1Department of Neurosurgery, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India. 2Department of Anaesthesiology, Mata Chanan Devi Hospital, New Delhi, India*Corresponding author
Accepted for publication: January 26, 2001
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Abstract |
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Br J Anaesth 2001; 86: 8935
Keywords: anaesthetic techniques, subarachnoid; complications, headache; complications, haematoma
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Introduction |
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Case report |
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The patient recovered fully and was discharged on the third day after the operation. He had no headache at the time of discharge. However, a week later, he developed a severe diffuse headache which did not subside with analgesia and bed rest. When he started to vomit, an intracranial lesion was suspected and a neurosurgical consultation was sought. There was no history of fever, trauma or bleeding diathesis. On examination, the patient was conscious and oriented: Glasgow coma score was 15, fundi were normal and there was no focal neurological deficit. He had no neck rigidity or Kernigs sign. Haemoglobin, total and differential leucocyte counts, platelet count, bleeding time, clotting time, prothrombin time and activated partial thromboplastin time (APTT) were normal. Biochemical values, including liver and renal function tests, were also normal.
Magnetic resonance imaging of the head showed a small acute subdural haematoma in the right temporo-occipital region with no mass effect. The patient was managed conservatively with bed rest, analgesia and intravenous fluids. He recovered completely and was discharged after a week.
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Discussion |
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Subdural haematomas have occurred after lumbar puncture in association with cerebral aneurysm, brain tumour, recent cerebrovascular accident and meningovascular syphilis. It is postulated that the haemorrhage is caused by a sudden decrease in intracranial pressure consequent to the loss of CSF at the lumbar puncture site. Sudden caudal shift of the brain may cause traction on the arachnoid mater and/or venous structures and may lead to bleeding from ruptured vessels. Thorsen has described multiple petechial haemorrhages on the surface of the brain after spinal anaesthesia.14 Pavlin and colleagues reported two cases of large subdural haematoma, which required surgical evacuation.1 Mantia reported a case of intracerebral haemorrhage after lumbar puncture with a 26G spinal needle; his patient improved with conservative treatment.5
The true incidence of subdural haematoma after dural puncture is not known. Most patients with headache are probably treated without investigation. Subdural haematomas are known to resolve spontaneously15 but they may be catastrophic as evident from the deaths recorded as a complication of lumbar puncture.9 16 In the case described here, the patient developed a subdural haematoma despite the use of a narrow gauge (23G) spinal needle. Altered CSF dynamics probably caused the rupture of a cerebral vein, resulting in the development of a subdural haematoma. Fortunately, the haematoma was only small and did not require surgical decompression.
Severe and prolonged PDPH should be regarded as a warning sign of an intracranial haematoma. In these patients, early neurosurgical consultation is recommended.
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References |
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2 Vaughan DJA, Stirrup CA, Robinson PN. Cranial subdural haematoma associated with dural puncture in labour. Br J Anaesth 2000; 84: 51820[Abstract]
3 Rudehill A, Gordon E, Rahn T. Subdural haematoma: a rare but life-threatening complication after spinal anaesthesia. Acta Anaesthesiol Scand 1983; 27: 3767[ISI][Medline]
4 Velarde CA, Zuniga RE, Leon RF, et al. Cranial nerve palsy and intracranial subdural hematoma following implantation of intrathecal drug delivery device. Regional Anaesth Pain Med 2000; 25: 768
5 Mantia AM. Clinical report of the occurrence of an intracerebral hemorrhage following post-lumbar puncture headache. Anesthesiology 1981; 55: 6845[ISI][Medline]
6 Alemohammad S, Bouzarth WF. Intracranial subdural hematoma following lumbar myelography. J Neurosurg 1980; 52: 2568[ISI][Medline]
7 Frankson C, Gordth T. Headache after spinal anaesthesia and a technique for lessening its frequency. Acta Chir Scand 1964; 94: 413
8 Gass H, Goldstein AS, Ruskin R, et al. Chronic post-myelogram headache. Isotopic demonstration of dural leak and surgical cure. Arch Neurol 1971; 25: 16870[ISI][Medline]
9 Suess O, Stendel R, Baur S, et al. Intracranial haemorrhage following lumbar myelography: case report and review of the literature. Neuroradiology 2000; 42: 21114[ISI][Medline]
10 Macon ME, Armstrong L, Brown EM. Subdural hematoma following spinal anesthesia. Anesthesiology 1990; 72: 38081[ISI][Medline]
11 Flaaten H, Rodt SA, Vamnes J, et al. Post-dural puncture headaches: a comparison between 26 and 29G needles in young patients. Anaesthesia 1989; 44: 1479[ISI][Medline]
12 Hart JR, Whitacre RJ. Pencil point needle in prevention of post spinal headache. J Am Med Assoc 1951; 147: 6578[ISI]
13 Abouleish E, Vega S, Blendinger I, et al. Long-term follow-up of epidural blood patch. Anesth Analg 1975; 54: 45963[Abstract]
14 Thorsen G. Neurological complications after spinal anaesthesia and results from 2,493 follow-up cases. Acta Chir Scand 1947; 95 (Suppl 121): 1272
15 Blake DW, Donnan G, Jensen D. Intracranial subdural haematoma after spinal anaesthesia. Anaesth Intens Care 1987; 15: 3412[ISI][Medline]
16 Newrick P, Read D. Subdural haematoma as a complication of spinal anaesthetics. Br Med J 1982; 285: 3412[ISI][Medline]