Journal: J Clin Anesth 20(5):376-378, 2008
Reprint: Department of Anesthesiology, Hospital General de Castellón, 12004 Castellon, Spain (R Ramos-Aparici, MD) RO.03 JA0923/023 ©2009
Faculty Disclosure: Abstracted by R. Ouellette, who has nothing to disclose.
Intracranial subdural hematoma is a serious complication of spinal anesthesia. The incidence of subdural hematomas after dural puncture is unknown because not all cases are reported. Dural puncture with Quincke spinal needles causes a hole in the dural sac. Symptoms of subdural hematoma are variable and depend on its size, localization, and speed of formation. Typical clinical symptoms include headache, decreased level of consciousness, contralateral hemiparesis, and dilated pupil ipsilateral to the lesion.
The authors report the case of a 31-yr-old woman who presented with headache and neurologic localizing signs after spinal anesthesia for cesarean delivery. She was a primipara for elective delivery at 39 weeks gestation because of breech presentation. Her medical history included gestational diabetes. The patient was placed in a sitting position and on the first attempt spinal anesthesia was achieved via a 25-ga Quincke spinal needle at the L3-L4 level with hyperbaric bupivacaine and fentanyl 10 mcg.
Intraoperatively she received oxytocin 10 units. Vital signs remained stable; 48 hours after surgery, the patient developed moderate and persistent right-sided headache and right retro-orbital pain, even in the recumbent position. Nonsteroidal anti-inflammatory drugs did not relieve the pain, and 2 hours later she developed drowsiness, progressive decreased level of consciousness, with a Glasgow Coma Scale (GCS) score of 8. Computed tomographic scan showed a right temporoparietal subdural hematoma, with mass effect and midline displacement. She was taken to the operating room and general anesthesia was induced with fentanyl, propofol, and succinylcholine. A right frontotemporal craniotomy was performed, and the hematoma was evacuated.
Postoperatively, the patient was taken to the ICU and her trachea was extubated 2 days later. Her neurologic examination showed a GCS score of 15, right lower extremity paresis and cranial nerve III palsy. The patient was subsequently discharged from the hospital with minimal weakness of the right lower extremity. |
