Chronisch subdurales Hämatom nach Periduralanästhesie

Does postdural puncture headache left untreated lead to subdural hematoma? Case report and review of the literature

The patient was a 39-year-old pregnant woman who was scheduled for cesarean section. Spinal anesthesia was induced using a 26-gauge needle with an atraumatic bevel. Postoperatively, the patient developed cranial subdural hematoma manifesting as severe non-postural headache, associated with right eye tearing, fifth cranial nerve palsy and left hemiparesis. The diagnosis was confirmed by computed tomography scan. The patient was managed by careful neurological follow-up associated with conservative treatment and recovered fully after 12 weeks. Our report reviews the literature on 46 patients who developed a postdural puncture headache complicated by subdural hematoma following spinal or epidural anesthesia. It is possible that postdural puncture headache left untreated may be complicated by the development of subdural hematoma. Patients developing a postdural puncture headache unrelieved by conservative measures, as well as the change from postural to non-postural, require careful follow-up for early diagnosis and management of possible subdural hematoma.

Epidural anaesthesia and spinal haematoma

PURPOSE

Haematoma formation in the spinal canal due to epidural anaesthesia is a very rare but serious complication. This paper presents a comprehensive review of case reports.

SOURCE

Sampling of case reports over a 10 yr period, medline-research (1966-1995) and cross-check with former reviews.

FINDINGS

Fifty-one confirmed spinal haematomas associated with epidural anaesthesia were found. Most were related to the insertion of a catheter, a procedure that was graded as difficult or traumatic in 21 patients. Other risk factors were: fibrinolytic therapy (n = 2), previously unknown spinal pathology (n = 2), low molecular weight heparin (n = 2), aspirin or other NSAID (n = 3), epidural catheter inserted during general anaesthesia (n = 3), thrombocytopenia (n = 5), ankylosing spondylitis (n = 5), preexisting coagulopathy (n = 14), and intravenous heparin therapy (n = 18).

CONCLUSION

Coagulopathies or anticoagulant therapy (e.g., full heparinization) were the predominant risk factors, where-as low-dose heparin thromboprophylaxis or NSAID treatment was rarely associated with spinal bleeding complications. Ankylosing spondylitis was identified as a new, previously unreported risk factor. Analysis of reported clinical practice suggests an incidence of haematoma of 1:190,000 epidurals.

Subdural hematoma after lumbar puncture: two case reports and review of the literature

Two cases of intracranial subdural hematoma following lumbar puncture are presented. A review of all previously reported cases shows that subdural hematoma after lumbar puncture is a rare but serious complication. The pathogenesis of subdural hematoma after lumbar puncture is probably related to that of post lumbar puncture headache. Application of an epidural blood patch may therefore be a safe way not only to treat typical post lumbar puncture headache but also to prevent subdural hematoma after lumbar puncture.