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Post-spinal hyperacute subdural hematoma

The development of intracranial subdural hematoma following spinal anesthesia is a rare (1/1 mil-1/1.5 mil) and this serious complication can be fatal.11 Zeidan A, Farhat O, Maaliki H, et al. Does postdural puncture headache left untreated lead to subdural hematoma? Case report and review of the literature. Int J Obstet Anesth. 2006;15:50-8.,22 Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth. 2003;91:718-29. Continuous leakage of 'cerebrospinal fluid (CSF) due to dural injury during puncture can lead to stretching, tearing, and bleeding in meningeal vessels. The symptoms of intracranial subdural hematoma are predisposition to sleeping, disorientation, blurred vision, diplopia, cortical blindness, tinnitus, loss of hearing, scalp paresthesia, vertigo, vomiting, and epileptic convulsions.22 Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth. 2003;91:718-29.,33 Kelsaka E, Sarihasan B, Baris S, et al. Subdural hematoma as a late complication of spinal anesthesia. J Neurosurg Anesthesiol. 2003;15:47-9. However, the most common symptom is headache. The probability of headache following dural puncture makes the diagnosis of subdural hematoma more difficult.44 Blake DW, Donnan G, Jensen D. Intracranial subdural haematoma after spinal anaesthesia. Anaesth Intensive Care. 1987;15:341-2.,55 Evans RW. Special report: complications of lumbar puncture and their prevention with a traumatic lumbar puncture needles 52nd Annual Meeting of the American Academy of Neurology; 2000. Nevertheless, the presence of neurological symptoms is pathognomonic and helps establish the differential diagnosis.

A 50 year-old female patient scheduled for total knee prosthesis had been on methotrexate for 4 year with the diagnosis of rheumatoid arthritis. Hemogram, biochemistry, and coagulation parameters were normal without her positive hepatitis C marker. The operation was performed with ASA II risk. Standard monitorization (electrocardiogram, pulse oximeter, noninvasive blood pressure measurement) was carried out. A 25G spinal needle was used, and the intrathecal space was entered on the second attempt at the L4-L5 level, followed by administration of 12.5 mg of heavy bupivacaine. The operation was carried out under spinal anesthesia and lasted after 2 h. The patient was then transferred to the orthopedics ward. The patient developed sudden loss of consciousness approximately 10 h post operation. Upon physical examination, the patient was unconscious, her eyes were anisocoric, and spontaneous respiration was present. Glasgow Coma Score (GCS) was 7 (no response to verbal stimuli, localizes painful stimulus) and Babinski reflex was not present. BP was 170/100 mmHg, oxygen saturation was 94%, and pulse was 110 bp/m. The patient's relatives reported that she complained of headache and dizziness after the operation. Emergency brain CT scan showed a right subdural hematoma as well as brain edema and shifting (Fig. 1). Emergency decompression was carried out by neurosurgery (Fig. 2). Hemodynamics were stable during the operation. The patient was awakened without any problems. She was then extubated and transferred to intensive care. On her postoperative day-1 examination, GCS was 15, but the right eye remained ptotic. The patient was discharged 1 week later. The development of subdural hematoma after spinal anesthesia is a rare but serious complication of anesthesia.11 Zeidan A, Farhat O, Maaliki H, et al. Does postdural puncture headache left untreated lead to subdural hematoma? Case report and review of the literature. Int J Obstet Anesth. 2006;15:50-8.,22 Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth. 2003;91:718-29. CSF leakage after dural injury can lead to low CSF pressure and intracranial hypotension, which can cause withdrawn on bridging veins and, rarely, bleeding associated the rupture of subdural veins via the compensatory vasodilatation of secondary veins.66 Amorim JA, Remígio DS, Damázio Filho O, et al. Intracranial subdural hematoma post-spinal anesthesia: report of two cases and review of 33 cases in the literature. Rev Bras Anestesiol. 2010;60(620-629):344-9.,77 Velarde CA, Zuniga RE, Leon RF, et al. Cranial nerve palsy and intracranial subdural hematoma following implantation of intrathecal drug delivery device. Reg Anesth Pain Med. 2000;25:76-8. Subdural veins rupture more easily due to the structure of the bridging vein walls, which are microscopically more fragile than other vein walls.

Figure 1
CT scan showed a right subdural hematoma.
Figure 2
Emergency decompression by neurosurgery.

Factors such as the use of anticoagulants, cerebral atrophy, vascular anomalies, dehydration, pregnancy, multiple penetrations of the dura, and thickness of the needle used are associated with intracranial bleeding.88 Scott DB, Hibbard BM. Serious non-fatal complications associated with extradural block in obstetric practice. Br J Anaesth. 1990;64:537-41. In a series of 35 cases with post-spinal subdural hematoma, no risk factor was determined in 15 cases.66 Amorim JA, Remígio DS, Damázio Filho O, et al. Intracranial subdural hematoma post-spinal anesthesia: report of two cases and review of 33 cases in the literature. Rev Bras Anestesiol. 2010;60(620-629):344-9. However, the use of a 25G rather than a 27G spinal needle, the presence of cerebral vasculitis in rheumatoid arthritis patients rarely, and weak vein wall structure were associated.99 Watts RA, Mooney J, Lane SE, et al. Rheumatoid vasculitis: becoming extinct? Rheumatology. 2004;43:920-3. One case where in the patient had no risk factors and developed subdural hematoma with the use of a 27G needle has been reported in the literature.66 Amorim JA, Remígio DS, Damázio Filho O, et al. Intracranial subdural hematoma post-spinal anesthesia: report of two cases and review of 33 cases in the literature. Rev Bras Anestesiol. 2010;60(620-629):344-9. Although the most common symptom is headache, the patient may also develop vomiting, blurred vision, predisposition to sleep, vertigo, tinnitus, loss of hearing, diplopia, and blindness.1010 Srivastava U, Agrawal A, Gupta A, et al. Intracranial subdural hematoma after spinal anesthesia for cesarean section: case report and review of literature. J Obstet Anaesth Crit Care. 2014;4:45-7. The most important factor in missed and delayed diagnoses of subdural hematoma is that its most common symptom is headache and the most common complication of spinal anesthesia is post-dural puncture headache (PDPH). Postural Headache is pathognomonic for PDPH.66 Amorim JA, Remígio DS, Damázio Filho O, et al. Intracranial subdural hematoma post-spinal anesthesia: report of two cases and review of 33 cases in the literature. Rev Bras Anestesiol. 2010;60(620-629):344-9. According to the International Headache Society (2004, ICHD-II), the diagnostic criteria for PDPH are (1) onset/increase of pain within 15 min of the patient lying down or getting up, with pain improvement in the same period; (2) onset within 5 days of dural injury; (3) spontaneous disappearance within a week; or (4) disappearance within 48 h of epidural patch application (9). In 95% of the reviewed studies, PDPH symptoms improved within 5 days. In addition, unlike intracranial lesions, bleeding, or infections, PDPH could not be demonstrated in neuroimaging and CSF pressure was low. However, PDPH may last for >5 d.66 Amorim JA, Remígio DS, Damázio Filho O, et al. Intracranial subdural hematoma post-spinal anesthesia: report of two cases and review of 33 cases in the literature. Rev Bras Anestesiol. 2010;60(620-629):344-9. In a study including 640 patients, postural headache continued for 15 days in one patient, although no lesion was visible in brain MR and the headache improved after only two epidural patches.66 Amorim JA, Remígio DS, Damázio Filho O, et al. Intracranial subdural hematoma post-spinal anesthesia: report of two cases and review of 33 cases in the literature. Rev Bras Anestesiol. 2010;60(620-629):344-9.

In cases where headache is atypical, lasts long, is not associated with posture, and is accompanied by neurological symptoms, subdural hematoma should be suspected and neuroimaging should be carried out for diagnosis.66 Amorim JA, Remígio DS, Damázio Filho O, et al. Intracranial subdural hematoma post-spinal anesthesia: report of two cases and review of 33 cases in the literature. Rev Bras Anestesiol. 2010;60(620-629):344-9. Subdural hematomas appear as hyperdense crescents between bone and brain in CT imaging. As the duration of hematoma increases, its density decreases; when it reaches the same density as the brain, diagnosis can be made with MR. The duration of hematoma is divided into four groups: (1) hyperacute (first 24 h); (2) acute (2-3 d); (3) subacute (3-14 d); and (4) chronic (≥2 weeks).1111 Moss D, Jalaluddin M. Pediatric subdural hematoma. In: Batjer HH, Loftus CM, editors. Textbook of neurological surgery. Philadelphia: Lippincott Williams & Wilkins; 2003. p. 1095-102. Our case had hyperacute subdural intracranial hematoma.

In a study by Amorim et al.,66 Amorim JA, Remígio DS, Damázio Filho O, et al. Intracranial subdural hematoma post-spinal anesthesia: report of two cases and review of 33 cases in the literature. Rev Bras Anestesiol. 2010;60(620-629):344-9. the period between the onset of symptoms and diagnosis ranged 4 h to 29 weeks, and the most common symptoms were headache (74.3%), changes in consciousness (40%), vomiting (31%), hemiplegia or hemiparesia (22%), diplopia or n. abdusence paresia (14%), and speech disorders. In the present case, diagnosis was made 10 h post-surgery, and the patient's symptoms were headache and loss of consciousness. In the work of Amorim et al.,66 Amorim JA, Remígio DS, Damázio Filho O, et al. Intracranial subdural hematoma post-spinal anesthesia: report of two cases and review of 33 cases in the literature. Rev Bras Anestesiol. 2010;60(620-629):344-9. subdural hematoma developed in a hyperacute manner in only three cases, and loss of consciousness occurred in only one of these. Subacute hematoma with loss of consciousness developed in three cases. Subdural intracranial hematoma may spontaneously resorb or may require surgical decompression or burr-hole drainage.1212 Azzarelli B. Neuropathology of the central nervous system: trauma, cerebrovascular disease, infections, demyelinating, neurodegenerative, nutritional and metabolic disorders. In: Batjer HH, Loftus CM, editors. Textbook of neurological surgery. Philadelphia: Lippincott Williams & Wilkins; 2003. p. 207-33. Of 21 subdural hematoma cases reported by Kayacan et al.,1313 Kayacan N, Arici G, Karsli B, et al. Acute subdural haematoma after accidental dural puncture during epidural anaesthesia. Int J Obstet Anesth. 2004;13:47-9. 15 required surgical decompression and two patients were lost. In a case reported by Ezri et al.,1414 Ezri T, Abouleish E, Lee C, et al. Intracranial subdural hematoma following dural puncture in a parturient with HELLP syndrome. Can J Anaesth. 2002;49:820-3. chronic subdural hematoma was spontaneously resorbed. In the present case, surgical decompression was also carried out.

The most common complication of spinal anesthesia is PDPH. The development of intracranial subdural hematoma following spinal anesthesia, though rare, is a serious complication that can be fatal if left untreated. Both complications present with headache, rendering definitive diagnosis difficult.22 Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth. 2003;91:718-29.,33 Kelsaka E, Sarihasan B, Baris S, et al. Subdural hematoma as a late complication of spinal anesthesia. J Neurosurg Anesthesiol. 2003;15:47-9. In cases where the headache is long in duration, is not postural, and is accompanied by neurological symptoms, subdural hematoma should be suspected and neuroimaging should be carried out. CT or MRI should be ordered depending on the duration of the headache.1010 Srivastava U, Agrawal A, Gupta A, et al. Intracranial subdural hematoma after spinal anesthesia for cesarean section: case report and review of literature. J Obstet Anaesth Crit Care. 2014;4:45-7. To avoid missed diagnosis of subdural hematoma in the 5-7 days period when post-spinal headache is present, headache should be investigated thoroughly and the patient should be monitored for neurological symptoms. Despite the very low incidence of subdural hematoma, headaches following spinal anesthesia should be fully examined and the possibility of subdural hematoma should not be underestimated.

References

  • 1
    Zeidan A, Farhat O, Maaliki H, et al. Does postdural puncture headache left untreated lead to subdural hematoma? Case report and review of the literature. Int J Obstet Anesth. 2006;15:50-8.
  • 2
    Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth. 2003;91:718-29.
  • 3
    Kelsaka E, Sarihasan B, Baris S, et al. Subdural hematoma as a late complication of spinal anesthesia. J Neurosurg Anesthesiol. 2003;15:47-9.
  • 4
    Blake DW, Donnan G, Jensen D. Intracranial subdural haematoma after spinal anaesthesia. Anaesth Intensive Care. 1987;15:341-2.
  • 5
    Evans RW. Special report: complications of lumbar puncture and their prevention with a traumatic lumbar puncture needles 52nd Annual Meeting of the American Academy of Neurology; 2000.
  • 6
    Amorim JA, Remígio DS, Damázio Filho O, et al. Intracranial subdural hematoma post-spinal anesthesia: report of two cases and review of 33 cases in the literature. Rev Bras Anestesiol. 2010;60(620-629):344-9.
  • 7
    Velarde CA, Zuniga RE, Leon RF, et al. Cranial nerve palsy and intracranial subdural hematoma following implantation of intrathecal drug delivery device. Reg Anesth Pain Med. 2000;25:76-8.
  • 8
    Scott DB, Hibbard BM. Serious non-fatal complications associated with extradural block in obstetric practice. Br J Anaesth. 1990;64:537-41.
  • 9
    Watts RA, Mooney J, Lane SE, et al. Rheumatoid vasculitis: becoming extinct? Rheumatology. 2004;43:920-3.
  • 10
    Srivastava U, Agrawal A, Gupta A, et al. Intracranial subdural hematoma after spinal anesthesia for cesarean section: case report and review of literature. J Obstet Anaesth Crit Care. 2014;4:45-7.
  • 11
    Moss D, Jalaluddin M. Pediatric subdural hematoma. In: Batjer HH, Loftus CM, editors. Textbook of neurological surgery. Philadelphia: Lippincott Williams & Wilkins; 2003. p. 1095-102.
  • 12
    Azzarelli B. Neuropathology of the central nervous system: trauma, cerebrovascular disease, infections, demyelinating, neurodegenerative, nutritional and metabolic disorders. In: Batjer HH, Loftus CM, editors. Textbook of neurological surgery. Philadelphia: Lippincott Williams & Wilkins; 2003. p. 207-33.
  • 13
    Kayacan N, Arici G, Karsli B, et al. Acute subdural haematoma after accidental dural puncture during epidural anaesthesia. Int J Obstet Anesth. 2004;13:47-9.
  • 14
    Ezri T, Abouleish E, Lee C, et al. Intracranial subdural hematoma following dural puncture in a parturient with HELLP syndrome. Can J Anaesth. 2002;49:820-3.

Publication Dates

  • Publication in this collection
    Jan-Feb 2017
Sociedade Brasileira de Anestesiologia R. Professor Alfredo Gomes, 36, 22251-080 Botafogo RJ Brasil, Tel: +55 21 2537-8100, Fax: +55 21 2537-8188 - Campinas - SP - Brazil
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