Acute Subdural Hematoma Post Spinal Anesthesia in a Parturient

Intracranial subdural hematoma is a rare complication in spinal anesthesia diagnosis may be difficult initially due to the similitary of symptoms to post dural puncture headaches but neglecting them can lead to serious complications [1].

Observation

We report the case of a 29-year-old patient with no medical history already operated for a cesarean section under spinal anesthesia without incident, l and classified ASA I, the spinal anesthesia was performed in a semi-seated position in a single attempt without incident. A day after postoperative headache on emergence, treated symptomatically peros, the discharge at home is done with a thromboprophylaxis of 8 days. At the 10th reappearance of the headaches, the patient sees her doctor again who prescribes aspirin 100mg which worsened the symptoms: headaches resistant to treatment and appearance of visual blurring in the right eye, seen by an ophthalmologist who’s the examination was normal; it completes the exploration by a cerebral CT scan revealing a 14mm right hemispherical subdural hematoma with falcorial involvement. The postoperative outcome was favorable with a control brain CT after removal of the drain showing the absence of a residual collection. A CT angio ruled out an arteriovenous malformation and a coagulation factor assay returned without abnormalities (Figures 1-3); [2-4].

Figure 1:The hematoma was drained by two trephine holes under sedation with placement of a drain.

Figure 2:

Figure 3:

Intracranial HSD is a rare complication after spinal anesthesia, its ignorance can lead to serious or even fatal sequelae. Its pathophysiology is explained by a persistence of the hard merian breach causing intracranial hypotension at the origin of a displacement of the neuraxis, depending on the gravity which exerts pressure on the bridging veins causing hemorrhage in the subdural space. These veins have a thinner wall in the subdural space than in the subarachnoid space.

The main causes:
a) excessive loss of CSF from multiple puncture attempts, the use of large gauge or sharp-edged needles
b) the existence of a background of dehydration or of a pre-existing neurological disease such as cerebral aneurysms or arteriovenous malformations
c) the use in the pre- or post-operative periods of anticoagulant drugs.
d) cortical atrophy or pregnancy.

The reported case illustrates that the first manifestations are identical to those of the post dural puncture headaches, namely the worsening in an orthostatic position and improving in strict decubitus which complicated the diagnosis initially, thereafter there was loss of postural character but dominated by ophthalmological signs [5].

The severe and progressive headache after spinal anesthesia should be considered as an alert for an intracranial complication: the subdural hematoma post spinal anesthesia is a rare complication but important to know by all practitioners given its severity. There is a definite interest in monitoring all patients with headaches after spinal anesthesia in order to facilitate early diagnosis, reduce morbidity and mortality and really know the incidence of this complication [6].

1. Kayacan N, Arici G, Kardhi B, Erman M (2004) Acute subdural haematoma after accidental dural puncture during epidural anaesthesia. Int J Obstet Anesth 13(1): 47-49.
2. Amorim JA, Remígio DSCA, Damázio FO, Marcos AGB (2010) Intracranial subdural hematoma post-spinal anesthesia: report of two cases and review of 33 cases in the literature. Rev Bras Anestesiol 60(6): 620-629.
3. Katricioglu K, Aydin O, Ozkalanli MY, Serdar S (2009) Cranial subdural haematoma: a rare complication of spinal anaesthesia. Eur J Anaesthesiol 26(9): 793-795.
4. Gaiser R (2006) Postdural puncture headache. Cur Opin Anesthesiol 19(3): 249-253.
5. Mokri B (2003) Headaches caused by decreased intracranial pressure: diagnosis and management. Curr Opin Neurol 16(3): 319-326.
6. Turnbull DK, Shepherd DB (2003) Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth 91(5): 718-729.