Rev. Bras. Anestesiol. vol.65 número4

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RevBrasAnestesiol.2015;65(4):306---309

REVISTA

BRASILEIRA

DE

ANESTESIOLOGIA

OfficialPublicationoftheBrazilianSocietyofAnesthesiology www.sba.com.br

CLINICAL

INFORMATION

Bilateral

subdural

hematoma

secondary

to

accidental

dural

puncture

Sofía

Ramírez

∗

_,

_Elena

_Gredilla,

_Blanca

_Martínez,

_Fernando

_Gilsanz

ServiciodeAnestesiologíayReanimación,HospitalUniversitarioLaPaz,Madrid,Spain

Received25May2014;accepted4July2014 Availableonline28April2015

KEYWORDS

Accidentaldural puncture;

Epiduralanalgesia; Post-duralpuncture headache;

Subduralhematoma; Epiduralbloodpatch

Abstract

Wereportthecaseofa25-year-oldwoman,whoreceivedepiduralanalgesiaforlaborpainand subsequently presentedpost-dural punctureheadache. Conservativetreatment was applied andepiduralbloodpatchwasperformed.Intheabsenceofclinicalimprovementanddueto changesintheposturalcomponentoftheheadache,abrainimagingtestwasperformedshowing abilateralsubduralhematoma.

Thepost-duralpunctureheadacheisrelativelycommon,butthelackofresponseto estab-lished medicaltreatment aswell as the change in its characteristics andthe presence of neurologicaldeficit,shouldraisethesuspicionofasubduralhematoma,whichalthoughisrare, canbelethalifnotdiagnosedandtreatedattherighttime.

PALAVRASCHAVE

Dura-Máter; Analgesiaepidural; Cefaleiapós-punc¸ão dural;

Hematomasubdural; Placadesangue epidural

Hematomasubduralbilateralsecundárioapunc¸ãoduralacidental

Resumo

Apresentamosocasoclínicodeumapacientede25anosdeidade,naqualumatécnicaperidural foirealizada duranteotrabalhode partoeposteriormenteapresentou cefaleiacom carac-terísticas de cefaleia pós-punção dural. Foi iniciado tratamento conservador e tampão de sangueperidural.Devidoaausênciademelhoraclínicaeàmudançadocomponente postu-raldacefaleia,decidiu-serealizarumexamedeimagemcerebralquedemostrouapresença dehematomasubduralbilateral.

Acefaleiapós-punçãodural érelativamentefrequente,mas afaltade respostaao trata-mentomédicoinstaurado,assimcomoamudançaemsuascaracterísticaseapresençadefoco

∗_{Corresponding}_author.

E-mail:sofiramirez@gmail.com(S.Ramírez).

http://dx.doi.org/10.1016/j.bjane.2014.07.017

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Bilateralsubduralhematomasecondarytoaccidentalduralpuncture 307

neurológico,devemlevantarasuspeitadepresenc¸adeumhematomasubduralque,embora infrequente,podechegaraserdevastadorsenãofordiagnosticadoetratadooportunamente. ©2014SociedadeBrasileira deAnestesiologia.PublicadoporElsevierEditoraLtda.Todosos direitosreservados.

Introduction

Thepost-duralpunctureheadache(PDPH)isthemost com-moncomplication aftera neuroaxial1 _anesthesia. _In_turn,

the subdural hematoma (SDH) is a rare, but potentially severecomplicationofduralpuncture,whichrequiresearly diagnosis and treatment. Initially the diagnosis of SDH is complicated because the early symptoms are similar to thoseofPDPH,butwhentheheadachedoesnotrespondto standardmedicaltreatment,losingitspostural characteris-ticsorbeingaccompaniedbyotherneurologicaldisorders, itis necessarytosuspectof anintracranial pathologyand urgentlyperformaneuroimagingscantoallowdiagnosisand correcttreatment.

Clinical

case

A25-five-year-oldwoman,gestathreeat39thweekof gesta-tion,wasadmittedtohospitalduetoearlyuterineactivity. Herpersonalhistorypointedoutthatin herfirstbirthshe did not receive epidural analgesiadue to impossibilityof performingthetechnique.Withacervicaldilationof2cm, andafter gynecological evaluation,the patientrequested epiduralanalgesiatocontrollaborpain.Withprior expla-nationoftherisks,andaftersigninginformedconsent,an epiduraltechniquewasperformed.Aftervariousattempts, usinga18GTuohyneedleandlossofresistancetoair,the epiduralspacewaslocatedat L3---L4andthecatheterwas leftin this position. Following a negative aspirationtest, adosetest of3mLbupivacaine0.25%withepinephrine1: 200,000wasadministeredwithnohemodynamicchangesor immediatesensoryormotorblockade.Theinitialdosewas 0.25%levobupivacaine10mLandthenanepiduralinfusion of0.125%levobupivacaine+fentanila2␮gmL−1at10mLh−1

wasconnected.

Laborwasuneventfuland2hlater,aftereutocicbirth,a girlof3090gwasbornwithApgarscore8at1minand9at 5min.Afterstayingforsurveillanceinpostpartumarea,the epiduralcatheterwasremoved,andthepatientwenttothe room.

With24h postpartumtheanesthesiaservice wascalled becausethepatienthadsevereheadache,withappreciation of pain in simple verbal scale (SVS) 9/10, which wors-enedwithstandingpositionandimprovedwhenrecumbent. Althoughduramaterpuncturehasnotbeennoticed,there was suspicion of a possible PDPH and with this supposed diagnosis analgesic treatment wasstarted with paraceta-mol1gIV/6handdexketoprofen50mgIV/8h.After48hof headacheonset,duetopersistentsymptomsdespite medi-caltreatmentadministeredanddiagnosisofPDPH,epidural blood patch (EBP) was performed with no other events.

Initially, the results were satisfactory, since the patient reportedimprovementin headacheduringthefirst hours, but the next day she showed non-orthostatic headache, withmaximumintensityinthesupineposition,inSVS10/10 associated withtinnitus and cervical contracture. Due to lack of clinical improvement, with change of headache characteristics and after ruling out neurological focus on physicalexamination,brainandlumbarspinenuclear mag-neticresonance(MRI)wasordered,whichshowedbilateral intracranialSDH(Figs.1and2).The NeurosurgeryService wasconsulted,indicatingtreatmentwithIVcorticosteroids (dexamethasone4mgIVevery8h)andrequestingcomputed tomography(CT)controlinaweek.

With 24h of treatment initiation with corticosteroids, thepatient reportedimprovementin headache, SVS3/10 and after 48h she reported no headache or other symp-toms.Thepatientremainedinhospitalforanotherweekfor medicaltreatmentandmedicalsupervision.Controlcranial CTshowedimprovementoflesionsandduetosatisfactory progress,withtotalremissionofheadacheandwithoutthe presenceofneurologicalfocus,shewasdischargedwith cor-ticoidoraltreatmentinadescendingregimenduring20days andcontrolbyneurosurgeryservice.

Discussion

Theincidenceofaccidentalduralpuncturedescribedinthe literatureafterperformanceofanepiduraltechniquevaries from0.4to6%,2_but_only_60%_of_patients_develop_PDPH.3_In

ouranesthesiaserviceatMaternalHospitalLaPaznumbers

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308 S.Ramírezetal.

Figure2 Coronalsectionofbrainmagneticresonancewhere bilateralsubduralhematomaisobserved.

aresimilar,withanincidenceofaccidentalduralpuncture of0.6%,andofPDPHof56%.4

According tothe diagnostic criteriaestablished by the International Headache Society, PDPH is characterized by itsposturalcharacter,worseningatthe15minofstandingor sittingposition,andimprovinginasimilartimewith decu-bitus; it develops within 5 daysof puncture and resolves spontaneouslywithinaperiodofoneweek in95%ofcases orinthefollowing48hoftheperformanceofanEBP.3

The SDHis ararebut potentially fatal complicationof duralpuncture, asaresultof a spinalanesthesiaor acci-dentalduralpunctureduringepiduraltechnique.2_Although

theliteraturecollectsonlyisolatedcasesofSDHsecondary toneuroaxialanesthesia,itisestimatedthattheprevalence ofthisconditionis1/500,000---1/1,000,000.5

PostulatedmechanismsforPDPHandSDHaresimilar:the lossofcerebrospinalfluid(CSF)throughtheholecreatedin the dura mater causes a reduction of volume and subse-quentlyinspinalandintracranialpressure.Thisintracranial hypotensioncausesacaudaldisplacementofthespinalcord andthebrain,withtractionofbrainstructuresthatare sen-sitive topain,thereby causing the headache.The venous drainageofthebrainisperformedthroughtheveinsinthe duralbridges,thatrunfromthebrainintotheduralsinuses, and that have their weakest part in the subdural space, and it is precisely the traction of these veins that cause theirdetachmentandsubsequentemergenceofaSDHand increasedintracranialpressure.6_Thus,_in_patients_with_SDH,

twoclinicalphasescanbeobservedasaresultofchanges generated on intracranial pressure: initially they present witha headachewitha clearposturalcomponent (associ-ated withintracranial hypotension). In a later stage they showincreasedintensityofheadachewithlossoforthostatic component,withoutimprovementwiththeusualtreatment ofPDPHandincludingclinicalworseningafterperformance of an EBP and that may be accompanied by neurological focussigns(relatedtointracranialhypertension).1

Conventional treatment of PDPH includes the adminis-trationofanalgesicsandantiemetics.Incaseofpersistent headachedespitethesemeasures,anEBPcanbeperformed, whichiscurrentlyconsideredthedefinitivetreatmentofthis clinicalentity.Thepostulatedmechanismforitsefficacyis dual:firstitcompressesthethecalsac,increasingthe pres-sureonthelumbarneuraxialchannel,leadingtothepassage

ofCSFfromthespinalcanaltothebrainandtherebycausing improvementofheadache;ontheotherhand,maintenance ofthetherapeuticeffectisattributedtotheformationofa clotwhichpreventsescapeofCSF.3

Inourhospitalweperformed theEBPincaseof severe PDPH that persists 48h after puncture and initiation of analgesic treatment.The procedure consistsofmakingan epidural puncture, preferably in the same intervertebral spacewheretheaccidentalduralpuncturewasperformed orbelow,andoncetheepiduralspaceislocated,15---20mL ofautologousbloodfromaforearmveinisaseptically col-lected, and is injected through epidural route, with care beingtakentostopinjectionifthepatientcomplainsofback painor pain inthe lowerlimbs. Subsequentlythepatient shouldremainsupineforonehourintheresuscitationarea. Regarding the diagnosis of SDH after accidental dural puncture,itisimportanttonotethatifthereisaheadache thatdoesnotrespondtousualtreatmentfor PDPH,which losesitsposturalcharacter(orthostaticornon-orthostatic), whichworsensafterthecompletionofaEBPorthat reap-pearsafter remission,an intracranial complicationshould besuspected,andaneuroradiologystudy---brainCTorMRI --- shouldbeperformedtoruleoutthepresenceofaSDH.7_As

forthesediagnostictests,itwasshownthatbothCTandMRI inisodensephasemaynotshowthepresenceofaSDH,and thereforetheyshouldbeperformedwithcontrasttoavoid false negativesin their results.1,8 _This _was _the_procedure

thatwasfollowedinourpatient’scase.

TreatmentofSDHcanbemedicalorsurgical,depending onitssizeandtheseverityofsumptoms.2_Most_of_the_time,

small(<5mm)and littlesymptomatic hematomasrespond clinicallyandradiologicallysatisfactorilywithconservative medicaltreatment.Ontheotherhand,patientswithlarger hematomas andmarkedneurological deteriorationusually requireurgentsurgicaldrainage.9,10_In_our_case,_the_patient

hadnoneurologicalfocus,soaconservativeapproachwas chosen,withgoodclinicalresults.

In conclusion, after an accidental dural puncture, the presence of severe, progressive headache, with changing of itsposturalcomponent,noimprovementor even wors-ening after thecompletion of a EBP, andassociated with other neurological signs,awarningsign should be consid-eredforintracranialcomplications,asitisforSDH.Thisisan infrequentsituation,butcanbecomecatastrophic, produc-ingpersistentneurologicalsequelaeandevendeath.Thus, itisnecessarytoinsistonearlydiagnosisandtreatmentof thisclinicalentity.

Conflict

of

interests

Theauthorsdeclarenoconflictofinterest.

References

1.Zeidan A, FarhatO, Maaliki H, et al. Does postdural punc-ture headache left untreated lead to subdural hematoma? Casereportandreviewoftheliterature.IntJObstetAnesth. 2006;15:50---8.

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Bilateralsubduralhematomasecondarytoaccidentalduralpuncture 309

3.GaiserRR. Postduralpunctureheadache:aheadachefor the patientandaheadachefortheanesthesiologist.CurrOpin Anes-thesiol.2013;26:296---303.

4.MartínezSerranoB[thesis]Cefaleapostpunciónduraltras anal-gesia epidural para trabajo de parto. Madrid: Facultad de Medicina,UniversidadAutónoma;2006.

5.MachurotPY,VergnionM,FraipontV,etal.Intracranialsubdural hematomafollowingspinalanesthesia:casereportandreview oftheliterature.ActaAnaesthesiolBelg.2010;61:63---6.

6.KK,ChatterjeeN,ShrivastavaA,etal.Sub-duralhematoma fol-lowingspinalanesthesiatreatedwithepiduralbloodpatchand burr-holeevacuation:acasereport.MiddleEastJAnesthesiol. 2013;22:117---20.

7.Liang MY, Pagel PS. Bilateral interhemispheric subdural hematomaafterinadvertentlumbarpunctureinaparturient. CanJAnaesth.2012;59:389---93.

8.Vaughan DJ, Stirrup CA, Robinson PN. Cranial subdural haematoma associated with dural puncture in labour. Br J Anaesth.2000;84:518---20.

9.Abbinante C, Lauta E, di Venosa N, et al. Acute subdural intracranialhematomaaftercombinedspinal-epidural analge-siainlabor.MinervaAnestesiol.2010;76:1091---4.