Intracranial Subdural Hematoma Versus Postdural Puncture Headache Following Epidural Anesthesia: A Case Report

Dia R Halalmeh, Aubin Sandio, Munteanu Adrian, Marc D Moisi, Dia R Halalmeh, Aubin Sandio, Munteanu Adrian, Marc D Moisi

Abstract

Headache is a relatively common complaint following dural puncture whether it is diagnostic (lumbar puncture) or unintentional (e.g., after epidural anesthesia). Although postdural puncture headache (PDPH) turns out to be the culprit in many cases, other serious etiologies should be ruled out such as postepidural intracranial subdural hematoma (PEISH). PEISH is usually overlooked because it is relatively rare and due to other frequent causes of headache (e.g., tension headache, migraine, and PDPH) being the main consideration. PEISH can be easily misdiagnosed as PDPH because of similar clinical manifestations. Herein, we report a case of this rare complication and demonstrate the major differences between PDPH and PEISH. This 27-year-old woman with intrauterine fetal death of dizygotic twins complained of severe headache immediately following receiving epidural anesthesia for labor induction. The patient was initially diagnosed with PDPH, and a blood patch was placed which provided complete resolution of the headache only for two days. Computed tomography of the brain revealed a small subdural hematoma over the left frontal convexity. Conservative management with close monitoring was recommended in this case due to the small size of the hematoma and absence of intracranial mass effect. An early follow-up CT scan showed complete and spontaneous resolution of the hematoma. In patients with recurrence or change in the pattern of the headache, persistence of headache despite treatment, and presence of neurological dysfunction following epidural anesthesia, suspicion of intracranial etiology must be raised. Therefore, knowledge of this condition and differentiating it from PDPH is necessary to avoid misdiagnosis and futile attempts of treatment.

Keywords: anesthesia; dural puncture; epidural; headache; subdural hematoma (sdh).

Conflict of interest statement

The authors have declared that no competing interests exist.

Copyright © 2022, Halalmeh et al.

Figures

Figure 1. Left subdural hematoma
Figure 1. Left subdural hematoma
Noncontrast coronal (A) and axial (B) CT scan of the brain demonstrating 4 mm thick subdural hematoma over the left frontal convexity (yellow arrows). This hematoma appears isodense to hypodense which is a characteristic of subacute subdural hematoma.
Figure 2. Radiological disappearance of subdural hematoma
Figure 2. Radiological disappearance of subdural hematoma
Noncontrast coronal (A) and axial (B) cranial CT scan showing complete resolution of the small left subdural hematoma.

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