Acute subdural intracranial hematoma after combined spinal-epidural analgesia in labor

Intracranial subdural hematoma is a rare, but well-described complication of epidural and spinal anesthesia, as documented by more than a decade of publications. Non-postural headache and vomiting are warning signs. A headache lasting more than 5 days should arouse suspicion of intracranial hemorrhage, whether or not it is associated with the appearance of neurological signs or the deterioration of neurological status. Urgent cranial computed tomography can confirm the diagnosis of subdural hematoma, which has the potential to cause a dramatic cerebral herniation syndrome. A combination of spinal epidural (CSE) anesthesia and analgesia is commonly used to obtain pain relief during caesarean sections and labor. We report the case of a patient who suffered from severe neurological deterioration and manifested signs of brain herniation due to the development of an acute intracranial subdural hematoma after CSE analgesia for labor. An emergency craniotomy was performed to remove the subdural hematoma and the patient recovered well. Close observation of patients undergoing CSE analgesia or anesthesia complaining of prolonged non-postural headaches, with or without neurological symptoms, is recommended.

Remifentanil vs fentanyl with a target controlled propofol infusion in patients undergoing craniotomy for supratentorial lesions

AIM

Remifentanil hydrochloride is an ultra-short acting m-opioid receptor agonist. This study compared the use of remifentanil with that of fentanyl during elective supratentorial craniotomy in a target controlled infusion (TCI)-propofol anesthesia regimen and evaluated the quality of recovery from anesthesia.

METHODS

After written informed consent for this prospective study, 40 adult patients were randomly divided into 2 groups: in group F analgesia was provided with fentanyl 2-3 mg kg(-1) h(-1) and in group R with remifentanil 0.25 mg kg(-1) h(-1). Anesthesia was induced with thiopental and pancuronium bromide, and maintained with propofol-TCI, pancuronium, air and oxygen and fentanyl (group F) or remifentanil (group R), respectively. After tracheal intubation, infusion rate of remifentanil was reduced and then adjusted to maintain stable hemodynamics. Hemodynamics and recovery time were monitored for 60 min after surgery. Analgesic requirements, propofol intraoperative consumption, nausea and vomiting in postoperative period were monitored. Recovery was evaluated according to a modified Aldrete score.

RESULTS

Baseline hemodynamics were similar in both groups. Mean arterial pressure differed between the 2 groups (P<0.05) with the greatest decrease in group R during dura opening (P<0.001). Postoperative mean arterial pressure was higher in group R. Patients in group R exhibited a faster recovery. The incidence of nausea and vomiting was similar in the 2 groups. Noteworthy, there was a reduction in the amount of propofol used in group R.

CONCLUSIONS

Remifentanil appears to be a reasonable alternative to fentanyl during elective surgery of supratentorial lesions.