Intracranial hematoma as the cause of headache after subarachnoid anesthesia for cesarean section – a case report

Abstract

Background: Intracranial subdural hematoma is an exceptionally rare but life-threating complication of epidural and spinal anesthesia. The diagnosis is rather difficult because the initial symptoms mimic post-dural puncture headache. Case report: A 33-year-old primipara was admitted to the hospital at 38 weeks gestation for a cesarean section due to premature rupture of membranes and meconium stained amniotic fluid. During the procedure a single puncture between L2 and L3 vertebrae was made with the use of a 26-gauge, pencil-point needle. The amount of 2.8 ml of analgesic solution was administered in order to obtain subarachnoid analgesia at the level of Th4 and Th5 vertebrae. Postpartum recovery was uneventful for the first two days. On the third day the patient developed strong headache in the forehead area and tinnitus. An anesthesiologist diagnosed post-dural puncture headache (PDPH). The patient received 1g of Paracetamol every 6 hours intravenously, together with 3000 ml of crystalloid solution for 24 hours. As a result, the patient recovered and was discharged home with her infant. Five days later the patient presented at the neurology clinic because of strong and chronic temporal lobe headache. No other complaints were reported. Upon admission, the patient had a head CT, followed by an MRI examination, which revealed cranial hematomas localized bilaterally in the area of the frontal, temporal and parietal lobes, spreading from the cranial vault to the skull base. The width of the hematomas was: 3-4 mm on the left and 5-6 mm on the right side. Hematomas infiltrated the anterior part of the medial longitudinal fissure. Magnetic resonance angiography showed normal images of the arteries, veins, and the dural venous sinuses. No vascular malformations, which may be a source of intracranial hemorrhage, were found. Other tests showed normal results. Patient condition during hospitalization was stable. Conservative treatment was implemented, i.e. fluids administered intravenously, anti-edematous drugs, analgesic medications and bed rest. All pain complaints subsided and a control CT scan showed that hematomas evolved as expected i.e. their HU density decreased. About 6 weeks later the patient had a CT head scan, performed in outpatient settings, which showed complete absorption of extravasated blood. Conclusion: The presented case shows headaches in obstetric patients require thorough diagnostic examinations and appropriate management. In addition to the most typical PDPH, it may be the first sign of life-threatening intracranial pathology.