Postpartum bilateral subdural hematomas following spinal anesthesia: Case report

ELSEVIER

POSTPARTUM HEMATOMAS ANESTHESIA:

BILATERAL SUBDURAL FOLLOWING SPINAL CASE REPORT

Jo& E. Cohen, M.D., Juan Codes, M.D., and Beatriz Morales, M.D.* Department of Neurosurgery, *Department of Neuroradiology, Hospital de Emergencias “Dr. Clemente Alvarez, ” Rosario, Argentina

Cohen JE, Codes J, Morales B. Postpartum bilateral subdural hematomasfollowing spinal anesthesia.Surg Neurol 1997;47:6-8. BACKGROUND

Intracranial subdural hematoma is an exceptionally rare complication of spinal anesthesia. We report a case of this infrequent event and consider the influence of cerebral atrophy as a predisposing factor. METHODS

AND

RESULTS

This H-year-old woman with severe headaches was admitted to the hospital 42 days after delivery. She had a history of normal pregnancy and uneventful labor and delivery. The epidural anesthesia was satisfactory. Computed tomography showed bilateral chronic subdural hematomas that were surgically removed. An early follow-up scan showed marked resolution of the hematomas and a small sized brain with large subarachnoid space. A late follow-up scan confirmed the diagnosis of brain atrophy. CONCLUSIONS

Persistance of headache and gradual progression despite treatment must be regarded as a sign of intracranial complication following spinal anesthesia. In this case, cerebral atrophy is considered to be a contributory factor for the development of subdural hematoma following dural puncture. 0 1997 by Elsevier Science Inc. KEY WORDS

Spinal anesthesia, complication, subdural hematoma, headache, brain atrophy.

D

ural puncture in the absence of underlying intracranial disease is generally considered a safe procedure. However, intracranial hemorrhage following lumbar puncture [l] and even fatal subdural hematoma occurring after attempted epidural anesthesia have been reported [7]. Intracranial subdural hematoma (SDI-Qis an exceptionally rare complication of spinal anesthesia [ 1,3,4,7,9,11]. A recent review of the literature re Address reprint requests to: Jose E. Cohen, M.D., Dorrego Rosario, Argentina. Received June 20, 1995; accepted March 5, 1996. 00903019/97/$17.00 PI1 SO0903019(96)00241-8

851, 2000-

ported 15 cases of this event and only four other obstetric patients [2]. In all the obstetric cases, the intracranial bleeding was bilateral and followed accidental dural puncture while attempting to place the extradural catheter for relief of labor pain. The purpose of this article is to report a case of this infrequent complication of spinal anesthetic procedures and to consider the influence of cerebral atrophy as a predisposing factor.

CASEREPORT This l&year old woman with severe headaches was admitted to the hospital 42 days after delivery. She had a history of normal pregnancy and uneventful labor and delivery. The epidural anesthesia was satisfactory and the anesthesiologist recorded no complications. The patient had no history of trauma, headaches, coagulation abnormalities, or neurologic disorders. One hour following delivery the patient assumed a sitting position and complained of a sudden and severe frontal headache. No associated neurologic symptoms or signs were found. The patient was discharged on day 6 although a mild left frontoparietal headache persisted. On day 14 she was examined and except for the headache she was otherwise normal. She was medicated with common analgesics. In the following weeks the headache became progressively incapacitating and unresponsive to oral medications. The patient developed photophobia, nausea, and vomited several times a day. On day 42 she was readmitted. The physical examination revealed right Babinski’s sign and bilateral papilledema. Computed tomography (CT) showed large bilateral chronic SDHs (Figure 1). The patient subsequently underwent two bilateral burr holes with drainage under general anesthesia without complications. A follow-up scan on postoperative day 6 showed 655 Avenue

0 1997 by Elsevier Science Inc. of the Americas, New York, NY 10010

Subdural Hematoma and Spinal Anesthesia

II

CT scan showing hematomas.

bilateral

chronic

Surg Neurol 1997;47:6-8

subdural

marked resolution of the SHs, correction of midline shift, and a small sized brain with large subarachnoid space (Figure 2). The patient was last seen in July 1995,ll months after surgery and the follow-up CT scan confirmed the diagnosis of brain atrophy (Figure 3).

DISCUSSION Acute subdural hemorrhage is attributed to rupture of a bridging cerebral vein [4,6,12]. Cerebral veins empty into dural sinuses that are adherent to the inner table of the skull. Many structural features based mainly on electron microscopic data, imply that bridging veins are more fragile in the subdural portion than in the subarachnoid space [ 121. There fore, any traction exerted on the bridging veins will make them rupture at their weakest point in the subdural space. It is presumed that cerebrospinal fluid loss through a dural fistula created accidentally by the spinal needle causes a caudal displace ment of the brain that pulls and tears bridging vessels resulting in subdural bleeding [2,3,8,9]. Several other etiologies of SDH-such as head trauma, coagulation abnormalities, medications, systemic diseases, or dehydration were ruled out in this previously well B-year-old woman. Physiologic sudden increases in venous pressure such as while defecating and coughing were also evaluated. Eerola et al [7] reviewed 12 patients quoted in five reports. A critical review showed that nine of

7

scan showing marked resolution of subdural he qspace.CTmatomas. Small sized brain with huge subarachnoid

these patients had a possible predisposing factor such as previous head trauma, intraoperative hiccups or coughing, postoperative hypotension, and dehydration [ 111. Only three of these patients could be considered previously healthy as many other cases later reported [ 3,4,11]. The postoperative CT scan revealed resolution of both SHs and a small sized brain with wide subarachnoid space. This finding induced us to consider the possibility of previous cerebral atrophy as a contributory factor for the development of subdural bleeding following dural puncture. In the presence of cerebral atrophy of any cause, the bridging veins run through a greater distance in the subdural space and are more susceptible to tearing with displacements of the brain [6,12]. Moreover, the relative increase of intracranial cerebrospinal fluid (CSF) contents [5] makes the brain more mobile and vulnerable to sudden loss of spinal CSF volume. In addition, a smaller brain shrunken away from the inner table of the skull may predispose the development of extracerebral fluid collections due to a delayed tamponade effect [6]. The patient was never CT scanned before the delivery and therefore, a conclusive distinction between the chronic brain compression effect due to bilateral extraaxial masses and prepartum brain atrophy may not be possible. However, this often unknown preexisting intracranial condition might be regarded as an attractive explanatory mecha-

8

Cohen et al

Surg Neurol 1997;47:6-8

EI CT scan reveals brain atrophy

11 months after surgery.

nism, especially in patients previously considered healthy. Bilateral SDHs were reported in all the obstetric patients but in only three of 15 nonobstetrical patients reviewed [2]. Rapid CSF loss through the fistula created by the larger Tuohy needle may be responsible for this fact. The presented case showed a strong temporal relation between the spinal procedure and the onset of neurologic symptoms. Accidental dural puncture resulted

in lowering

the intracranial

pressure

5. Cardozo ER, Del Bigio MR, Schroeder 6. 7. 8. 9.

and caused postspinal headache. Headache is the most common complaint following spinal anesthesia and in the majority of patients the symptom subsides within a few days with conservative treat-

10.

ment [lo]. Persistance

11.

of the headache

progression despite treatment a sign of a serious intracranial

and gradual

must be regarded

as

complication.

REFERENCES 1. Alemohammad S, Bouzarth WF. Intracranial subdural hematoma following lumbar myelography. Case report. J Neurosurg 1980;52:256-58. 2. Baldwin LN, Galizia EJ. Bilateral subdural haematomas: a rare diagnostic dilemma following spinal anaesthesia. Anaesth Intensive Care 1993;21:120-21. 3. Bisinoto FM, Martins Sobrinho J, August0 CM, Sobreira DP, Araujo LP. Hematoma subdural encefalico apes anestesia subaracnoidea. Rev Bras Anestesiol 1993;43:199-200. 4. Blake DW, Donnan G, Jensen D. Intracranial subdural haematoma after spinal anaesthesia. Anaesth Intensive Care 1987;15:341-42.

12.

G. Agedependent changes of cerebral ventricular size. Acta Neurochir (Wien) 1989;97:40-46. Doherty DL. Posttraumatic cerebral atrophy as a risk factor for delayed acute subdural hemorrhage. Arch Phys Med Rehabil 1988;69:642-44. Eerola M, Kauklnen L, Kauklnen S. Fatal Brain lesion following spinal anaesthesia. Report of a case. Acta Anaest Stand 1981;25:115-16. Jack TM. Postpartum intracranial subdural haematoma. A possible complication of epidural analgesia. Anaesthesia 1979;34:176-80. Jonsson LO, Einarsson P, Olsson GL. Subdural haematoma and spinal anaesthesia. A case report and an incidence study. Anaesthesia 1983;38:144-46. Macon ME, Armstrong L, Brown EM. Subdural hematoma following spinal anesthesia. Anesthesiology 1990;72:380-81. Newrlck P, Read D. Subdural haematoma as a complication of spinal anaesthetic. Br Med J 1982;285:341-42. Yamashima T, Friede RL. Why do bridging veins rupture into the virtual subdural space? J Neurol Neurosurg Psychiatry 1984;47:121-27.

COMMENTARY I believe this is an interesting article about a poorlyknown complication that usually occurs in obstetrical patients. I feel that neurosurgeons should read it and become aware of the significance of a chronic headache in this type of patient. Jose L. Salazar, M.D., F.A.C.S. Neurosurgeon Chicago, Illinois