|Year : 2017 | Volume
| Issue : 3 | Page : 178-180
A case of subdural hematoma following lumbar puncture
Ramatharaknath Vemuri1, D Seshadri Sekhar2, Sambasivarao Chandu3, Lalith Kolukonda3
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 Publication||25-Sep-2017|
Door No: 4-5-165/1, 2nd Lane, Koretipadu, Guntur - 522 007, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
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
| Introduction|| |
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. 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|| |
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|| |
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). The post-LP headache is classically postural and responds within 48 h to increased fluid intake and bed rest.
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. 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.,
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. All such patients should undergo a CT scan of the brain to rule out subdural hematoma.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]