Non-surgical management of intracranial subdural hematoma complicating spinal anesthesia

Postdural puncture subdural hematoma or postdural puncture headache?: two cases report

Spinal anesthesia is widely used for many obstetric, gynecological, orthopedic, and urological operations. Subdural hematomas may occur after trauma and are associated with high morbidity and mortality rates. Postdural puncture headache (PDPH) is a benign condition and the most frequent complication of spinal anesthesia. The high rate of headache after spinal anesthesia may mask or delay the diagnosis of subdural hematoma. The true incidence of postdural puncture subdural hematoma (PDPSH) is unknown because most affected patients are probably managed without investigation. Therefore, the true incidence of PDPSH may be greater than suggested by previous reports. The differentiation of headache associated with subdural hematoma from PDPH is crucial. We herein report two cases of bilateral subdural hematoma after epidural anesthesia and emphasize the importance of suspicion for PDPSH and careful evaluation of patients with headache after spinal anesthesia.

Intracranial hemorrhage following surgery for occult spinal dysraphism: a case-based update

BACKGROUND

Intracranial cerebrospinal fluid (CSF) volume depletion causes diverse clinical syndromes most of them constituting the manifestations of decreased intracranial pressure. Subdural collections or chronic subdural hematomas are the best-known consequences of persistent CSF leaks, especially in overshunted hydrocephalus. Continuous CSF escape also occurs after lumbar puncture, spinal anesthesia, and diverse spinal surgeries.

CASE DESCRIPTION

A 6-year-old boy submitted to reoperation of spinal cord compression due to partial sacral agenesis complained of postoperative orthostatic headaches and vomiting initially attributed to CSF hypotension. There were neither subcutaneous fluid accumulations nor CSF leakage from the wound. The child was treated with strict bed rest and intravenous hydration for 5 days. On reassuming orthostatism, the patient had syncope but did not hit his head. A cranial computerized tomography scan showed an acute subdural hematoma that was managed conservatively with total recovery.

DISCUSSION AND CONCLUSION

A review of current literature showed scanty reports of acute intracranial bleeding occurring after CSF depletion following spinal surgical procedures. To our knowledge, our reported patient represents the second case of this occurrence following surgery for closed spinal dysraphism in a child. The authors briefly review documented instances of acute subdural hematoma following spinal procedures, advise about its diagnosis, and suggest preventive measures.

Arachnoid Membrane Suturing for Prevention of Subdural Fluid Collection in Extracranial-intracranial Bypass Surgery

Objective

Water-tight closure of the dura in extracranial-intracranial (EC-IC) bypass is impossible because the superficial temporal artery (STA) must run through the dural defect. Consequently, subdural hygroma and subcutaneous cerebrospinal fluid (CSF) collection frequently occur postoperatively. To reduce these complications, we prospectively performed suturing of the arachnoid membrane after STA-middle cerebral artery (STA-MCA) and evaluated the clinical usefulness.

Materials and Methods

Between Mar. 2005 and Oct. 2010, extracranial-intracranial arterial bypass (EIAB) with/without encephalo-myo-synangiosis was performed in 88 cases (male : female = 53 : 35). As a control group, 51 patients (57 sides) underwent conventional bypass surgery without closure of the arachnoid membrane. Postoperative computed tomography (CT) scan was performed twice in three days and seven days later, respectively, for evaluation of the presence of subdural fluid collection and other mass lesions.

Results

The surgical result was excellent, with no newly developing ischemic event until recent follow-up. The additional time needed for arachnoid suture was five to ten minutes, when three to eight sutures were required. Post-operative subdural fluid collection was not seen on follow-up computed tomography scans in all patients.

Conclusion

Arachnoid suturing is simple, safe, and effective for prevention of subdural fluid collection in EC-IC bypass surgery, especially the vulnerable ischemic hemisphere.

Intracranial subdural hematoma after spinal anesthesia for cesarean section

Intracranial subdural hematoma following spinal anesthesia is an infrequent occurrence in the obstetric population. Nevertheless, it is a potentially life-threatening complication. In the majority of the cases, the first clinical symptom associated with intracranial subdural bleeding is severe headache, but the clinical course may have different presentations. In this report, we describe the case of a 38-year-old woman with an acute intracranial subdural hematoma shortly after spinal anesthesia for cesarean section. Early recognition of symptoms of neurologic impairment led to an emergency craniotomy for hematoma evacuation with good recovery of neurologic functions. The possibility of subdural hematoma should be considered in any patient complaining of severe persistent headache following regional anesthesia, unrelieved by conservative measures. Only early diagnosis and an appropriate treatment may avoid death or irreversible neurologic damage.

Intracranial subdural hematoma post-spinal anesthesia: report of two cases and review of 33 cases in the literature

BACKGROUND AND OBJECTIVES

Intracranial subdural hematoma is a rare complication of spinal anesthesia. We report two cases of women who developed chronic subdural hematoma post-spinal anesthesia diagnosed after prolonged clinical evolution of post-dural puncture headache (PDPH) and we analyze other 33 cases found on literature review.

CASE REPORTS

In 35 patients (ages 20-88 years, 19 males), 14 were older than 60 years (40%), of which 12 (86%) were males. The relationship is inverted in the group of younger patients (< 60 years), in which we observed twice as many women (14:7). Two peaks of higher incidence were observed: 30-39 years (31%) and 60-69 years (29%). The length of time from the beginning of symptoms until diagnosis ranged from 4 hours to 29 weeks. Headache was the main complaint in 26/35 (74.3%) patients; changes in the level of consciousness in 14/35 (40.0%); vomiting in 11/35 (31,4%); hemiplegia or hemiparesis in 8/35 (22.9%); diplopia or VI nerve paresis in 5/35 (14.3%); and language disorders in 4/35 (11.4%). Contributing factors included: pregnancy, multiple punctures, use of anticoagulants, intracranial vascular abnormalities, and brain atrophy. In 15 cases, a contributing factor was not mentioned. Four out of 35 patients (11.4%) remained with neurologic sequelae, and 4/35 (11.4%) died.

CONCLUSIONS

The presence of any of the signs or symptoms mentioned above should alert for the possibility of an intracranial subdural hematoma as a complication of puncture of the dura mater, especially in those patients with PDPH for more than one week, at which time investigation by neuroimaging is necessary.