Case Presentation: Intracranial subdural hematoma (ISH) is a rare and fatal complication of spinal anesthesia (SA); therefore a high index of suspicion for ISH should be considered when a case of suspected postdural puncture headache (PDPH) does not improve with conservative management. A 36-year-old female presented to the emergency room complaining of worsening headache of 3 weeks duration; described as severe with standing and improved upon lying supine. She reported cesarean section one month prior to presentation complicated by massive bleeding requiring SA. One week postpartum she returned to the ED complaining of recurring moderate headache. She was treated with hydration and acetaminophen due to clinical suspicion of PDPH. On our presentation, she reported related neck pain without rigidity. No neurological deficits identified. Laboratory studies were pertinent for WBC of 11500; coagulation studies unremarkable. A brain tomography without contrast revealed bilateral, acute subdural hematomas measuring 12 mm in thickness, subacute to chronic blood product in the right hemisphere, and mild prominence of the temporal ventricle horns bilaterally, with the cerebellar tonsils low-lying bilaterally suggesting early sequelae of tonsillar herniation. A brain angiogram was unremarkable. A brain MRI identified dural enhancement, low-lying cerebellar tonsils, and slouching of the bilateral prechiasmatic optic nerves suggestive of intracranial hypotension. A lumbar spine MRI was pertinent for low-lying conus medullaris suggestive of central hypotension. The direct CSF leak was not visualized. The patient was managed with strict bedrest at 15-30 degrees Trendelenburg, intravenous hydration and pulse steroids for 3 days. The treatment was unsuccessful. Subsequently, a blood patch was performed at bedside resulting in complete resolution of symptoms. She was discharged the next day with a follow-up brain CT and clinic appointment.
Discussion: ISH is an extremely rare event following epidural anesthesia with only a few cases being reported. A higher incidence is noted in obstetric population. PDPH and ISH can initially present similarly, resulting in a delayed diagnosis of ISH as in our patient.
Conclusions: However, persistence of symptoms with worsening severity should raise suspicion for ISH and warrants a brain CT to evaluate for acute lesions as well as an MRI to detect chronic lesions.