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CASE REPORT
Year : 2017  |  Volume : 6  |  Issue : 3  |  Page : 178-180

A case of subdural hematoma following lumbar puncture


1 Consultant Neurologist, Amaravati Hospital, Guntur, Andhra Pradesh, India
2 Department of Neurosurgery, Govt. General Hospital, Guntur, Andhra Pradesh, India
3 Department of General Medicine, Katuri Medical College, Guntur, Andhra Pradesh, India

Date of Web Publication25-Sep-2017

Correspondence Address:
Lalith Kolukonda
Door No: 4-5-165/1, 2nd Lane, Koretipadu, Guntur - 522 007, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_44_17

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  Abstract 

Lumbar puncture (LP) is a frequent procedure done for administration of spinal anesthesia or for obtaining cerebrospinal fluid for analysis. The common complications of LP are pain at the local site and headache. Fortunately, the serious complications such as infections of central nervous system, brain stem herniation, and subdural hematoma are rare. We present a rare case of subdural hematoma following a LP.

Keywords: Cerebrospinal fluid leakage, lumbar puncture, postdural puncture headache, subdural hematoma


How to cite this article:
Vemuri R, Sekhar D S, Chandu S, Kolukonda L. A case of subdural hematoma following lumbar puncture. J NTR Univ Health Sci 2017;6:178-80

How to cite this URL:
Vemuri R, Sekhar D S, Chandu S, Kolukonda L. A case of subdural hematoma following lumbar puncture. J NTR Univ Health Sci [serial online] 2017 [cited 2020 Apr 9];6:178-80. Available from: http://www.jdrntruhs.org/text.asp?2017/6/3/178/215532


  Introduction Top


The incidence of subdural hematoma following a lumbar puncture (LP) may be negligible, but it is a dangerous complication. The true incidence of cerebral subdural hematoma following a LP is unknown because not all cases are reported and probably treated without investigation.[1] If any patient who after a dural puncture develops severe headache which is not relieved in supine posture and with adequate hydration, a subdural hematoma should be suspected, and the patient should be investigated and treated accordingly.


  Case Report Top


A 23-year-old female patient underwent fistulectomy under spinal anesthesia which was given through dural puncture at L3–4 vertebral level using a 23-gauge spinal needle. The procedure was uneventful, and the patient was shifted to postoperative ward. Twelve hours after the surgery, she developed headache which rapidly became severe and was not relieved by assuming supine posture or with hydration. The severity of headache did not change with the change in the posture. On the following day, she had an episode of nonbilious projectile vomiting, and she had an episode of loss of consciousness without Tonic-Clonic movements for a few minutes. A computed tomography (CT) scan of the brain was done, and it showed a cerebral subdural hematoma [Figure 1]. She was shifted to our hospital.
Figure 1: Computed tomography scan image showing right cerebral convexity - acute subdural hemorrhage with subfalcine herniation to left

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When shifted to our hospital, the patient was conscious, oriented, and was in severe discomfort because of headache. She preferred to remain in bed undisturbed. There was no history of trauma or any drug intake before the surgery. On examination, her vitals were normal, pupils were normal in size, and were reacting to light. There were no signs of any neurological deficit, and there were no signs of meningial irritation.

A magnetic resonance (MR) imaging scan of the brain was done and it showed a subdural hematoma in right frontal and parietal regions. She was immediately investigated for bleeding diathesis and her coagulation profile was normal. Her MR angiogram and venogram showed no vascular abnormality [Figure 2] and [Figure 3]. Based on the temporal association of the subdural hematoma with spinal anesthesia and as the laboratory investigations showed no bleeding diathesis, the hematoma was considered to be due to dural puncture done to give spinal anesthesia.
Figure 2: Magnetic resonance angiogram - arteries are patent with no evidence of aneurysm or arteriovenous malformations

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Figure 3: Magnetic resonance venogram - no evidence of dural venous sinus thrombosis

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She was treated conservatively for 14 days. The severity of headache decreased initially. Later, she began to develop persistant dull headache with episodes of excacerbation when she was subjected to surgery for the subdural hematoma [Figure 4]. Evacuation of the hematoma was done. After the surgery, her symptoms subsided.
Figure 4: Chronic right subdural hemorrage in the computed tomography image taken after 2 weeks

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  Case Discussion Top


The most common complication following a dural puncture is headache. Post-LP headache is caused by stretch on the intracranial dura mater which is sensitive to pain. The stretch on the dura mater is due to the caudal displacement of intracranial structures due to excessive leakage (>200 ml/day) of cerebrospinal fluid (CSF).[2] The post-LP headache is classically postural and responds within 48 h to increased fluid intake and bed rest.[3]

Rarely, the headache following an LP can be due to a more severe complication like the subdural hematoma. Subdural hematoma after dural puncture is probably caused by the sudden decrease in intracranial pressure due to CSF leakage. Sudden caudal shift of the brain causes traction on the arachnoid mater and venous structures and may lead to bleeding from the ruptured veins.[3] The size of the spinal needle used for dural puncture is an important factor in causing subdural hematoma. The larger the size of the needle, the more is the risk of subdural hematoma. Pregnancy, dehydration, multiple LPs, large dural hole, use of anticoagulants, cerebral vascular abnormalities, and brain atrophy are the other risk factors.[4],[5]

Unlike the usual post-LP headache, the headache due to subdural hematoma does not resolve with bed rest or by giving adequate fluids. It is associated with vomiting and can lead to more serious neurological complications such as decreasing consciousness, convulsions, and hemiplegia. If the headache persists for more than 5 days despite giving prompt treatment with adequate hydration and bed rest, a subdural hematoma should be suspected. Usually, the subdural hematomas resolve spontaneously but occasionally may require surgical decompression when the headache persists for a longer time or when associated with other serious neurological complications.

In patients with persistant severe headache following dural puncture, with the headache persisting even in the supine posture and associated with nausea and vomiting, the possibility of subdural hematoma should be considered.[6] All such patients should undergo a CT scan of the brain to rule out subdural hematoma.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Reina MA, Lopez A, Benito-Leon J, Pulido P, Maria F. Cerebral and spinal subdural hematoma: A rare complication of epidural and subarachnoid anesthesia. Rev Esp Anestesiol Reanim 2004;51:28-39.  Back to cited text no. 1
    
2.
Gass H, Goldstein AS, Ruskin R, Leopold NA. Chronic postmyelogram headache isotopic demonstration of dural leak and surgical cure. Arch Neurol 1971;25:168-70.  Back to cited text no. 2
[PUBMED]    
3.
Acharya R, Chhabra SS, Ratra M, Sehgal AD. Chronic subdural hematoma after spinal anaesthesia. Br J Anaesth 2001;86:893-5.  Back to cited text no. 3
[PUBMED]    
4.
Zeidan A, Farhat O, Maaliki H, Baraka A. Does postdural puncture headache left untreated lead to subdural hematoma? case report and review of the literature. Int J Obstet Anesth 2006;15:50-8.  Back to cited text no. 4
[PUBMED]    
5.
Amorim JA, Remígio DS, Damázio Filho O, de Barros MA, Carvalho VN, Valença MM, et al. Intracranial subdural hematoma post-spinal anesthesia: Report of two cases and review of 33 cases in the literature. Rev Bras Anestesiol 2010;60:620-9.  Back to cited text no. 5
    
6.
Kaplan C, Dandin O, Kaya E, Cuce F, Durmus M, Karapinar U, et al. A rare complication of spinal anesthesia: Intracranial subdural haemorrhage. Arch Clin Exper Surg 2015;4:54-6.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Abstract
Introduction
Case Report
Case Discussion
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