Acute intracranial subdural hematoma after accidental dural puncture in epidural anesthesia

A case is reported of an acute intracranial subdural haematoma following an accidental dural puncture during an epidural anaesthesia. A seventy-year old man, class ASA I, was operated on for prostatic adenoma under epidural anaesthesia. Dural puncture occurred during the first introduction of the needle into the L4-L5 epidural space. Epidural anaesthesia was nevertheless obtained by introducing the catheter at the L3-L4 level. The immediate peroperative and postoperative course was uneventful, apart from persisting headache. After removing the epidural catheter at 24 h postoperatively, the patient received calcium heparinate. 26 h later, he complained of worsening headache and became rapidly deeply comatose. The computer tomographic scan showed air in the ventricles and a large right-sided subdural haematoma which was immediately discharged. Although the link between subdural haematoma and dural puncture is well known, the acuteness and rapidly fatal evolution of this case were exceptional and may have been facilitated by the big size of the needle, dehydration and hypercoagulability.     

Intracranial subdural hematoma following dural puncture in a parturient with HELLP syndrome

PURPOSE: To present a case of postpartum bilateral intracranial subdural hematoma after dural puncture during attempted epidural analgesia for labour. CLINICAL FEATURES: This complication occurred following accidental dural puncture in a parturient with thrombocytopenia (99,000 x microL-1) who subsequently developed the syndrome of hemolysis, elevated liver enzymes and low platelets. On the first postoperative day, postdural puncture headache (PDPH) developed. An epidural blood patch (EBP) was deferred to the third postoperative day because of a platelet count of 21,000 x micro L-1. However, the headache intensified from a typical PDPH to one which was not posturally related. A second EBP was abandoned after the injection of 5 mL of blood because of increasing headache during the procedure. Magnetic resonance imaging revealed bilateral temporal subdural hematomas. The patient was managed conservatively and discharged home without any sequelae. CONCLUSION: It is conceivable that thrombocytopenia together with possible abnormal platelet function increased the risk of subdural hematoma. Alternative diagnoses to PDPH should be considered whenever headache is not posturally related.     

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.     

Epidural blood patch for postdural puncture headache in a five-year-old child

A case was presented of a 5-year-old girl who suffered an accidental dural puncture during placement of an epidural catheter under general anesthesia for orthopedic surgery. She complained of headache 4 days after the operation, which was relieved on supine position but became worse on sitting position. Her symptoms failed to respond to conservative management. An epidural blood patch was performed under general anesthesia and completely resolved her symptoms. The reported incidence of epidural blood patch for post dural puncture headache following accidental dural puncture in children is low. We outline this case and the consideration for management for epidural blood patch in pediatric patients.     

Epidural blood patch with allogeneic blood for post-dural puncture headache

A parturient suffered post dural puncture headache following accidental dural puncture during attempted epidural anesthesia for cesarean section. Post partum fever was regarded as a contraindication to autologous epidural blood patch; compatible and infection-free allogeneic blood was therefore used with good effect and without apparent complications.     

An audit of accidental dural puncture during epidural insertion of a Tuohy needle in obstetric patients

We report a prospective audit of 100 parturients who experienced accidental dural puncture by a Tuohy needle, while attending a tertiary referral obstetric unit during the period 1993-1999. The post dural puncture headache rate was 81% and the diagnosis of dural puncture was delayed until presentation of the headache in 27% of these cases. The incidence of unrecognised dural puncture was not influenced by the technique used for identification of the epidural space. Intraspinal opioid administration after dural puncture was associated with a significant reduction in the incidence of headache (P < 0.04). There was no association between mode of delivery and post dural puncture headache. Deliberate cannulation of the subarachnoid space with an epidural catheter at the time of dural puncture, for continuous spinal analgesia or anaesthesia, did not affect the incidence of post dural puncture headache but was associated with a significantly reduced rate of epidural blood patch (43% versus 80%, P < 0.01). Of those who developed post dural puncture headache, 48% were classified 'severe' and in 49% the headache presented within 24 h of dural puncture. There was a trend to earlier onset of headache (either immediate or within 24 h) when the epidural identification technique was loss-of-resistance to air rather than saline (54% versus 33%, P = 0.07). Twenty-eight percent of those suffering from post dural puncture headache were treated expectantly and 72% received a therapeutic blood patch. Of seven parturients who received sumatriptan, six found it ineffective and five subsequently received a blood patch.     

Which and what headache were we treating? Epidural blood patch for atypical headache following obstetric epidural anaesthesia

We present a case of headache following epidural anaesthesia for caesarean section. The patient did not exhibit the classical features of post dural puncture headache and the cause was uncertain. The headache was complicated by post partum seizure and a history of pregnancy-induced hypertension. A diagnostic lumbar puncture had to be done to exclude meningitis as she had a raised white blood count. An epidural blood patch performed 12 days post partum resolved the headache immediately.     

Dural puncture: the patients' perspective A patient survey of cases at a DGH maternity unit 1983–1993

Background: This study was designed to investigate the patient experience following accidental dural puncture complicating obstetric epidural analgesia.
Methods: Sixty-three patients who had suffered from accidental dural puncture during obstetric epidural analgesia over a ten-year period were sent a questionnaire enquiring about their experiences. 68% responded.
Results: Headache was the most severe symptom, occurring in 86% of this group; it lasted for a median of eight days and recurred after discharge in 47%. Backache occurred in 70% and 58% suffered with backache following discharge.
Headache was considered to be the worst aspect by 49% of responders, backache by 19% and bedrest by 33%. Bed rest was frequently voluntary (as opposed to being enforced on medical orders) since many patients only gained relief from their headache when supine.
Twenty patients (47%) received a blood patch, which was effective in relieving headache in 14 patients; however, the headache recurred after discharge in 10 of these 14 patients. Only 8 patients (19%) stated that they were aware of the risk of dural puncture prior to their epidural, three of whom were members of paramedical professions.
Conclusions: Headache and backache are both common following dural puncture with a 16G needle and both frequently recur after discharge from hospital. It was the strongly expressed opinion of this selected group that all mothers should be warned of the risk of dural puncture before undergoing epidural analgesia.     

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.     

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.     

Long-term morbidity following dural puncture in an obstetric population

Immediate and long-term symptoms, particularly headache, are recognised complications of dural puncture. To investigate long-term symptoms, a case-controlled retrospective questionnaire study was performed. The questionnaire was sent to 194 mothers who had suffered either accidental dural puncture during the placement of an epidural catheter or had developed a significant headache following spinal anaesthesia. The mothers were questioned about the nature and severity of symptoms and the impact upon their normal daily lives. They were also asked about the type and efficacy of any treatment they had received for these symptoms. An equal number of controls matched for ethnicity, age, modes of delivery and needle type were also questioned. There was increased reporting of new long-term headache and neckache in the spinal study group and an increased reporting of new long-term backache in the accidental dural puncture group compared to the epidural controls. These symptoms had a significant impact upon the mother's daily life and in some instances lasted for years. Disappointingly, although epidural blood patching was beneficial in the short term, it failed to produce any reduction in the incidence of long-term symptoms.     

Accidental dural puncture and post dural puncture headache in obstetric anaesthesia: presentation and management: a 23-year survey in a district general hospital

Post dural puncture headache can be a debilitating complication of epidural and subarachnoid anaesthesia for a new mother. In a survey of 18 337 epidurals and 5021 subarachnoid blocks performed for obstetric procedures over a 23-year period in a district general hospital maternity unit, there were 167 recognised accidental dural punctures after epidurals (0.91%), with 147 patients (88%) developing post dural puncture headache. In addition there were 52 post dural puncture headaches after subarachnoid blocks (1.04%). Successful management of accidental dural puncture and post dural puncture headache requires adherence to clear policies and protocols, with close follow-up of patients by an experienced obstetric anaesthetist.     

Subdurales Hämatom nach Duraperforation

Subdural hematoma may occur as rare, although intervention- specific complications of accidental dural puncture by neuroaxial block. Bleeding may be caused by rapid cerebrospinal fluid loss related to traction on fragile intracranial bridging veins. This article reports a case of postdural puncture headache in a 43-year-old woman after accidental dural puncture during attempted placement of an epidural catheter for induction of abortion. Bed rest, analgesics, theophylline and hydration were to no avail and only a blood patch improved the headaches. The patient presented 7 weeks later with headache and left-sided hemiplegia. Magnetic resonance imaging showed a right frontoparietal subdural intracranial hematoma which had to be surgically evacuated. The patient recovered completely. Intracranial hematoma is a rare but serious complication of central neuroaxial block. According to current German jurisdiction this risk must be addressed when informed consent is obtained. Intracranial hematoma should be considered in the differential diagnosis of atypical headache and neurological signs (e.g. focal motor and sensory deficits and seizures) following neuroaxial block and adequate image diagnostics should be carried out without delay.     

Epidural blood patch, never too late

Long lasting postural puncture headache secondary to an unintentional dural puncture (UDP) during epidural anaesthesia (EA) or following deliberate dural puncture for spinal anaesthesia, and neurological or neuroradiological examination, is becoming unusual. Placing the bevel of Tuohy needle parallel to the longitudinal axis of the dural cylinder when searching for epidural space, and in the later cases, widespread use of small diameter, atraumatic needles, have decreased both its incidence and severity. Furthermore, in the absence of any contraindication, patients suffering from such troubles are now quite systematically offered a curative epidural blood patch (EBP) whose effectiveness is documented. Authors report an original case of a fainthearted patient who underwent caesarean section under EA when she was 31-year-old, and whose disabling painful symptoms related to a UDP were successfully relieved by one EBP that she ended to accept more than seven years later. On the occasion of a short literature review, physiopathology and management are debated.     

Cranial subdural haematoma associated with dural puncture in labour

A 23-yr-old primagravida sustained a dural puncture during epidural catheter insertion and developed a headache that settled with oral diclofenac and codydramol. On the third day after delivery, she convulsed twice without warning. As plasma urate was increased, the putative diagnosis of an eclamptic fit was made, and magnesium therapy was started. A contrast CT scan revealed that the cause of the patient's symptoms was a subdural haematoma with raised intracranial pressure. A coincidental arteriovenous malformation was noted. This case emphasises the need to consider the differential diagnoses of post- partum headache. The management of acute intracranial haematoma is described.      

Cranial subdural hematoma with intracranial hypotension related to epidural anesthesia and Trendelenburg position: a case report

We report a case of cranial subdural hematoma with intracranial hypotension. A 34-year-old woman had laparoscopic ovarial cysterectomy under general anesthesia combined with epidural anesthesia. Two days later, she developed a severe headache and nausea. She underwent cranial magnetic resonance imaging (MRI) scanning, and was diagnosed with cranial subdural hematoma with intracranial hypotension. The patient had had no anticoagulant therapy before the surgery. She was managed conservatively with bed rest and additional intravenous infusion. Her symptoms gradually improved except a slight headache, and she was discharged on the 38th postoperative day. Intracranial hypotension is a syndrome characterized by orthostatic headaches and hypovolemia of cerebrospinal fluid (CSF). There were typical findings on MRI, which include linear enhancement of the pachymeninges, pituitary hyperemia and subdural hemorrhage. We thought that these were due to epidural anesthesia first, but there was no evidence of dural puncture. It was also considered that it is influenced by change in CSF pressure, and intracranial venous engorgement may be due to Trendelenburg position for several hours. Because cranial subdural hematoma is a life-threatening complication, it is necessary to reconsider application of epidural anesthesia for laparoscopic surgery with Trendelenburg position.     

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).     

Blood patches may cause scarring in the epidural space: two case reports

The use of epidural blood patches has become standard treatment for postdural puncture headache. Two cases suggest that there may occasionally be incomplete resorption of the blood patch, resulting in scarring in the epidural space that can be visualised using postpartum contrast injection and fluoroscopy. Both patients had a previous caesarean delivery during which they had suffered inadvertent dural punctures followed by epidural blood patches. When subsequently presenting for repeat caesarean delivery, both had inadequate epidural anaesthesia. Epidural insertion was then repeated, resulting in successful anaesthesia in one patient but a total subdural block with delayed apnoea and unconsciousness in the other. Distortion of epidural anatomy by fibrosis was considered to be a possible cause.     

Cranial subdural haematoma after spinal anaesthesia

Intracranial subdural haematoma is an exceptionally rare complicationof spinal anaesthesia. A 20-yr-old male underwent appendicectomyunder partial spinal and subsequent general anaesthesia. A weeklater, he presented with severe headache and vomiting not respondingto bed rest and analgesia. Magnetic resonance imaging showeda small acute subdural haematoma in the right temporo-occipitalregion. The patient improved without surgical decompression.The pathogenesis of headache and subdural haematoma formationafter dural puncture is discussed and the literature brieflyreviewed. Severe and prolonged post-dural puncture headacheshould be regarded as a warning sign of an intracranial complication. Br J Anaesth 2001; 86: 893–5     

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.