

blurredvision,vomiting.

Suicidalattemptsand

puerperalpsychosis

Surgical/recovered

Thons39

19/F


Pregnancy?

Normaldelivery

Tuohy?-G

Persistentheadache

Surgical/recovered

Garcia-Sanchez40

54/F

5months,CTscan:rightSDH

None

Forbilateral

saphenectomy

Tuohy?-G

PersistentNPH

Surgical/recovered

Cohen41

18/F

42days,CTscan:bilatSDH

Pregnancy?

Normaldelivery

Tuohy?-G

NPH;photophobiavomiting

andrightBabinski’ssign

Surgical/recovered

Skoldefors42

19/F


Pregnancy?

Normaldelivery

Tuohy16-G

Severeheadacheand

drowsiness

Surgical/recovered

Diemunsch43


Pregnancy?

Normaldelivery

Tuohyneedle

18-G.Duralpuncture

bythecatheter?

NPH,lefthemiparesis

andaphasia

Surgical/recovered

Vaughan2

23/F


Pregnancy?A-V

malformations

Normaldelivery

Tuohy?-G

Convulsionandcoma

Medical/recovered?

Davies44

39/F

16days,MRI:leftSDH

Pregnancy?

Laborandthen

cesareansection

Tuohy16-G

Severeheadache,dysphasia,

rightarmsensoryloss

Surgical/recovered

Ferrari45

29/F

9days,CTscan

withcontrast:leftSDH

Pregnancy?

Normaldelivery

Tuohy18-G

NPH,nauseaandvomiting

Medical/recovered

(con

tinuedon

next

page)


ANIS bARAkA490

residual dural compression after seven hours afterepidural blood patch, indicating that the sustainedtherapeutic response to blood patches reflects sealingof the thecal tear by clot. Blood could persist formore than 18 h after epidural blood patch.65

Other modalities of treatment for PDPH have beenproposed. Ayad et al.66 showed that an epidural catheterleft in the subarachnoid space for 24 h after a duralpuncture significantly reduced both PDPH and the needof epidural blood patch. The mechanism for subarach-noid catheter prevention of PDPH is speculative. Thelarge-bore intrathecal catheter may act as a barrier toCSF leakage by plugging the dural tear, decreasing theCSF efflux from the subarachnoid space to the epiduralcompartment. Furthermore, the effect of leaving thecatheter in place for 24 h may provoke an inflammatoryprocess that facilitates closure of the dural puncture aftercatheter removal. Also, Charsley et al.67 showed that theintrathecal injection of normal saline (10 mL) was asso-ciated with a significantly reduced incidence of PDPHand a reduced need for epidural blood patch. One expla-nation for the beneficial effect of intrathecal saline isthat the increased CSF pressure may result in approxi-mation of the dura and arachnoid at the puncture site,thus sealing the defect.In conclusion, our patient developed a cranial sub-

dural hematoma following untreated PDPH. Patientsdeveloping PDPH unrelieved by conservative measures,as well as the change of PDPH from postural to non-pos-tural, require careful follow-up for early diagnosis andmanagement of possible subdural hematoma.

REFERENCES

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able

2.continued

References

Age/Sex



Predisposingfactors

Procedure

Needleandsize

Warningsign

Treatment/

Outcome

Ezri46

19/F

4days,M

RI:bilatSDH

Preeclampsia

andHELLP

syndrome

(thrombocytopenia)

Laborandthen

cesareansection

Tuohy18-G

SevereNPH

Medical/recovered

Kardash47

33/F

3days,CTscan

withcontrast:leftSDH

Pregnancy?

Normaldelivery

Tuohy?-G

Headache,seizure

Medical/recovered

Nolte48

31/F


Pregnancy?

Normaldeliveryoftwins

Tuohy17-G

NPH,vomiting,

drowsiness

Surgical/recovered

Kayacan49

36/F

On7thdayscanwasnormal;

11daysbyMRI:rightSDH

Pregnancy?

Normaldelivery

Tuohy18-G

Persistentsevere

headacheandconvulsion

Medical/recovered

SDH:subduralhematoma;NPH:non-posturalheadache;PDP:post-duralpuncture.


M.E.J. ANESTH 20 (4), 2010


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24. Acharya R, Chhabra S S, Ratra M, Sehgal A D. Cranial subduralhaematoma after spinal anaesthesia. Br J Anaesth 2001; 86:893–895.

25. Eggert S M, Eggers K A. Subarachnoid haemorrhage followingspinal anaesthesia in an obstetric patient. Br J Anaesth 2001; 86:442–444.

26. Sharma K. Intracerebral hemorrhage after spinal anesthesia.J Neurosurg Anesthesiol 2002; 14: 234–237.

27. Wells J B, Sampson I H. Subarachnoid hemorrhage presenting aspost-dural puncture headache: a case report. Mt Sinai J Med 2002;69: 109–110.

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33. Edelman J D, Wingard D W. Subdural hematomas after lumbardural puncture. Anesthesiology 1980; 52: 166–167.

34. Reinhold P, Lindau B, Bohm P. Chronic subdural haematomafollowing epidural anaesthesia. Anasth Intensivther Notfallmed1980; 15: 428–431.

35. Deglaire B, Duverger P, Muckensturm B, Maissin F, DesbordesJ M. Acute intracranial subdural hematoma after accidental dural

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36. Scott D B, Hibbard B M. Serious non-fatal complicationsassociated with extradural block in obstetric practice. Br J Anaesth1990; 64: 537–541.

37. Wyble S W, Bayhi D, Webre D, Viswanathan S. Bilateral subduralhematomas after dural puncture: delayed diagnosis after falsenegative computed tomography scan without contrast. Reg Anesth1992; 17: 52–53.

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53. Loo C C, Dahlgren G, Irestedt L. Neurological complicationsin obstetric regional anaesthesia. Int J Obstet Anesth 2000; 9:99–124.

54. Ravindran R S, Viegas O J, Tasch M D, Cline P J, Deaton R L,Brown T R. Bearing down at the time of delivery and the incidenceof spinal headache in parturients. Anesth Analg 1981; 60:524–526.

55. Sharshar T, Lamy C, Mas J L. Incidence and causes of strokesassociated with pregnancy and puerperium. Stroke 1995; 26:930–936.

56. Witlin A G, Mattar F, Sibai B M. Postpartum stroke: Atwenty-year experience. Am J Obstet Gynecol 2000; 183:83–88.

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ANIS bARAkA492

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