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\begin{document}

\title{A Case of Post-partum Chronic Subdural Hematoma.}



\author[1]{Suyasha Rajbhandari}%
\author[1]{Pritam Gurung}%
\author[1]{Gopi Nepal}%
\author[1]{Samir Acharya}%
\author[1]{Basant Pant}%
\affil[1]{Annapurna Neurological Institute and allied Sciences}%


\vspace{-1em}



  
  \date{May 03, 2024}


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\selectlanguage{english}
\begin{abstract}
Intracranial subdural hematoma following spinal anesthesia is an
infrequent occurrence and has variable presentation. Due to rarity, it
may often be misdiagnosed as post-dural puncture headache. In this
report, we describe a case of a 25-year-old woman who presented with a
headache following lower segment cesarean section after spinal
anesthesia.%
\end{abstract}%



\sloppy


\textbf{A Case of Post-partum Chronic Subdural Hematoma.}

\textbf{Authors:}

Suyasha Rajbhandari M.B.B.S\textsuperscript{1}

Pritam Gurung, M.D, Ph.D\textsuperscript{1}

Gopi Nepal, M.B.B.S\textsuperscript{1}

Samir Acharya, M.S\textsuperscript{1}

Basant Pant, M.D.,Ph.D\textsuperscript{1}

1 = Department of Neurosurgery, Annapurna Neurological Institute and
allied Sciences, Maitighar, Kathmandu, Nepal.

\textbf{Corresponding Author:}

Suyasha Rajbhandari

Annapurna Neurological Institute and allied Sciences, 44700, Kathmandu,
Nepal

Email: suyasharajbhandari1882@gmail.com

Phone No.: +977-9849620285

\textbf{INTRODUCTION:}

Spinal anesthesia is commonly used anesthesia during obstetric
procedures. Although complications related to spinal anesthesia are
generally benign, about 0.05\% of complications are
critical\textsuperscript{1,2}. Post-dural puncture headache (PDPH ) and
hypotension are the most common complication of spinal
anesthesia\textsuperscript{3}.

Intracranial subdural hematoma (ISH) is one of the rare but fatal
complications of spinal anesthesia \textsuperscript{1}. ISH following
spinal anesthesia is reported to be more common in the obstetric
population. The incidence rate of ISH following neuraxial anesthesia in
the obstetric population is 0.0002\% \textsuperscript{2}.

The most common presentation of intracranial subdural hematoma is
headache (74--91\%) \textsuperscript{2,4}. When headache is the
presenting complaint in the puerperal period, ISH is rarely presumed,
leading to misdiagnosis and delay in treatment. Although an infrequent
complication, early diagnosis of this disease manifested by headache is
crucial during the post-partum period to avoid potentially fatal
complications that will impact both mother and the baby.

This study aims to report a rare case of chronic subdural hematoma
(CSDH) following lower segment cesarean section (LSCS) delivery after
spinal anesthesia and discuss the measures we can take for early
diagnosis and prevention of potentially fatal complications.

\textbf{CASE PRESENTATION:}

A 25-year-old woman presented to our emergency department with a
complaint of persistent progressive, non-postural headache for 3 days.
The headache was insidious in onset and was not associated with nausea,
vomiting, impairment of consciousness, focal weakness, or numbness.
Sixteen days prior to the presentation, she had delivered a baby via
LSCS after spinal anesthesia. She had no history of pre-eclampsia, head
trauma, connective tissue disorder during her pregnancy, and
preoperative hematological, serological, and coagulation studies were
normal. Following the spinal anesthesia and LSCS, she did not have any
reported complications. Her neurological examination at the time of
presentation was unremarkable.

Computed tomography (CT) scan of the head was performed which revealed
up to 0.9 cm thick hypodense CSDH in right fronto-parieto-temporal
convexity with some degree of mass effect and left-sided midline shift
measuring about 0.6 cm from the center (Figure 1). The cerebral CT
arteriogram and cerebral venogram study were normal. Preoperative
hematological and coagulation studies were normal. The patient
subsequently underwent a right frontoparietal burr hole and evacuation
of the hematoma under general anesthesia without complications. On her
third postoperative day, the patient was discharged home.

\textbf{DISCUSSION:}

ISH is a rare complication of spinal anesthesia. About 41 \% of
postpartum ISH becomes chronic and the ratio of acute (31\%) and
subacute (33\%) subdural hematomas (SDH) are similar\textsuperscript{3}.

While the exact incidence of ISH following spinal anesthesia is unknown,
as patients are usually treated conservatively without any
investigations and reporting, it is known that the incidence of
intracranial subdural hematoma following this anesthesia is 1:500,000 --
1,000,000 \textsuperscript{5}.

The mechanism of development of ISH following spinal anesthesia is
analogous to PDPH. It is postulated that the orifice made in the dura
mater after puncturing with the cerebrospinal fluid (CSF) needle,
remains open for several weeks after the puncture. This leads to rapid
loss of CSF which reduces the intraspinal and intracranial pressure.
This causes a caudal shift of the brain, which causes traction of the
structures sensitive to pain and bridging veins in the subdural space
leading to its rupture causing ISH and headache \textsuperscript{5,6}.
The time taken for diagnosis of ISH following a dural puncture ranges
from 4 h to 29 weeks\textsuperscript{2,4}.

The time that is taken from CSF loss to progress to headache and develop
hematoma range from 2 hours to 44 days \textsuperscript{5}. Most often
when physicians come upon a case of headache following spinal
anesthesia, PDPH is assumed to be the cause \textsuperscript{3,7}.
Headache due to PDPH worsens or develops within 15 minutes after sitting
or standing up, and it improves within a similar period after laying
down. It appears within 5 days after the puncture and resolves
spontaneously within 1 week or up to 48 hours after epidural blood
patch\textsuperscript{8,9}. This distinguishing feature helps us to
exclude other causes of postpartum headache. However, in rare
situations, the headache may last for months or even years
\textsuperscript{10}. ISH should be suspected in a patient when PDPH
changes its characteristics to non-postural headache with possible
accompanying features like focal central nervous system (CNS) signs,
impairment in consciousness level, paresis, ptosis, vomiting, blurring
of vision, drowsiness, disorientation, prolonged unresolved headache
\textsuperscript{1,6}. Unlike these typical features, ISH may present
only as a headache and may be unrelated to PDPH \textsuperscript{8}.

Postpartum headaches are quite common (39\%) \textsuperscript{4},
majority of them are primary headaches such as (migraine, tension-type,
and cluster headache) and are therefore considered first in the
differential diagnosis \textsuperscript{4}. Secondary postpartum
headache can be fatal and includes PDPH, eclampsia/pre-eclampsia,
cerebral venous thrombosis, reversible cerebral vasoconstriction
syndrome, pituitary mass/hemorrhage \textsuperscript{4}. It is common
that these headaches coexist and simulate each other in the puerperium
causing difficulty in differentiation \textsuperscript{8}.

Predisposing factors for ISH following spinal anesthesia are pregnancy,
use of large-sized needles, multiple dural punctures dehydration, use of
anticoagulants, cerebral vascular abnormalities, and brain
atrophy\textsuperscript{1,2,9}. Increased susceptibility during
pregnancy may be due to differences in elasticity of the dura,
hemostatic imbalance, and possibly gender-based differences in cranial
morphology\textsuperscript{1}. Due to venous dilatation in pregnancy
intracranial vessels are prone to tear and bleed. Moreover, postpartum
diuresis, peripartum dehydration which could decrease the amount of CSF,
sudden reduction of intra-abdominal pressure, vena caval pressure at
delivery, hormonally-induced ligamentous changes \textsuperscript{3},
Valsalva maneuver at labor \textsuperscript{3,9},
thrombocytopenia\textsuperscript{3,9} increases the susceptibility to
develop cerebral SDH.

Diagnosis of ISH is usually made by a CT scan of the head. However,
cranial Magnetic resonance imaging is more sensitive and specific for
iso-dense CSDH \textsuperscript{7}. Surgery is indicated if the
thickness of hematoma is more than 10 mm, midline shift is greater than
5 mm, or there is neurologic deterioration \textsuperscript{4}. In
absence of the above features, conservative management is recommended
which requires close neurological and radiological follow
ups\textsuperscript{1,2}. In addition, it is established that ISH caused
by dural punctures resulting in long-standing CSF leakage can also be
treated with epidural dural patching \textsuperscript{4}.

The incidence of ISH following spinal anesthesia and development of
related complications is preventable to some extent, vigilance regarding
procedure-related factors, prophylactic monitoring of susceptible
patients, and regular follow-up after discharge help in avoiding
potential morbidity and mortality\textsuperscript{6}.

In the reported case the patient developed headache 13 days after LSCS.
Her headache did not have an association with PDPH and other neurologic
signs. As her symptoms were vague, there was a possibility of
misdiagnosis. Perhaps, the development of CSDH in her case was chiefly
due to the lumbar puncture during spinal anesthesia. Moreover, her
post-pregnancy status may have added up as a predisposing factor for the
progression of the CSDH.

\textbf{CONCLUSIONS:}

ISH is a rare but serious complication following spinal anesthesia and
may mimic PDPH. Cases presenting solely with headaches during the
postpartum period are often assumed to be benign, and conditions such as
ISH may be masked initially resulting in a delay in diagnosis and
intervention. Therefore, with proper neurological examination and
regular follow up the possibility of an ISH must be kept in mind when
evaluating these cases.

\textbf{ABBREVIATION:}

CNS: Central nervous system

CSDH: Chronic subdural hematoma

CSF: Cerebrospinal fluid

CT: Computed tomography

ISH: Intracranial subdural hematoma

PDPH: Post-dural puncture headache

LSCS: Lower segment cesarean section

SDH: Subdural hematoma

\textbf{AUTHOR CONTRIBUTION:}

Suyasha Rajbhandari: Original draft, Conceptualization, review and
editing

Pritam Gurung: Review, editing and supervision

Gopi Nepal: Established the diagnosis and treated the patient.

Samir Acharya: Established the diagnosis and treated the patient.

Basant Pant: Supervision

\textbf{ACKNOWLEDGEMENTS:}

The authors express their gratitude to Dr. Saujanya Rajbhandari for
proof reading of the manuscript.

\textbf{CONFLICT OF INTEREST}

None of the authors have potential conflicts of interest to be
disclosed.

\textbf{ETHICS APPROVAL AND CONSENT TO PARTICIPATE}

Ethical approval of case report is not needed in accordance to the local
ethical guideline. Written informed consent was obtained from the
patient to include the clinical details.

\textbf{KEY CLINICAL MESSEGE}

Headache is common presentation during postpartum period.
Anesthesiologist, obstetrician, and neurosurgeon should be aware about
the possibility of subdural hematoma in patient complaining of headache
following spinal anesthesia.

\textbf{Abstract}

Intracranial subdural hematoma following spinal anesthesia is an
infrequent occurrence and has variable presentation. Due to rarity, it
may often be misdiagnosed as post-dural puncture headache. In this
report, we describe a case of a 25-year-old woman who presented with a
headache following lower segment cesarean section after spinal
anesthesia.

\textbf{Key words}

Post-partum, chronic, subdural

\textbf{References:}

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hematoma following spinal anesthesia: Report of two cases. \emph{Case
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2. Lin S-L, Yeh C-C, Wu Z-F, Pan R-Y, Tseng W-C. Intracranial Subdural
Hematoma Following Spinal Anesthesia: A Case Report and Literature
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Sci} . 2020;41(2):92-95. doi:10.4103/jmedsci.jmedsci\_104\_20

3. Saridogan E. Postpartum subdural hematoma following neuraxial
anesthesia: A case report and review of literature. \emph{Med Sci} .
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4. Szeto V, Kosirog J, Eilbert W. Intracranial subdural hematoma after
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7. \selectlanguage{ngerman}Özdem\selectlanguage{english}{\guilsinglleft}r N, Ari MK, Gelal MF, Bez\selectlanguage{english}{\guilsinglleft}rc\selectlanguage{english}{\guilsinglleft}o\selectlanguage{english}/lu H, Ataturk
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9. Eldemrdash A, Elsharkawy M, Shams G, Ismail K. Chronic Subdural
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10. Kwak KH. Postdural puncture headache. \emph{Korean J Anesthesiol} .
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\textbf{Figure legends:}

Figure 1: Computed tomography scan of the head showing chronic subdural
hematoma in right fronto-parieto-temporal convexity.\selectlanguage{english}
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