Severe Intracranial Subdural Hematoma Following Epidural Anaes the siain Pregnancy: A Case Report

1. Abstract Severe headache is one of the quite common complication after a duralpuncture procedure be it diagnostic (lumbarpuncture) orunintentional (e.g., after epiduralanaesthesia). Knowing that Postur- al Puncture Headache (PDPH) most often becomes the culprit in mostcases, many severe and seriousetiologists should beassessed though its frequently raredue to other causes of head ache after Duralpuncture.

2. Introduction Epiduralblockisoneofthemajortechniquesusedinanaesthesia. Ingeneral,majorityofanesthetistphysiciansbelieveit’sthemost appropriate and safe procedure that can help patients in adequate analgesia mostly in the lower part of the body [1]. It is employed inabroadrangeofprocedures,mostlyduringchildbirthinobstet- ric procedures [1]. However, it is important to mentioned that it can be the source of some major complications such as intracranialsubduralhematoma[4-6].Manypatientswithmajorsubdural hematoma following epidural block can be mistakenly diagnosed with postural puncture headache (PDPH).While intracranial subduralhematomafollowingepiduralanaesthesiaisveryrarealmost impossible (1:500,000) [3], it is very important and critical for everyphysiciantounderstandandmakeacleardifferencebetween PDPH, as subdural hematoma can potentially lead to significant morbidity and mortality.

3. Case Presentation A25-year-oldfemalegravida1(G1)para1(P1)comestothehos- pital for prenatal follow-up visit at 20 weeks’gestation of monoamniotic-monochorionic pregnancy. The patient described some vague feelings, decreased foetal movement earlier in the morningthatdaypriortothevisit.Shewasadmittedbecauseofsevere headache intensity 7/10. Patient described difficulty sitting and loss of focus. 2 weeks later, the intensity of headache went up to 9/10generalizedwithphotophobiaandwasnottoleratinganti-inflammatory medication. A scan was done that showed sub-acute subduralhematomawithrebleedingwhichledtotheindicationof surgery.Shebenefitedfrombi-drapanationextraction.Shewasdischargeonday5post-opandwasadvisetothefollowupforwound dress.Bodysurfaceultrasoundshowednormalcardiacmotionfor foetus. She was then admitted to the hospital for C-section. The patientreceivedepiduralanaesthesiaandhadsincecomplainedof postural headache and severe neck pain that radiated bilaterallyto shoulders and mid upper back. She stated that the headache is worsenedbysittinguprightandbymovingherheadtotherightor to the left and improved when she lies down. She denies any fever,vomiting,confusion,orvisualchanges.Asidefromneckpain, rightlowerextremityweakness,andlightheadedness.Onphysical examination, the patient was alert and oriented with no remarkableneurologicalsignsexceptformildweaknessintherightlower extremity(4+/5).Shewasafebrilewithnormalbodytemperature, bloodpressure,pulse,andrespiratoryrate(37°C(97.88°F),112/84 mm Hg, 81/beat per minute (bpm), and 17/min, respectively). The patient was initially diagnosed with PDPH, and an epidural bloodpatchwasthenplacedthenextday.Theheadacheresolved, but she was not able to move her neck due to pain.Analgesic and muscle relaxant were recommended which she claims helped alleviate the pain partially. An MRI of the cervical, thoracic, and lumbar spine was obtained and showed changes related to her recent blood patch; however, there was no significant canal stenosis.BrainCTscanwithnocontrast(Figures1A,1B)revealedleft frontal convexity subdural hematoma measuring 10 mm in thickness with no midline shift, herniation, or associated mass effect.

4. Discussion Epidural anesthesia procedure mostly used in obstetrical by anesthetist anesthesiology is well established. Over all, the complications related to the neuraxial anesthesia have been proven to be unusual [10]. Furthermore, certain adverse manifestations suchas intracranial subdural hematoma are recognized as major issues andcanbepotentiallyfatalifmisdiagnosedorneglectedearlyand addressed promptly. The number oneincidence of Postepidural IntracranialSubduralHematoma(PEISH)isstillnotclearenough because of the uncertainty nature of the data collected on variouscases.However,anincidenceof1:500,000hasbeenestimated basedonalargequestionnaireinvolving203obstetricunitsinthe United Kingdom [2]. Despite the great variation in reported incidence, acute subdural hematoma is not uncommon after dural puncture, especially in anticoagulated patients and patients with coagulation abnormalities. In such cases, a CTscan should be alwaysobtained.Althoughbothcomplicationssharesimilarclinical characteristics,PDPHisamorefrequentsequelathanPEISH.This may have contributed to the initial misdiagnosis of PDPH in our case. In a survey of 18,337 epidural blocks, 0.91% had accidental dural puncture with more than 88% of these developed PDPH [8,9]. After all, both PDPH and PEISH should be considered in any patient with postdural puncture headache. In addition, PDPH and PEISH are very similar with respect to pathophysiology[2,4].Cerebrospinalfluid(CSF)leakagetypical- ly occurs upon puncture of the dura mater. Excessive loss of the CSFleadstomarkedreductionintheCSFvolumeandsubsequent intracranial hypotension [2,10]. This results in traction on the intracranial,pain-sensitivestructurescausingtheheadache.Stretchingoftheduralbridgingveins(whicharetypicallydilatedtocompensate for the CSF loss according to Monro-Kellie hypothesis) duetocaudaldisplacementofthebrainmayleadtotearinthewall of subdural veins and consequently leaking blood in the subdural space with hematoma formation [2,3,6,9]. In our patient, the hematomawasmostlikelytheresultofunintentionalduralpuncture during the epidural block and probably continuous CSF leakage thereafter (Figure 2).

5. Conclusion Figure2: Bi-lateral andPan- hemisphericsubacute subdural hematoma. As matter of fact, the concept of major mass of intracranial subdural hematoma consequent to epidural anaesthesia is a clinical concern and a serious complication since it is commonly misdiagnosed as PDPH. The index of suspicion for PEISH should be high, as this condition is a serious life-threatening and can result in definite neurological sequelae. Nevertheless, knowledge of the clinical features and clues of PEISH and early diagnosis are of paramount importance.

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Casimir Fankem. Severe Intracranial Subdural Hematoma Following Epidural Anaes the siain Pregnancy: A Case Report. Annals of Clinical and Medical Case Reports 2023