Postdural puncture headache and cerebral subdural hematoma are among complications of spinal anesthesia with some common characteristics; however misdiagnosis of these two could result in a catastrophic outcome or prevent unwanted results by urgent interventions. With the purpose of increasing awareness of such complications and a speedy diagnosis, we report two cases of postspinal anesthesia headache that was timely diagnosed as cerebral subdural hematoma and prevented the likelihood of a disastrous outcome

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Fariba Farhadifar

Karim Nesseri

Mehrdad Moradi

Shoaleh Shami

English

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Postdural puncture headache and cerebral subdural hematoma are among complications of spinal anesthesia with some common characteristics; however misdiagnosis of these two could result in a catastrophic outcome or prevent unwanted results by urgent interventions. With the purpose of increasing awareness of such complications and a speedy diagnosis, we report two cases of postspinal anesthesia headache that was timely diagnosed as cerebral subdural hematoma and prevented the likelihood of a disastrous outcome.</jats:p

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Hindawi Publishing CorporationCase Reports in MedicineVolume 2012, Article ID 352028, 4 pagesdoi:10.1155/2012/352028Case ReportCerebral Subdural Hematoma Following Spinal Anesthesia:Report of Two CasesMehrdad Moradi,1 Shoaleh Shami,2 Fariba Farhadifar,3 and Karim Nesseri41Department of Neurosurgery, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran2Faculty of Nursing and Midwifery, Kurdistan University of Medical Sciences, Sanandaj, Iran3Department of Gynecology and Obstetrics, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran4Department of Anesthesia, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, IranCorrespondence should be addressed to Karim Nesseri, nasseri k@muk.ac.irReceived 16 January 2012; Accepted 6 February 2012Academic Editor: Dianne L. AtkinsCopyright © 2012 Mehrdad Moradi et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.Postdural puncture headache and cerebral subdural hematoma are among complications of spinal anesthesia with some commoncharacteristics; however misdiagnosis of these two could result in a catastrophic outcome or prevent unwanted results by urgentinterventions. With the purpose of increasing awareness of such complications and a speedy diagnosis, we report two cases ofpostspinal anesthesia headache that was timely diagnosed as cerebral subdural hematoma and prevented the likelihood of adisastrous outcome.1. IntroductionSpinal anesthesia is an ordinary and daily practice of anesthe-siologists. Although the incidence of benign complicationsis relatively high, only 0.05% of complications are critical[1, 2]. Cerebral subdural hematoma (SDH) is among theserare, serious, and life-threatening complications, that maybe misdiagnosed with postdural puncture headache (PDPH)[3, 4]. Because of some common characteristics of typicalPDPH with cerebral subdural hematoma (SDH), awarenessof clinicians regarding its signs and symptoms could resultin the prevention of unwanted outcomes through urgentintervention. This leads us to present two patients of cerebralSDH following spinal anesthesia.Case 1. A 27-year-old woman, ASA I, with history of pre-vious cesarean section under spinal anesthesia 29 monthsago was admitted at 37 weeks gestational age of hersecond pregnancy with uterine contractions and underwentemergency cesarean section at night. Routine preoperativeexams including coagulation tests were within the normallimits and she had no signs of preeclampsia, history ofhead trauma, headache, or connective tissue disorders duringher pregnancy. Spinal anesthesia was performed in sittingposition with midline approach at L3-L4 space, using aWhitacre 25-gauge needle. The drugs used included 2mL of0.5% hyperbaric bupivacaine (10mg) and 5 µg of sufentaniland were administered successfully on the first attempt.She was hydrated with 1500mL of 0.9% normal salineintravenously prior to surgery and an additional 1500mLof 0.9% normal saline was administered during surgery.During anesthesia systolic blood pressure was decreased by30% and 2 bolus doses of ephedrine (total of 10mg) wereadministered. She showed signs of sinus bradycardia andnausea and was treated with 0.5mg atropine too.At the end of surgery, she complained of shivering andheadache and was treated with 35mg of meperidine whichwas eﬀective and the headache subsided. In the ward thepatient complained of headache once again and PDPHwas diagnosed and treated with intravenous morphine,hydration, and bed rest. She ambulated 24 hours later andwas discharged from hospital with partial relief of symptomsafter 48 hours. Thirteen days after the puncture, the patientremained with constant, nonpostural headache, and withoutneurological changes.2 Case Reports in Medicine(a) (b)Figure 1: (a) Brain computed tomography scan showed a late subacute SDH of the left frontotemporal region and midline shift. (b) Normalcontrol Computed tomography scan.Figure 2: Brain CT scan showed acute SDH of the left frontotem-poral region and midline shift.During this period, she was in supine position mostlyand went to her surgeon twice and was advised to continuetaking the oral analgesics, but the pain did not improve.After 13 days, nausea, vomiting, and right side hemiparesiswere added to her unbearable headaches. She was referredto a neurologist and brain computed tomography (CT) scanwas ordered which showed a late subacute cerebral SDH onthe left side (Figure 1). Subsequently, because of neurologicalsymptoms and a large size lesion, she underwent surgeryand the hematoma lesion was removed. Her symptomsresolved entirely and the patient did not develop any furthersymptoms. The followup of the patient continued for threemonths and control CT scan was normal.Case 2. A 49-year-old woman was referred to our hospitalfor severe, nonpostural headache as a result of undergoingumbilical herniorrhaphy under spinal anesthesia two daysbefore. Based onmedical records received, she had no historyof medical disease and head trauma before and after surgeryand had not taken any drugs before surgery. Preoperativehematologic laboratory values were normal. She had beenhydrated with 500mL of 0.9% normal saline before theprocedure, and dural puncture had been performed at theL3-L4 interspace in the sitting position, using a midlineapproach with Whitacre 25-gauge spinal needles, using15mg of 0.5% hyperbaric bupivacaine.Headaches started immediately after the patient wasdischarged from the postoperative care unit and diagnosed asPDPH. The patient had been treated with morphine sulfate,hydration, and bed rest. She was in supine position andrestricted to ambulation because of her headache. Twenty-four hours later, the patient had still not responded totreatment and left eye ptosis, right hemiparesis, nausea,and vomiting were also added to the symptoms. Patienthad undergone a CT scan (Figure 2) which detected acutesubdural hematoma, and the patient was referred to ourhospital for aggressive management. We decided to removethe hematoma. After surgery the symptoms disappeared, andno pathological traces remained.At followup that was continued for three months, thepatient did not have any more problems and all of theneurological sequels were reversed.2. DiscussionPDPH is the most common complication of lumbar punc-ture (LP) and manifested by signs and symptoms of excessiveCase Reports in Medicine 3cerebrospinal fluid (CSF) leakage in 70% of the cases. Itis thought to be caused by a downward displacement ofintracranial structures that causes cerebral hypotension andstretches the intracranial pain- sensitive structures [5]. About90% of typical PDPHmay occur within the first 72 hours and66% within the first 48 hours of LP and usually subsides in afew days with bed rest and analgesia [6].The primary mechanism for cranial SDH after spinalanesthesia is the same as PDPHwith someminor diﬀerences.Intracranial hypotension allows caudal shift of the brain,with traction on the arachnoid mater and dural veins. Thiscauses lesions to the blood vessels and could result in bloodextravasations and formation of subdural hematomas [7].Although the true incidence of cerebral SDH after LP isunknown because not all cases are reported and probablytreated without investigation [7], it is clear that the incidenceof cerebral SDH is negligible in comparison with PDPHapparently. Based on a case series with a total of 1.5 millionpatients, hemorrhagic complications following spinal anes-thesia occurred in 1 : 220,000 [8].The changing characteristic of PDPH (including symp-toms of nonpostural headaches along with focal neurologicalabnormalities), decreasing level of consciousness, ptosis,paresis, plegia, vomiting, headache lasting more than 5days, [9], and unresponsiveness of the headache to ordinarytreatments are warning signs and should arouse suspicionto search for a cerebral lesion [10, 11]. In case one, theheadache lasted 13 days and neurologic signs were not addedtill the diagnosis was complete, and in case two, the signsand symptoms were severe and persistent at first and did notrespond to routine treatments.Zeidan et al. [12] state that cerebral SDH, like PDPH,grows due to leakage of CSF from the hole created by spinalneedle, so the size of the needle and degree of dural tear havepositive relation to PDPH and cerebral SDH. In the case ofusing a large needle diameter and making more attempts atinserting the needle, loss of CSF may be over 200mL per day[4]. In both cases the 25-gauge needle was used (the smallestneedle in our province), and CSF flow was detected at firstattempt.Amorim et al. [13] and Zeidan et al. [12] reviewed 35 and25 cases of cerebral SDH following spinal anesthesia, respec-tively, and concluded that pregnancy, dehydration, multipledural punctures, large dural hole, use of anticoagulants,cerebral vascular abnormalities, and brain atrophy are therisk factors. Other possible risk factors that are apparentlyunrelated to spinal anesthesia but may coexist in patientsundergoing SDH included head trauma, coagulopathy, cere-bral aneurysm, arteriovenous malformation, tumors, cere-bral hypotension, chronic alcoholism, cardiovascular disease,and diabetes mellitus.Only one of these possible risk factors was present incase one (she was pregnant). Susceptibility of pregnantpatients to postdural puncture cerebral SDH might beattributed to the frequent use of epidural analgesia duringlabor, [14] which was absent in our cases. A review of theliterature demonstrated that 20 out of 22 cases [13, 15] ofcerebral SDH after inadvertent dural puncture during epidu-ral block were obstetric patients. Some authors believe thatdue to haemostatic imbalance, diﬀerences in elasticity ofthe dura and possibly gender-based diﬀerences in cranialmorphology cerebral SDH may take place more frequentlyin pregnant patients in comparison with other patients[16, 17]. Furthermore, there are two reports of cerebralsubdural hematomas in parturient women, despite a lack ofevidence of dural puncture [18, 19]. In case two, cerebralSDH occurred even in the absence of any risk factors.Zeidan and Baraka reported that cerebral SDH afterspinal anesthesia occurred more frequently on the left side[14]. In both of our cases, cerebral SDH occurred on theleft side too. We did not find any propensity for left sideformation of cerebral SDH on the left side in the existingliterature.The treatment of subdural hematoma may be surgicalor conservative [20, 21]. Conservative treatments are rec-ommended for small size hematomas, minimal to mildneurological manifestations, and nondeviation of cerebralstructures from midline. This approach requires a closeneurological and neuroradiological followup to recognize apotential worsening as early as possible [8]. Surgical de-compression is considered the treatment of choice formarked and progressive neurological deficits. Our two caseshad a thick hematoma, and surgical management wasdeemed appropriate, thus, both were treated surgically.3. ConclusionCerebral SDH as a serious complication of spinal anesthesiamust be kept in mind and may mimic PDPH. History ofLP, prolonged and nonpostural PDPH, and developmentof neurological symptoms should be regarded as a warningsign of an intracranial hematoma and prompt immediatediagnosis and treatment.AcknowledgmentThe authors are grateful to Mrs. Lamiah Hashemi for herhelp in editing the paper.References[1] Y. Auroy, P. Narchi, A. Messiah, L. Litt, B. Rouvier, and K.Samii, “Serious complications related to regional anesthesia:results of a prospective survey in France,” Anesthesiology, vol.87, no. 3, pp. 479–486, 1997.[2] U. Aromaa, M. Lahdensuu, and D. A. Cozanitis, “Severecomplications associated with epidural and spinal anaesthesiasin Finland 1987–1993. A study based on patient insuranceclaims,” Acta Anaesthesiologica Scandinavica, vol. 41, no. 4, pp.445–452, 1997.[3] R. Acharya, S. S. Chhabra, M. Ratra, and A. D. Sehgal, “Cranialsubdural haematoma after spinal anaesthesia,” British Journalof Anaesthesia, vol. 86, no. 6, pp. 893–895, 2001.[4] M. E. Macon, L. Armstrong, and E. M. Brown, “Subduralhematoma following spinal anesthesia,” Anesthesiology, vol.72, no. 2, pp. 380–381, 1990.[5] H. Gass, A. S. Goldstein, R. Ruskin, and N. A. Leopold,“Chronic postmyelogram headache. Isotopic demonstration4 Case Reports in Medicineof dural leak and surgical cure,” Archives of Neurology, vol. 25,no. 2, pp. 168–170, 1971.[6] E. C. Weir, “The sharp end of the dural puncture,” BritishMedical Journal, vol. 320, no. 127, p. 128, 2000.[7] M. A. Reina, A. Lo´pez, J. Benito-Leo´n et al., “Cerebral andspinal subdural hematoma: a rare complication of epiduraland subarachnoid anesthesia,” Revista Espan˜ola de Anestesi-olog´ıa y Reanimacio´n, vol. 51, pp. 28–39, 2004.[8] R. Rocchi, C. Lombardi, I. Marradi, M. di Paolo, and A.Cerase, “Intracranial and intraspinal hemorrhage followingspinal anesthesia,” Neurological Sciences, vol. 30, no. 5, pp.393–396, 2009.[9] O. Suess, R. Stendel, S. Baur, A. Schilling, and M. Brock,“Intracranial haemorrhage following lumbar myelography:case report and review of the literature,” Neuroradiology, vol.42, no. 3, pp. 211–214, 2000.[10] C. H. Nolte and T. N. Lehmann, “Postpartum headacheresulting from bilateral chronic subdural hematoma afterdural puncture,” American Journal of Emergency Medicine, vol.22, no. 3, pp. 241–242, 2004.[11] N. Ozdemir, M. K. Ari, M. F. Gelal, and H. Bezircioglu,“Intracranial chronic subdural haematoma as a complicationof epidural anesthesia,” Turkish Neurosurgery, vol. 19, no. 3,pp. 285–287, 2009.[12] A. Zeidan, O. Farhat, H. Maaliki, and A. Baraka, “Doespostdural puncture headache left untreated lead to subduralhematoma? Case report and review of the literature,” Interna-tional Journal of Obstetric Anesthesia, vol. 15, no. 1, pp. 50–58,2006.[13] J. A. Amorim, D. S. Remı´gio, O. Dama´zio Filho et al., “Cerebralsubdural hematoma post-spinal anesthesia: report of two casesand review of 33 cases in the literature,” Revista Brasileira deAnestesiologia, vol. 60, no. 6, pp. 620–629, 2010.[14] A. Zeidan and A. Baraka, “Is bilateral cerebral subduralhematoma more frequent after epidural anesthesia than spinalanesthesia?” Anesthesiology, vol. 105, no. 6, pp. 1277–1278,2006.[15] D. J. A. Vaughan, C. A. Stirrup, and P. N. Robinson, “Cranialsubdural haematoma associated with dural puncture inlabour,” British Journal of Anaesthesia, vol. 84, no. 4, pp. 518–520, 2000.[16] C. L. Wu, A. J. Rowlingson, S. R. Cohen et al., “Gender andpost-dural puncture headache,” Anesthesiology, vol. 105, no. 3,pp. 613–618, 2006.[17] J. A. Amorim and M. M. Valenc¸a, “Postdural puncture head-ache is a risk factor for new postdural puncture headache,”Cephalalgia, vol. 28, no. 1, pp. 5–8, 2008.[18] A. Albertin, C. Marchetti, D. Mamo, D. Poli, and E. Dedola,“Intracranial hypotension: a case of spontaneous arachnoidrupture in a parturient,” Anesthesiology, vol. 104, no. 3, pp.609–610, 2006.[19] G. A. Mashour, L. H. Schwamm, and L. Leﬀert, “Intracranialsubdural hematomas and cerebral herniation after laborepidural with no evidence of dural puncture,” Anesthesiology,vol. 104, no. 3, pp. 610–612, 2006.[20] E. A. Akpek, D. Karaaslan, E. Erol, H. Caner, and Z. Kayhan,“Chronic subdural haematoma following caesarean sectionunder spinal anaesthesia,” Anaesthesia and Intensive Care, vol.27, no. 2, pp. 206–208, 1999.[21] J. E. Cohen, J. Godes, and B. Morales, “Postpartum bilateralsubdural hematomas following spinal anesthesia: case report,”Surgical Neurology, vol. 47, no. 1, pp. 6–8, 1997.Submit your manuscripts athttp://www.hindawi.comStem CellsInternationalHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014MEDIATORSINFLAMMATIONofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Behavioural NeurologyEndocrinologyInternational Journal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Disease MarkersHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014BioMed Research InternationalOncologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Oxidative Medicine and Cellular LongevityHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014PPAR ResearchThe Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Journal ofObesityJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014 Computational and  Mathematical Methods in MedicineOphthalmologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Diabetes ResearchJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Research and TreatmentAIDSHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Gastroenterology Research and PracticeHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Parkinson’s DiseaseEvidence-Based Complementary and Alternative MedicineVolume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

Case Reports in Medicine

Cerebral Subdural Hematoma Following Spinal Anesthesia: Report of Two Cases

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Copyright © 2012 Mehrdad Moradi et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Postdural puncture headache and cerebral subdural hematoma are among complications of spinal anesthesia with some common characteristics; however misdiagnosis of these two could result in a catastrophic outcome or prevent unwanted results by urgent interventions. With the purpose of increasing awareness of such complications and a speedy diagnosis, we report two cases of postspinal anesthesia headache that was timely diagnosed as cerebral subdural hematoma and prevented the likelihood of a disastrous outcome. 1

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A m o r i ma n dM .M .V a l e n c ¸a, “Postdural puncture headache is a risk factor for new postdural puncture headache,”

Chronic postmyelogram headache. Isotopic demonstration4 Case Reports in Medicine of dural leak and surgical cure,”

Chronic subdural haematoma following caesarean section under spinal anaesthesia,” Anaesthesia and Intensive Care,

Cranial subdural haematoma associated with dural puncture in labour,”

Does postdural puncture headache left untreated lead to subdural hematoma? Case report and review of the literature,”

Gender and post-dural puncture headache,”

Intracranial and intraspinal hemorrhage following spinal anesthesia,”

Intracranial chronic subdural haematoma as a complication of epidural anesthesia,”

Intracranial haemorrhage following lumbar myelography: case report and review of the literature,”

Intracranial hypotension: a case of spontaneous arachnoid rupture in a parturient,”

Intracranial subdural hematomas and cerebral herniation after labor epidural with no evidence of dural puncture,”

Is bilateral cerebral subdural hematoma more frequent after epidural anesthesia than spinal anesthesia?”

Postpartum bilateral subdural hematomas following spinal anesthesia: case report,”

Postpartum headache resulting from bilateral chronic subdural hematoma after dural puncture,”

R e i n a ,A .L ´ opez,

R.Acharya,S.S.Chhabra,M.Ratra,andA.D.Sehgal,“Cranial subdural haematoma after spinal anaesthesia,”

S.R em´ ıgio,O.Dam´ azioFilhoetal.,“Cerebral subduralhematomapost-spinalanesthesia:reportoftwocases and review of 33 cases in the literature,”

Serious complications related to regional anesthesia: results of a prospective survey in

Severe complicationsassociatedwithepiduralandspinalanaesthesias in Finland 1987–1993. A study based on patient insurance claims,”

Subdural hematoma following spinal anesthesia,”

The sharp end of the dural puncture,”

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Cerebral Subdural Hematoma Following Spinal Anesthesia: Report of Two Cases

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