Summary We report the case of a 29 year-old woman who pre- sented a symptomatic intracranial subdural hematoma developing shortly after spinal anesthesia
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- Manejo no quirúrgico de hematoma subdural intra- craneal tras anestesia espinal complicada Resumen
- Non-surgical management of intracranial subdural hematoma complicating spinal anesthesia
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Recibido: 40 Neurocirugía 2007; 18: Neurocirugía 41 2007; 18: 40-43 Summary We report the case of a 29 year-old woman who pre- sented a symptomatic intracranial subdural hematoma developing shortly after spinal anesthesia. The patient was fully conscious at clinical onset, and thus we treated her conservatively with an epidural autologous blood patch and close neurological observa- tion. Given the clinical improvement the possibility of surgery was discauded in agreement with the neurosur- gical team. Most cases of subdural hematoma appearing after spinal anesthesia are treated with surgery. In the pre- sent case the subdural hemorrhage was detected at our hospital 20 days after the anesthetic procedure, and given the excellent state of consciousness, we choosed a conservative management. KEY WORDS: Complications. Epidural blood patch. Mag- netic resonance imaging. Postdural puncture headache. Subdural hematoma. Manejo no quirúrgico de hematoma subdural intra- craneal tras anestesia espinal complicada Resumen El hematoma subdural (SDH) es una complicación evolutiva rara, documentada y de riesgo vital en los cuadros de cefalea post punción subdural (PDPH). Pre- sentamos un caso de esta rara complicación resuelto con un parche de sangre autóloga epidural y tratamiento conservador, sin precisar evacuación quirúrgica. PALABRAS CLAVE: Resonancia magnética. Cefalea postural. Hematoma subdural. Complicación. Parche epidural hemático. Introduction Subdural hematoma (SDH) is a rare but, documented and life-threatening complication after dural punctu- res often manifested by post-dural puncture headache (PDPH) 1,6
. We report a case of this uncommon compli- cation resolved through autologous epidural blood patch (EBP) and conservative treatment without the need for surgical drainage. Case description A 29-year old woman was admitted to our neurosur- gery department presenting with expressive dysphasia and complaining of headache and numbness in her upper right limb and face. She had undergone an emergency cesarean section for acute fetal distress while under subarachnoid anesthesia in another hospital 20 days prior to admittance in our hospital. The patient’s pregnancy had evolved nor- maly, having received the routine prenatal care. The patient had no history of a neurological or blood disease, migraine, cancer or infection. No antecedent of head injury before or after the spinal anesthesia was reported. She denied the intake of cronic treatment or using tobacco, alcohol, or street drugs. Her history revealed an allergy to pyrazolone. While undergoing spinal anesthesia the patient appea- red anxious, and the anesthesiologist encountered technical difficulties with needle insertion. On a second attempt a subarachnoid puncture at L2-L3 level was achieved with a 26-gauge needle, pencil-point (Sims Portex Limited, Hythe, Kent, UK). The anesthetic level was appropriate with hyperbaric bupivacaine 0.5% (10 mg) plus 15 µg of fentanyl. Surgery elapsed uneventfully. Twelve hours after the procedure, the patient complai- ned of an intense generalized headache that got worse upon sitting upright. No fever or signs of meningeal irritation Non-surgical management of intracranial subdural hematoma complicating spinal anesthesia M.T. Verdú; J.F. Martínez-Lage*; B. Alonso; J.L. Sánchez-Ortega and A. Garcia-Candel Services of Anesthesiology and Neurosurgery*. Hospital Universitario Virgen de la Arrixaca. Murcia. Spain.
Recibido: 40 Neurocirugía 2007; 18: Neurocirugía 41 2007; 18: 40-43 were noted. A diagnosis of PDPH was made and accordin- gly, she was given analgesics, oral hydration, and bed-rest. By the fourth day, the patient showed a sligth improvement and was discharged home. Twenty days later the patient was brought to the emer- gency department of our hospital complaining of severe headaches that was not relieved by lying down, and num- bness in her upper rigth limb and face. On examination, the patient was afebrile, alert and orientated but showed expressive dysphasia. No papilloedema was detected upon eye examination. Coagulation tests and complete blood count, including platelets and white blood, where within normal range. A plain cranial computed tomography (CT) and a emergency gadolinium-enhanced cranial and lumbar MRI revealed an extensive left frontal - temporo- parietal SDH with scattered areas of acute and subacute supratentorial hemorrhage and lumbar meningeal thickening without evidence of cerebrospinal fluid (CSF) fistula (figures 1,2 and 3). Upon consultation with neurosurgery and given the good neurological health status of the patient, it was decided not to surgically evacuate the collection but rather maintain a “wait and watch” approach, initiate medical treatment, and perform a lumbar autologous EPB. Blood Figure 1. Cranial computed tomography scan showing
Figure 2. Coronal T1-weighted MRI: hyperintense hema- toma in the subdural wall and the tentorium cerebelli (subacute or with evident chronicity) with mass effect on cortical sulci. Figure 3. Axial T1-weighted MRI of hyperintense crescent- shaped hemorrhage with isointense areas due to subacute hematoma and inner areas of acute bleeding. Very mild mass effect on the midline, ventricles, and cortical sulci is visible. Non-surgical management of intracranial subdural hematoma complicating spinal anesthesia Neurocirugía 42 2007; 18: Neurocirugía 43 2007; 18: Verdú and col cultures were obtained, and 12 hours after admission an EPB was performed under sterile conditions with 17 mL of autologous blood at L3-L4 level using an 18-gauge Tuohy needle. No complications arose. The patient remained in the intensive care unit for close neurological monitoring. Treatment consisted of analgesics, hydration, dexa- methasone (4 mg t.d.s.), and strict bed-rest. The patient’s condition gradually improved, her previous dysphasia and numbness completely disappeared during the first week. She was discharged home at day 15 with mild headache, and a follow-up cranial CT demonstrated near resolution of the SDH, no midline shift, and ventricular re-expansion (Figure 5). A cranial CT performed at day 30 after diagno- sis was reported as normal (Figure 6).
According to the literature, cases of intracraneal SDH- acute, subacute, or chronic- secondary to dural punctures have mainly been treated through surgery, especially if focal neurological deficits have been detected. The neurosurgery department in our hospital opted for conservative treatment. Our anesthesiology department suggested to perform a lumbar autologous EBP as a posible means to stop the CSF leakage as the primary cause triggering the patient’s clinical picture as well as any resulting persistence. Recent publications 3,4
suggest that an EBP does not reliably prevent SDH development when performed after 40-43 Figure 4. Sagittal T1-weighted gadolinium-enhance MRI of the lumbar spine: enhancement of a cauda equina nerve root is seen. Figure 5. Plain computed tomography scan 15 days after diagnosis: almost complete resolution of the subdural hematoma with centered midline and ventricular reexpan- sión (blacks arrow). Figure 6. A normal plain cranial computed tomography scan. Neurocirugía 42 2007; 18: Neurocirugía 43 2007; 18: the onset of the clinical symptoms secondary to intracra- nial hypotension. The CT and gadolinium-enhance cranial and lumbar MRI images of our patient showed a large subacute left fronto-temporo-parietal and supratentorial hematoma with images of acute rebleeding that produced a minimal midline shift (Figure 1 and 2). The presence of an intracraneal space-occupying lesion with accompanying raised intracraneal pressure should be ruled out if an EBP is to be performed. The gadolinium-enhance MRI of our patient suggested indirect signs of meningeal thickening consistent with intracranial hypotension secondary to a persistent fistula in the dura mater causing CSF loss, although there was no neuroimaging confirmation 7,10
. (Figure 4). The mecanism responsible for subdural hygromas or hematomas is persistent CSF leakage through the dura mater after lumbar puncture; subsequent cerebral hypoten- sion with caudal displacement of the shifting brain structu- res in turn causes subdural veins to stretch and tear 9,5 .
reappear later and may be accompanied with new neurolo- gical symptoms. We consider it essential to establish a diffe- rential diagnosis as early as posible to rule out other posible causes (PDPH, migraine, pregnancy-induced hypertension, meningitis, brain tumors, subarachnoid hemorrhage, SDH, cerebral venous thrombosis, or nonspecific causes 8 ) , to prevent serious and life-threatening complications such as those in our patient. We strongly recommend the early collaboration between neurosurgery and anaesthesiology departments in deciding the most appropriate management option, whether it be surgery or conservative. The epidural autologous blood patch 2 and conservative treatment should also be considered as valid and less aggresive alternative therapy in cases of postdural puncture SDH. Close obser- vation of the patients’ neurological evolution seems to be mandatory. References 1. Acharya, R., Chabra, S.S., Ratra, M., Sehgal, A.D.: Cranial subdural haematoma after spinal anaesthesia. Br J Anaesth 2001; 86: 893-895. 2. Barbara-Scavone, B.M., Wong, C.A., Sullivan, J.T., Yaghmour, E., Sherwani, S.S., McCarthy, R.J..: Efficacy of a prophylactic dural puncture patch in preventing post dural puncture headache in parturients after inadvertent dural puncture. Anesthesiology 2004; 101: 1422-1427. 3. Davies, J.M., Muphy, A., Smith, M., O’Sullivan, G.: Subdural haematoma after dural puncture headache treated by epidural blood patch. Br J Anaesth 2001; 86: 720-723. 4. Diemunsch, P., Balabaud, V.P., Petiac, C., et al.: Bilate- ral subdural hematoma following epidural anesthesia. Can J Anaesth 1998; 45: 328-331. 5. Lee, K.S.: The pathogenesis and clinical significance of traumatic subdural hygroma. Brain Inj 1998; 12: 595- 603. 6. Macon, M.E., Armstrong, L., Brown, E.M.: Subdural hematoma following spinal anestesia. Anesthesiology 1990; 72: 380-381. 7. Reina, M.A., Alvarez-Linera, J., López, A., Benito- León, J., De Andrés, J.A., Sola, R.G.: Applicationsss of magnetic resonance imaging to postdural puncture headache in patients with cerebrospinal fluid hypotension. Rev. Esp. Anestesiol. Reanim. 2002; 49: 89-100. 8. Stocks, G.M., Wooller, D.J., Young, J.M., Fernando, R.: Postpartum headache after epidural blood patch: investigation and diagnosis. Br J Anaesth 2000; 84: 407- 410. 9. Verdú, M.T., Alonso, B., Burguillos, S., Martínez-Lage, J.F.: Postpartum Subdural Hygroma after Epidural Analgesia: Anesthesiology 1999; 91: 867-869. 10. Weitz, S.R., Drasner, K.: Spontaneous intracraneal hypotension: a series. Anesthesiology 1996; 85: 923- 925. Verdú, M.T; Martínez-Lage, J.F.; Alonso, B.; Sánchez- Ortega, J.L.; Garcia-Candel, A.: Non-surgical management of intracranial subdural hematoma complicating spinal anesthesia. Neurocirugía 2007; 18: 40-43.
Francisco 10, 1ºD. 30004, Murcia. Spain. 40-43 Non-surgical management of intracranial subdural hematoma complicating spinal anesthesia Yüklə 46,67 Kb. Dostları ilə paylaş:
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