Cranial subdural hematoma after inadvertent dural puncture at epidural anesthesia

Intracranial subdural haematoma has been reported to be an exceptionally rare complication of accidental dural puncture. An accidental lumbar dural puncture occurred in a 36-yr-old male undergoing orthopedic knee surgery. On the morning after the operation, the patient complained of severe occipital headache, although this was relieved with loxoprofen and rest. This was assumed to be a postdural puncture headache (PDPH) because it had a postural component (it was worse on sitting up). On the third day after the operation, the patient developed a severe diffuse headache together with nausea, which did not subside with analgesia and bed rest. Magnetic resonance imaging of the head showed a small acute subdural hematoma in the bilateral temporooccipital region with no mass effect. The patient was conscious and oriented. There was no focal neurological deficit. The patient was managed conservatively with bed rest and intravenous fluids. His condition improved without surgical decompression and was discharged on the 40 th day after the operation. Severe and prolonged PDPH shoud be considered as a warning sign of an intracranial complication.     

The epidural blood patch. Resolving the controversies

PURPOSE: To review the literature regarding epidural blood patch (EBP) to generate conclusions relating to the controversial issues surrounding its application. SOURCE: A Medline search was made for relevant publications using keywords epidural blood patch, prophylactic epidural blood patch, dural puncture, and postdural puncture headache. Bibliographies of retrieved articles were hand-searched for relevant articles. Case series and comparative trials were emphasized in the analyses. These were culled and those deemed relevant were reviewed. PRINCIPAL FINDINGS: The majority of the literature consists of observational reports: there are few comparative studies. Headache most likely results from cerebrospinal fluid (CSF) loss leading to intracranial content shift and traction on pain sensitive structures; cerebrovascular alterations may be implicated. An EBP with 10-15 ml blood is indicated and effective therapy for severe headache after dural puncture. There is conflicting evidence regarding larger volume blood injections or delaying EBP for 24 hr or more after the diagnosis of postdural puncture headache (PDPH). Efficacy of EBP is related to a "patch effect" as well as transmission of increased epidural space pressure to the CSF space. Previous estimates of EBP efficacy were overgenerous; persistent symptomatic relief can be expected in 61-75% of patients with initial EBP. Patching with non-blood solutions, although initially effective, is associated with a high incidence of headache recurrence. Prophylactic injection of saline or blood decreases the incidence of severe headache after dural puncture. CONCLUSION: Blood-patching is an effective treatment of PDPH but further research is required regarding its mechanisms and prophylaxis.     

Fluoroscopically guided epidural blood patch in patients with postdural puncture headache after spinal and epidural anesthesia

Postdural puncture headache (PDPH) is one of the major complications after spinal and epidural anesthesia. An epidural blood patch (EBP) may be applied when PDPH persists regardless of conservative treatment. We describe the results of management including fluoroscopically guided EBP in a series of patients with moderate to severe PDPH. From January 2007 to December 2009, PDPH developed in 15 of 3,381 patients (0.44%) who received epidural or spinal anesthesia: 5 (0.21%) after general anesthesia combined with epidural anesthesia, 8 (0.81%) after spinal anesthesia, and 2 (3.14%) after combined spinal and epidural anesthesia. Of 15 patients, PDPH was relieved without the EBP in 9 patients and 6 patients required the EBP. EBP was performed under fluoroscopy in a prone position; a 4:1 mixture of autologous blood and contrast medium was injected to cover the site of dural puncture. The success rate of fluoroscopically guided EBP was 100% with a mean blood volume of 7.2 ml. No complications were associated with EBP except for a mild backache. Fluoroscopically guided EBP may be successfully and safely performed to treat persistent PDPH with a relatively small volume of blood for epidural injection.     

Intracranial subdural hematoma after obstetric dural puncture

The authors report a case of subdural haematoma (HSD), which occurred following epidural analgesia for labour, complicated by post dural puncture headache (PDPH). A 26-year-old woman displayed a typical PDPH following epidural anaesthesia. On the sixth day, she was given a blood patch (BP), which was partially efficacious. Because of worsening of the headache, of disappearance of the postural characteristics, and of vomiting without focal neurological signs on the 9th day, a CT-scan was done. The CT-scan showed a small hemispheric subdural haematoma. The recovery was complete with only medical treatment. HSD is a rare serious complication of dural puncture. When the characteristics of PDPH change, HSD should be evoked even without focal neurological signs. An early diagnosis and the small size of the haematoma may allow HSD to be treated medically and avoid surgical evacuation.     

Seizures after epidural blood patch with undiagnosed subdural hematoma

OBJECTIVE: We present a case of new-onset seizures in a parturient who received an epidural blood patch (EBP) in the presence of an undiagnosed cerebral subdural hematoma. We review the relevant literature and examine the implications for management. CASE REPORT: A 33-year-old parturient developed symptoms of postdural puncture headache 16 hours after initiation of epidural analgesia for labor. On the third postpartum day, she likely had an unwitnessed and unrecognized seizure. Presenting to hospital with headache and fatigue, she received an EBP. Forty-five minutes after the EBP, she had a generalized seizure followed by another 2 hours later. Imaging revealed a small cranial subdural hematoma. She had no further seizures, her headache improved, and she was discharged home on postpartum day 5. CONCLUSIONS: We believe that the subdural hematoma and not the EBP was the cause of the seizures. Earlier recognition of confusion and fatigue as a postictal state may have led to earlier diagnosis of the hematoma. Our experience suggests that EBP be avoided in the setting of subdural hematoma.     

Subdural hematoma after atraumatic spinal

We report a case of subdural hematoma in a 68-year-old white man who underwent left inguinal hernia repair with spinal anesthesia. The patient had a postdural puncture headache (PDPH) on postoperative day 4, but he refused invasive treatment. Instead, he self-administered acetaminophen, aspirin, and caffeine. On postoperative day 11, he was diagnosed with a subdural hematoma. At 49 days postoperatively, a computed axial tomographic scan was taken, the results of which were normal, after no surgical intervention. This patient had none of the risk factors as reported in the literature for this rare complication. Although a headache postoperatively, after spinal anesthesia, is often assumed to be PDPH, clinicians should not rule out the possibility of subdural hematoma, especially if the headache is persistent. We advise that the smallest-bore spinal needles be used when administering spinal anesthesia and that patients be carefully evaluated before their surgery for use of anticoagulants, herbal medications, or history of cerebrovascular disease. Immediate treatment of the PDPH with an epidural blood patch should be considered. If a patient refuses invasive treatment, he should be counseled for the possibility of subdural hematoma. The patient also should be advised to avoid medications with anticoagulant properties.     

Efficacy of a prophylactic epidural blood patch in preventing post dural puncture headache in parturients after inadvertent dural puncture

BACKGROUND: Postdural puncture headache (PDPH) occurs in up to 80% of parturients who experience inadvertent dural puncture during epidural catheter placement. The authors performed a randomized double blind study to assess the effect of prophylactic epidural blood patch on the incidence of PDPH and the need for therapeutic epidural blood patch. METHODS: Sixty-four parturients who incurred inadvertent dural puncture were randomized to receive a prophylactic epidural blood patch with 20 ml autologous blood (prophylactic epidural blood patch group) or a sham patch (sham group). Subjects were evaluated daily for development of PDPH for a minimum of 5 days after dural puncture. Those who developed a PDPH were followed daily for a minimum of 3 days after resolution of the headache. Subjects with moderate headaches who reported difficulties performing childcare activities and all those with severe headaches were advised to receive a therapeutic epidural blood patch. RESULTS: Eighteen of 32 subjects in each group (56%) developed PDPH. Therapeutic blood patch was recommended in similar numbers of patients in each group. The groups had similar onset time of PDPH, median peak pain scores, and number of days spent unable to perform childcare activities as a result of postural headache. The median duration of PDPH, however, was shorter in the prophylactic epidural blood patch group. CONCLUSIONS: A decrease in the incidence of PDPH or the need for criteria-directed therapeutic epidural patch was not detected when a prophylactic epidural blood patch was administered to parturients after inadvertent dural puncture. However, prophylactic epidural blood patch did shorten the duration of PDPH symptoms.     

Accidental dural puncture,postdural puncture headache,intrathecal catheters,and epidural blood patch: revisiting the old nemesis

One of the controversial management options for accidental dural puncture in pregnant patients is the conversion of labor epidural analgesia to continuous spinal analgesia by threading the epidural catheter intrathecally. No clear consensus exists on how to best prevent severe headache from occurring after accidental dural puncture. To investigate whether the intrathecal placement of an epidural catheter following accidental dural puncture impacts the incidence of postdural puncture headache (PDPH) and the subsequent need for an epidural blood patch in parturients. A retrospective chart review of accidental dural puncture was performed at Hutzel Women’s Hospital in Detroit, MI, USA for the years 2002–2010. Documented cases of accidental dural punctures (N = 238) were distributed into two groups based on their management: an intrathecal catheter (ITC) group in which the epidural catheter was inserted intrathecally and a non-intrathecal catheter (non-ITC) group that received the epidural catheter inserted at different levels of lumbar interspaces. The incidence of PDPH as well as the necessity for epidural blood patch was analyzed using two-tailed Fisher’s exact test. In the non-ITC group, 99 (54 %) parturients developed PDPH in comparison to 20 (37 %) in the ITC [odds ratio (OR), 1.98; 95 % confidence interval (CI), 1.06–3.69; P = 0.03]. Fifty-seven (31 %) of 182 patients in the non-ITC group required an epidural blood patch (EBP) (data for 2 patients of 184 were missing). In contrast, 7 (13 %) of parturients in the ITC group required an EBP. The incidence of EBP was calculated in parturients who actually developed headache to be 57 of 99 (57 %) in the non-ITC group versus 7 of 20 (35 %) in the ITC group (OR, 2.52; 95 % CI, 0.92–6.68; P = 0.07). The insertion of an intrathecal catheter following accidental dural puncture decreases the incidence of PDPH but not the need for epidural blood patch in parturients.     

Epidural blood patch for management of postdural puncture headache in adolescents

BACKGROUND: In some patients spinal puncture (SP) is followed by postdural puncture headache (PDPH). When the symptoms of PDPH are severe and are not relieved within a few days an epidural blood patch (EBP) might be performed. The aim of this survey was to review requests for EBPs and to evaluate the effectiveness of EBP in patients aged 13-18 years during a 6.5 year period ending in June 2001. METHODS: The Information System Patient Measures Database was interrogated to identify patients who were referred for EBP. After identification, the patients' medical records were reviewed in detail for the characteristics of PDPH and other symptoms, and for the effectiveness of the EBP. RESULTS: Forty-two EBPs were performed after 40 SPs on 37 patients (24 girls, 13 boys). Epidural blood patches were performed twice in five patients. The reasons for repeating the procedure were repeat SP with new PDPH in three patients and an unsatisfactory effect in two patients. Twenty-eight of the 40 spinal punctures (70%) had been performed for diagnostic use and 10 (25%) for spinal anesthesia. Two patients (5%) developed PDPH after inadvertent dural puncture with an epidural needle. In 37 cases the criteria for PDPH were fulfilled, and one patient had a cerebrospinal fluid fistula headache. Two-thirds of the girls had associated symptoms of headache compared with one-third of the boys. Epidural blood patch was performed 1-22 days after SP with 0.2 ml/kg (mean) of autologous blood injected into the epidural space. The success rate of the first injection was 37 out of 40 EBP (93%), and the second injection was effective in both patients with recurred PDPH. CONCLUSION: Epidural blood patch seems to be an effective and safe procedure in adolescents for treating severe and persistent PDPH.     

Second stage pushing correlates with headache after unintentional dural puncture in parturients

PURPOSE: To determine the association between bearing down, postdural puncture headache (PDPH) and epidural blood patch (EBP) following single 17 gauge unintentional dural puncture (UDP) in parturients. METHODS: The charts of 60 parturients identified with UDP in our institutional database during epidural placement were independently reviewed. Patients were divided into categories based on the anesthetic record: well-documented single punctures; well-documented multiple punctures; catheter-related puncture; unclear category (not clear if more than one puncture occurred or if dural puncture had occurred at all) and no evidence of dural puncture. Patients with single 17 gauge punctures were divided into those who had pushed (Group 1) and those who had not (Group 2). Group 2 patients had undergone Cesarean section before reaching second stage labour. The incidence of PDPH, EBP, and cumulative duration to delivery after UDP were compared between groups. RESULTS: Thirty-three patients with well-documented single punctures were identified: 23 had engaged in active pushing as part of second stage labour (Group 1); 10 had not (Group 2). Seventy-four percent of Group1I developed PDPH compared with 10% in Group 2 (P < 0.002). Fifty-seven percent of Group 1 received an EBP compared with 0% in Group 2 (P < 0.002). Increasing the duration of pushing was associated with an increasing incidence of PDPH; the majority of women who pushed > 30 min developed headache. CONCLUSIONS: An increased incidence of PDPH and EBP after UDP occurs in women bearing down in 2nd stage labour when compared with those who never pushed. There was also an association between the cumulative duration of bearing down and the incidence of PDPH.     

Efficacy of a Prophylactic Epidural Blood Patch in Preventing Post Dural Puncture Headache in Parturients after Inadvertent Dural Puncture

Background: Postdural puncture headache (PDPH) occurs in up to 80% of parturients who experience inadvertent dural puncture during epidural catheter placement. The authors performed a randomized double blind study to assess the effect of prophylactic epidural blood patch on the incidence of PDPH and the need for therapeutic epidural blood patch.

Methods: Sixty-four parturients who incurred inadvertent dural puncture were randomized to receive a prophylactic epidural blood patch with 20 ml autologous blood (prophylactic epidural blood patch group) or a sham patch (sham group). Subjects were evaluated daily for development of PDPH for a minimum of 5 days after dural puncture. Those who developed a PDPH were followed daily for a minimum of 3 days after resolution of the headache. Subjects with moderate headaches who reported difficulties performing childcare activities and all those with severe headaches were advised to receive a therapeutic epidural blood patch.

Results: Eighteen of 32 subjects in each group (56%) developed PDPH. Therapeutic blood patch was recommended in similar numbers of patients in each group. The groups had similar onset time of PDPH, median peak pain scores, and number of days spent unable to perform childcare activities as a result of postural headache. The median duration of PDPH, however, was shorter in the prophylactic epidural blood patch group.     

Post-dural puncture headache in the parturient

Post-dural puncture headache (PDPH) is one of the most common and debilitating complications of neuraxial blockade in the parturient. The obstetric population is at particular risk with up to 80% of women developing symptoms after inadvertent dural puncture during epidural insertion. PDPH typically develops 24–48 hours post-puncture and is classically described as an occipito-frontal headache with postural features. Diagnosis and assessment should include consideration of other potential causes of post-partum headache. At the time of inadvertent dural puncture (IDP) one may insert an intrathecal catheter, re-site the epidural or use alternative analgesia. Initial treatment of a PDPH includes bed rest, adequate hydration and simple analgesics. Epidural blood patch (EBP) remains the gold standard treatment of PDPH.     

Post-dural puncture headache in the parturient

Post-dural puncture headache (PDPH) is a common and debilitating complication of central neuraxial blockade in the parturient. The obstetric population is at particular risk with up to 80% of women developing symptoms after accidental dural puncture (ADP) during labour epidural insertion. PDPH typically develops 24–48 hours post puncture and is classically described as an occipito-frontal headache with postural features. Diagnosis and assessment should include consideration of other potential causes of post-partum headache. Initial treatment of PDPH includes adequate hydration and analgesics. Epidural blood patch (EBP) remains the gold standard treatment. It is more successful if performed over 24–48 hours after the development of symptoms. Complete and permanent relief of symptoms following a single EBP occurs in up to one third of cases where headache follows ADP with an epidural needle. Complete or partial relief may be seen in 50–80% overall. Higher success rates are achieved following a second EBP. There is now UK national guidance on the treatment of post dural puncture headache published by the Obstetric Anaesthetists Association (OAA).     

Management of postdural puncture headache with epidural blood patch in children

BACKGROUND: Until the last decade, it was believed that postdural puncture headache (PDPH) was an uncommon complaint in children, but recent studies indicate that young children may develop PDPH after spinal puncture. When the symptoms are severe and are not relieved within a few days with analgesics, forced hydration and bed rest, then epidural blood patch (EBP) might be performed. METHODS: In this retrospective survey, we analysed EBP performed in Kuopio University Hospital between the years 1995 and 2000. RESULTS: During the 6-year period, seven EBP were performed in children aged 12 years or younger. Four out of the seven children had undergone a diagnostic spinal puncture, two had spinal anaesthesia and one child had spinal puncture for treatment of postoperative hygroma. Five children had a typical PDPH, one child had a cerebrospinal fluid fistula headache and one child had a headache similar to his migraine. EBP was performed 2-19 days after spinal puncture with 0.3 ml.kg-1 (mean) of autologous blood injected into the epidural space. CONCLUSIONS: EBP gave some relief of symptoms in all children. No complications related to EBP were noticed.     

The injection of intrathecal normal saline reduces the severity of postdural puncture headache

BACKGROUND AND OBJECTIVES: We investigated whether the injection of 10 mL of normal saline into the subarachnoid space following accidental dural puncture reduced the incidence of postdural puncture headache (PDPH) and the need for epidural blood patch (EBP). METHODS: Twenty-eight patients who experienced accidental dural puncture with an epidural needle had 10 mL of normal saline injected into the subarachnoid space. In 22 patients, the injection was performed immediately through the epidural needle. In 6 patients who had intrathecal catheters placed through the epidural needle, the saline was injected through the catheter before removal. All other patients who experienced wet taps during the same period that the study was in progress but did not receive the saline injection served as a control group, 26 in number. Patients with severe or persistent PDPHs were treated with EBP. RESULTS: Of those patients who received intrathecal normal saline immediately through the epidural needle, 32% developed a headache compared with 62% of controls. Of these, 1 patient who received saline required EBP compared with nine in the control group (P =.004). Of those patients who had intrathecal catheters placed, there were no headaches in the saline group of 6 compared with 3 in the control group of 5, 1 of whom was treated with EBP (P >.05). CONCLUSIONS: The immediate injection of 10 mL intrathecal normal saline after a wet tap significantly reduced the incidence of PDPH and the need for EBP. When an intrathecal catheter had been placed following a wet tap, injection of 10 mL of normal saline before its removal effectively prevented PDPH.     

Hématome sous durai bilatéral après analgesie péridurale

Purpose

The authors report a case of bilateral subdural hematoma (SDH) which occurred following epidural analgesia for labour, complicated by post durai puncture headache (PDPH). Physiopathological mechanisms are discussed.

Clinical features

A 27-yr-old woman displayed typical PDPH following epidural anaesthesia. On the fifth day she was given a blood patch (BP) which proved immediately effective. Further developments were marked by late recurrence of PDPH and by administration of a second BP on the 24th day. With the aggravation of the headaches, the disapearance of their postural nature and with the appearance of transitory focal neurological signs on the 30th day, a CT-Scan was done and showed bilateral subdural haematoma. Following surgical drainage, the patient made an uneventful recovery.

Conclusion

The presence of PDPH complicated by a typical neurological deterioration should prompt the anaesthetist to seek an immediate clinical and x-ray diagnosis in order to look for the existence of intracranial complications.     

Inadvertent dural puncture during attempted thoracic epidural catheter placement complicated by cerebral and spinal subdural hematoma

Minor complications of inadvertent dural puncture during attempted epidural anesthesia are common, related to the size of the needle and the incidence of postdural puncture headache. Serious complications are much less common. We report a case where inadvertent dural puncture with an 18-gauge epidural needle was associated with the creation of intracranial and spinal subdural hematoma.     

Utility of ultrasound imaging for epidural blood patch in postdural puncture headache patients after caesarean section

Although epidural blood patch (EBP) is an effective treatment for postdural puncture headache (PDPH), the adequate blood volume has not been determined. We reported two cases of EBP for PDPH after caesarean section with spinal anesthesia using ultrasound imaging with a 2-5 MHz convex probe. In case 1, the dura mater was expanded and subarachnoid space was compressed by 8 ml of autologous blood with paresthesia at bilateral L5 area during EBP and blood infusion was finished at 10 ml. In case 2, although the area of the epidural space was unchanged by 17 ml of EBP, contrast of the epidural space was altered in as a mosaic pattern. We conclude that ultrasound imaging is useful to confirm the adequate blood infusion during EBP Therefore, there is a possibility of estimating the optimal blood volume by ultrasound imaging.     

Conventional treatment or epidural blood patch for the treatment of different etiologies of post dural puncture headache

Post dural puncture headache (PDPH) represents a complication of anesthesia (with an increased incidence in obstetric patients) or as the consequence of a diagnostic lumbar puncture. The aim of the present study was to evaluate the efficacy of the epidural blood-patch (EBP) versus the conventional medical treatment of post-anesthetic headaches also including the PDPH following a diagnostic puncture, a category of patients rarely referred to the anesthesia consultation in our hospital because it was believed that they might have equal benefit from conventional measures due to the smaller size of needles used. We studied in a prospective, randomized, double-blinded manner 32 obstetric and non-obstetric patients with PDPH having the onset of the symptoms 24 hours before the inclusion in the study. The patients were randomly divided in two groups: group A (16 patients) receiving conventional treatment (oral and intravenous fluid replacement, non-steroidal anti-inflammatory drugs--NSAIDs--, caffeine) and group B (16 patients) in whom an epidural blood-patch was performed. The intensity of the headache was evaluated using a visual analogue scale (VAS) from 0-10, before, 2 hours and 24 hours after the EBP. There were no statistical differences concerning the demographic data and the cause of PDPH between the groups (p > 0.05). The intensity of PDPH was similar before performing the EBP (p > 0.05), with a value on VAS of 8.2 +/- 1,4. in group A and 8,0 +/- 1.6 in group B. Two hours after the treatment, the intensity of headache on VAS diminished extremely significant (p < 0.0001): in group B the value was 1.0 +/- 0,18 versus 8.2 +/- 1.4 in group A. The difference recorded after 24 hours remained statistically significant (p < 0.0001): the VAS scores were 0.7 +/- 0,16 and 7.8 +/- 1.2 respectively. The epidural blood patch represents the first choice treatment of PDPH no matter the etiology, being significantly superior to the conventional treatment which did not affect pain scores. In severe PDPH there is no reason to delay the EBP more than 24 hours after the diagnosis as all except two patients of the conventional treatment group required blood patching following the study period.