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On-line version ISSN 1806-907X
Rev. Bras. Anestesiol. vol.58 no.4 Campinas July/Aug. 2008
Subdural hematoma after inadvertent dura mater puncture. Case report*
Hematoma subdural después de la punción inadvertida de la duramadre. Relato de caso
Wallace Lage Duarte, TSAI; Fabiano de Souza Araújo, TSAI; Marcelo Figueiredo AlmeidaII; Débora Grimberg GeberI; Carlos Henrique Viana de Castro, TSAIII
do Hospital Lifecenter
IICirurgião Plástico do Hospital Lifecenter
IIIAnestesiologista do Hospital Lifecenter; Diretor Técnico do Hospital Lifecenter
OBJECTIVES: Post-dural puncture headache is a well-known complication of
epidural and subarachnoid blockades and the blood patch is the treatment used
more often. In most patients, the blood patch relieves the headache completely,
but for the remaining there is no improvement or only partial relief of the
symptom. In those cases, it is prudent to look for other differential diagnosis,
such as subdural hematoma or pneumoencephalus. In those situations, imaging
exams are extremely useful. The objective of this report was to present the
case of a patient who developed subdural hematoma after accidental puncture
of the dura mater during epidural block.
CASE REPORT: A 47-year old male patient, 147 kg, 1.90 m, physical status ASA II, was admitted for abdominal dermolipectomy after undergoing gastroplasty. The dura mater was accidentally punctured during the epidural block. The patient developed post-dural puncture headache treated with an epidural blood patch, with partial improvement of his symptoms. However, it was followed by worsening of the headache and an MRI showed the presence of an intracranial subdural hematoma, which was treated clinically. The patient evolved with progressive improvement of the symptom and full recovery after 30 days.
CONCLUSIONS: Subdural hematoma is a rare, but severe, complication of dura mater puncture. It is difficult to diagnose, but it should always be remembered when post-dural puncture headache shows no resolution or even worsens after an epidural blood patch. An imaging exam is fundamental for the diagnosis of this rare complication.
Key Words: ANESTHETIC TECHNIQUE, Regional: Epidural; COMPLICATIONS: subdural hematoma.
Y OBJETIVOS: La cefalea pos punción de la duramadre es una complicación
bastante conocida de las anestesias subaracnoidea y epidural, siendo que el
tratamiento más difundido es el tapón sanguíneo. El tapón
sanguíneo alivia totalmente la cefalea en la gran mayoría de los
pacientes, y en los demás no hay mejorías o apenas se ve una mejoría
parcial. En esos casos, es prudente buscar diagnósticos diferenciales,
como el hematoma subdural o neumoencéfalo. Los métodos de imagen
son extremadamente útiles en esas situaciones. El objetivo de este relato
fue el de presentar el caso de un paciente que debutó con hematoma subdural
intracraneal después de la punción inadvertida de la duramadre
en anestesia epidural.
RELATO DEL CASO: Paciente del sexo masculino, 47 años, 147 kg, 1,90 m, estado físico ASA II, fue admitido para la realización de dermolipectomía abdominal, después de haberse sometido a la gastroplastía reductora. Durante la anestesia epidural, hubo perforación accidental de la duramadre. El paciente evolucionó con síntomas de cefalea pospunción de la duramadre que fueron tratados con tapón sanguíneo, obteniéndose una mejora parcial. Hubo posteriormente, un empeoramiento de la cefalea y la resonancia nuclear magnética de encéfalo mostró un hematoma subdural intracraneal, que se trató clínicamente. Hubo una mejoría progresiva, con recuperación total después de 30 días.
CONCLUSIONES: La aparición de hematoma subdural es una complicación rara, pero grave de la perforación de la duramadre. El diagnóstico es difícil y debe ser siempre pensado, cuando la cefalea pospunción de la duramadre no se resuelva con el tapón sanguíneo o tampoco se resuelva su empeoramiento. En la aclaración del diagnóstico es fundamental la ayuda de un método de imagen.
Intracranial hematoma is a serious but rare complication of puncture of the dura mater. There are reports of this complication after spinal block, inadvertent puncture of the dura mater during epidural block, diskography, myelogram, and diagnostic lumbar tap. The diagnosis is hindered by the similarities with the symptoms of post-dural puncture headache (PDPH). The objective of this report was to show the development of an intracranial subdural hematoma after inadvertent puncture of the dura mater during an epidural block.
A 47-year old male patient, weighing 147 kg, height 1.90 m, physical status ASA II, was admitted for abdominal dermolipectomy in the late postoperative period of reduction gastroplasty. He denied any history of trauma, headaches, or blood clotting abnormalities. Preoperative exams were normal, including platelet count, PTT, and INR. An anti-coagulant was not administered.
Monitoring included continuous electrocardiogram, pulse oximetry, and non-invasive blood pressure, and peripheral venipuncture with an 18G catheter. The patient was placed in left lateral decubitus and the L2-L3 space was punctured with a 16G Tuohy needle. During the introduction of the needle, there was a sudden loss of resistance and, when the stylet was removed, spinal fluid drained through the needle. The needle was removed and another attempt was made in L1-L2 without intercurrences. The patient was informed of the inadvertent dural puncture and the possibility of developing a headache.
After 36 hours, the patient complained of typical post-dural puncture headache. Clinical treatment was instituted initially but it was unsuccessful. Sixty hours after the surgery an epidural blood patch in L3-L4 was attempted due to persistence of the symptoms. During the administration of blood through the needle the patient complained of increasing pain intensity and the procedure was discontinued after the injection of 10 mL of blood. Only partial relief of the headache was achieved, and the clinical treatment was maintained. Five days after the blood patch the patient returned to the hospital complaining of diplopia and severe headache that did not decrease with decubitus. After the neurological exam, an MRI showed the presence of a left subdural hematoma with a slight midline deviation. It was then decided to re-admit the patient to the hospital for clinical treatment for 48 hours. After this period, the patient was discharged with a significant headache improvement but he still presented diplopia due to paralysis of the left abducens nerve, which resolved completely in 30 days.
Regional block techniques have become quite frequent in our field. However, this technique can cause several complications, especially those related with puncture of the dura mater. This perforation is mandatory in subarachnoid block and myelogram, but can be accidental in epidural block and discography 1-3. In the literature, the incidence of inadvertent dural puncture in epidural blocks varies from 0.4 to 6% 4,5, and the incidence of subdural hematoma is even lower. In 1898, Bier 6 was the first one to describe PDPH and proposed the loss of spinal fluid through the puncture as a possible cause. In 1943, Kunkle 6 argued that the loss of spinal fluid would cause a sudden decrease in intracranial pressure, allowing the brain and meninges to fall resulting in traction of sensitive vascular structures. The pathophysiology of hematoma formation is related with the loss of spinal fluid through the puncture site, decreased spinal fluid pressure, and sagging of the brain. The caudal movement of the brain would stretch sensitive and vascular structures in the subdural space, which could lead to their rupture and formation of a hematoma 7,8. It also should be considered that the epidural blood patch, even when performed early, does not seem to prevent the formation of a subdural hematoma when symptoms of PDPH have already developed 2,7,9. Epidural blood patch relives the headache completely in more than 90% of the cases 10-12; the remaining show no improvement or only partial relief of the pain. Other signs and symptoms that could be associated with a subdural hematoma, such as nausea, vomiting, visual cloudiness, and disorientation 7,13 were not present, only headache and diplopia, which are common in cases of PDPH 14.
The treatment of subdural hematoma can be surgical or clinical 15,16. In the present case, surgery was not necessary, only clinical treatment, due to the small size of the hematoma, gradual improvement of neurologic symptoms, and regression of the hematoma on follow-up imaging exams. The epidural blood patch can increase the index of suspicion of intracranial hematoma when the headache does not improve or is worsened during this procedure 17, because the injection in the epidural space can cause a sudden increase in spinal fluid pressure and intracranial pressure. When facing those problems, an imaging exam is necessary to rule out other causes 11. Therefore, the second blood patch should have been preceded by a neurologic evaluation with an intracranial imaging exam. One should always be attentive to the possibility of this complication, especially in pregnant women with hypertensive disease of pregnancy (HDP).
A review of the literature revealed 22 cases 7,18 of subdural hematoma after inadvertent dural puncture during epidural block. Twenty of those cases affected obstetric patients. The earliest diagnosis was made 2 days after the puncture, and the latest 20 weeks afterwards. Almost half of the patients developed bilateral hematomas (11 bilateral, 6 in the left, and 5 in the right). Fifteen patients out of the 22 patients required surgical treatment, and 2 patients died 10. Rupture of an unsuspected aneurism or arterial-venous malformation, associated with post-puncture low spinal fluid pressure, is a rare cause of subdural hematoma.
The real incidence of post-dural puncture subdural hematoma is unknown. Therefore, changes in the characteristic of the headache, lack of response to treatment, absence of improvement when the patient is recumbent, associated symptoms, or worsening during the blood patch should raise the suspicion of other diagnosis, and not only PDPH, such as subdural hematoma.
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Correspondence to: Submitted em 9
de maio de 2007 *
Received from Departamento de Anestesiologia do Hospital Lifecenter, Belo Horizonte,
Dr. Wallace Lage Duarte
Rua Padre Rolim, 395/1302 - Santa Efigênia
30130-090 Belo Horizonte, MG
Accepted para publicação em 7 de abril de 2008
Submitted em 9
de maio de 2007
* Received from Departamento de Anestesiologia do Hospital Lifecenter, Belo Horizonte, MG