P055: A RARE CASE OF SUBDURAL HEMATOMA AFTER ACCIDENTAL DURAL PUNCTURE
Ajay Kurup, DO; Rob Zusman, DO; Nazir Noor, MD; Miguel Perez, MD; Jared Herman, DO; Salomon Poliwoda, MD; Alvaro Castro; Mount Sinai Medical Center
Introduction: Epidural analgesia is an effective option for the management of labor pain. The last few decades have demonstrated a marked increase in its use to provide safe and sufficient pain coverage for women undergoing labor. Epidural analgesia provides more pain relief while causing less neonatal depression than parenteral opioids with minimal incidence of permanent maternal injury. We present a case demonstrating a rare adverse effect occurring after epidural anesthesia.
Case: We present a 23-year-old G3P2 female (BMI 28.4) with no past medical history and had received prior labor epidurals without issues. The patient requested an elective epidural for labor analgesia, and a combined-spinal-epidural technique was planned. The L3-L4 interspace was marked where an 18-gauge Tuohy needle was inserted. Loss of resistance (LOR) technique to air technique was employed, but unfortunately this was a technically difficult epidural to place despite repeated attempts at multiple levels. At the L4-L5 interspace, the Tuohy was inserted approximately 7 centimeters, and the LOR syringe filled with cerebrospinal fluid (CSF), indicating violation of the dura; thus, the decision was made to thread an intrathecal catheter. The patient was connected to continuous spinal anesthesia; bupivacaine 0.125% with fentanyl 2 micrograms per milliliter was infused at 1 milliliter per hour. The patient delivered vaginally without complication. The following day, the patient was discharged without complaints. Two days later, during follow-up by phone the patient stated she developed symptoms of a postural headache, consistent with a post dural puncture headache (PDPH). Conservative management with caffeine and acetaminophen did not provide relief. She was instructed to return to the hospital allowing us to perform an epidural blood patch at the L2-L3 level. LOR to air technique was employed, and 18 milliliters of autologous blood was injected at that level. The headache persisted, warranting further investigation. MRI brain without contrast demonstrated diffuse dural thickening overlying the left temporal lobe along with posterior falcine subdural hematoma (SDH) measuring 2 millimeters. Within the next 2 days, the patient subsequently underwent diagnostic cerebral angiography which found a partially thrombosed dural arteriovenous fistula leading to a curative transarterial embolization of the arteriovenous fistula. Patient was monitored in the ICU for 24 hours before being transferred to the medical wards for an additional 24 hours. She was discharged home with instructions to follow up with neurology and neurosurgery in 2 weeks. Patient received daily calls for one week after discharge to ensure complete resolution of symptoms.
Discussion: Although subdural hematoma is an uncommon complication from neuraxial anesthesia, for women with post-dural puncture headache, the rate of incidence of SDH was found to be approximately 147 per 100,000 deliveries. Patients who develop PDPH after labor analgesia should be closely monitored for neurologic signs that could be attributed to subdural hematoma. This can either be done with the patient remaining in the hospital or with daily calls to assess for concerning neurologic signs and symptoms for a minimum of one week after the onset of the headache.