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\begin{document}

\title{A right-sided subdural frontoparietal hemorrhage in a patient after
spinal anesthesia for cesarian section surgery. Case report}



\author[1]{Shahpour Shoja}%
\author[1]{Shokrollah Zandi}%
\author[1]{Nasrin soufizadeh}%
\author[1]{Shaho Shoja}%
\affil[1]{Kurdistan University of Medical Sciences}%


\vspace{-1em}



  
  \date{June 05, 2024}


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\textbf{A right-sided subdural frontoparietal hemorrhage in a patient
after spinal anesthesia for cesarian section surgery. A Case report}

Sh Shoja MD\textsuperscript{1*}, Sh Zandi MD\textsuperscript{2}, N
Soufizadeh MD\textsuperscript{3}, Sh Shoja MD\textsuperscript{4}

\textsuperscript{For this manuscript,written informed consent was
obtained from the patient to publish this report in accordance with the
journal's patient consent policy. Additionally, if the
patient/participant is unable to give written consent or is deceased,
the same can be obtained from the patient's next of kin. If the patient
is a child or under the age of 16, written consent should be obtained
from a parent/guardian.}

\begin{enumerate}
\tightlist
\item
  Department of Anesthesiology, Faculty of Medicine, Kowsar Hospital,
  Kurdistan University of Medical Sciences, Sanandaj, Iran,
  shshoja@hotmail.com ORCID: 0009-0005-2828-5591
\item
  Department of Neurosurgery, Faculty of Medicine, Kowsar Hospital,
  Kurdistan University of Medical Sciences, Sanandaj, Iran,
  zandi611@yahoo.com ORCID: 0000-0003-2733-1961
\item
  Department of Obstetrics and Gynecology, Faculty of Medicine, Besat
  Hospital, Kurdistan University of Medical Sciences, Sanandaj, Iran
  nsoofizadeh@hotmail.com ORCID: 0000-0001-8284-8440
\item
  Student Research Committee, Kurdistan University of Medical Sciences,
  Sanandaj, Iran, shahoshoja@gmail.com ORCID:
  0000-0003-1982-9102\textbf{*Corresponding Author:}Mobile:
  +989183724633 E-Mail (1): shshoja@hotmail.com E-Mail (2):
  shahoshoja@gmail.com
\end{enumerate}

Abstract:

\textbf{Background} : Peridural and subdural hemorrhage are rare but
important complications after regional anesthesia.

\textbf{Case presentation:} A 29 year old female gravid 1, para 1, with
a history of cesarian section, was admitted for headache exacerbation.
The patient received spinal anesthesia. The patient didn't have any
specific disease or previous headache. The drug history was negative
except for routine pregenetic drugs. Although, at the time of Spinal
anesthesia, the patient was slightly nervous. All previous pre-operation
tests and exams were normal. The patient experienced a mild headache a
day after the surgery; adequate liquid intake was recommended. The
patient was discharged 48 hours after the surgery. Furthermore, after
about a week, the patient contacted her primary physician for
exacerbated headache. The physician recommended her liquid intake, rest,
and proper analgesia. Ten days after surgery, the patient visited a
clinic for an excruciating headache with vomiting. Therefore, the
patient was admitted emergently. The neurosurgery consult and Magnetic
Resonance Imaging (MRI) scan was performed. A subdural frontoparietal
hemorrhage on the right side was diagnosed. The patient's hematoma was
drained emergently afterward. The patient was discharged four days after
the drainage surgery without neurological complications.

\textbf{Conclusion:} Peridural and subdural hemorrhages are rare
complications of spinal anesthesia that can be lethal. The chief
complaint of this complication is headache. It is essential to keep this
complication in mind for patients experiencing headaches after spinal
anesthesia surgeries.

\textbf{Keywords:} Spinal anesthesia, Subdural hematoma, Regional
anesthesia, Post dural puncture headache, Cesarian section

\textbf{Introduction:} Peridural or subdural hematoma is one of the rare
but essential complications of spinal anesthesia(1). The main complaint
of this complication is headache. Additionally, the risk of Post Dural
Puncture Headache in obstetric patients is higher than in the general
population(2).

\textbf{Case:} A 29 year old female gravid 1, para 1, with a history of
the cesarian section, was admitted on 21 August 2022 at Kowsar Hospital
(Sanandaj, Iran) for headache exacerbation. The patient received spinal
anesthesia with a gauge 25 needle placed L3-L4. The patient didn't have
any specific disease or previous headache. The drug history was negative
except for routine pregenetic drugs. Although, at the time of Spinal
anesthesia, the patient was slightly nervous. All previous pre-operation
tests and exams were normal. The patient experienced a mild headache a
day after the cesarian section surgery; adequate liquid intake was
recommended. The patient was discharged 48 hours after the surgery.
Furthermore, after about a week, the patient contacted her primary
physician for exacerbated headache. The physician recommended her liquid
intake, rest, and proper analgesia. Ten days after surgery, the patient
visited a clinic for an excruciating headache with vomiting. Therefore,
the patient was admitted emergently. The neurosurgery consult and
Magnetic Resonance Imaging (MRI) scan was performed. A subdural
frontoparietal hemorrhage on the right side was diagnosed (Figure 1).
The patient's hematoma was drained emergently afterward. The patient was
discharged four days after the drainage surgery without neurological
complications. Furthermore, a follow-up CT was done after two months,
and the result was normal (Figure 2). For reporting as a manuscript,
written informed consent was obtained from the patient to publish this
report in accordance with the journal's patient consent policy\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

Figure 1. Magnetic Resonance Imaging (MRI) of the patient's brain
showing A right-sided subdural frontoparietal hemorrhage (A: Coronal
view B: Sagittal view)\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

Figure 2. 2-month follow-up CT of the patient's brain showing no
abnormality (Coronal view)

\textbf{Discussion:} Neuraxial anesthesia (NA) for labor and delivery is
generally very safe, but all interventions are associated with adverse
effects(3). Some documented NA complications in obstetrics are Local
anesthetic systemic toxicity (LAST), Inadequate anesthesia, Motor block,
Post dural puncture headache, Pneumocephalus (Injection of air into the
subarachnoid space during placement of neuraxial block), Spinal epidural
hematoma, Spinal epidural hematoma, Postpartum neuropathy, and severe
infection(4-6). Serious and permanent neuraxial anesthesia complications
are rare, and most injuries are resolved within six months(7).

Headache is one of the common signs seen in postpartum after delivery.
Commonly, these postpartum headaches are benign, primary headaches such
as migraine or tension type headaches resulting from sleep deprivation,
stress, or estrogen withdrawal seen in the postpartum period(8).
However, since most cesarean deliveries are done with NA anesthesia,
anesthesiologists are frequently consulted to evaluate and treat
postpartum headaches. More importantly, to differentiate between benign
primary headaches, post-dural puncture headache (PDPH), and severe
structural diseases such as intra-cranial subdural hematoma(2).

A subdural hematoma can develop as a rare complication of dural
puncture; the loss of CSF may shift the brain caudally and cause
intracranial subdural veins to tear. According to Yamashima and Friede
study, the thinnest parts of a bridging vein's wall are in the subdural
space, which is more fragile than the subarachnoid portion(2).

In Yanmei Bi and colleagues' study done in 2021. A 21-year-old
parturient, gravida 1, para 1, with twin pregnancies, underwent cesarean
delivery. Unlike the current study, the Spinal anesthesia was with
several failed attempts. Subsequently, it caused unexpected blockade
above T2, tinnitus, dyspnea, and inability to speak after the delivery;
the patient was awake with normal tidal volume, and the endotracheal
tube was removed. Postoperative magnetic resonance imaging suggested a
spinal subdural hematoma extending from T12 to the cauda equina. Sensory
and motor function completely recovered five hours after surgery. She
denied headaches, low back pain, or any other neurologic deficit. The
patient was discharged six days after surgery. One month later, a repeat
MRI was normal. The patient. In this study, the hematoma may be due to
complications accrued during anesthesia due to technical errors, unlike
the current case study, where no complications were recorded(9).

In Bulent Bakara and colleagues' study done in 2013, similar to the
current case report, a 34 year old primigravid woman underwent a
cesarean section with combined spinal-epidural anesthesia and gave birth
to a healthy boy. However, about 32 hours after the surgery, she
experienced a progressively moderate headache accompanied by nausea and
vomiting, subsequently causing generalized tonic-clonic seizure and
ensuing lethargy. The brain CT showed a right-sided
fronto-temporo-parietal acute subdural hematoma with diffuse cerebral
edema. She underwent urgent FTP craniotomy and evacuation of the
hematoma. Despite early postoperative CT showing a clean operative site,
she became lethargic again Eight days after the surgery. The new CT
showed an extradural hematoma under the bone flap, for which she had to
undergo surgery again. Ultimately, the follow up showed no
abnormality(10)

In Hoang and colleagues' case report in 2022, a 34 year old female
underwent spinal anesthesia for her cesarian delivery. Similarly to the
current study, she experienced a headache two days after the surgery.
Right facial paralysis, mild eye pain, and blurred vision were other
signs and symptoms. The cranial CT showed a mildly hyperattenuating
pituitary gland and a thin layer of subdural hematoma in the left
frontal region. The MRI revealed pituitary apoplexy and left frontal
subdural hematoma. Subsequently, The patient was treated conservatively,
and ultimately in the follow, laboratory tests and imaging exams to
check pituitary function did not reveal any abnormalities(11).

According to the current case and other case reports, the subdural
hematoma can develop as a rare complication of dural puncture. The main
complication is headache, and the incidence of Post Dural Puncture
Headache in obstetric patients is higher, especially in young pregnant
women with low body mass index(12).

Ongoing headaches that are not relieved with conservative approaches and
are accompanied by other manifestations like nausea, vomiting, and
neurological deficits are recommended to be investigated and followed
radiologically and neurologically(1, 13).

\textbf{Conclusion:} Peridural and subdural hemorrhages are rare but
essential complications of spinal anesthesia that can be lethal. The
chief complaint is a headache seen more frequently in obstetric patients
and cesarian section surgeries. It is essential to keep this
complication in mind for patients experiencing headaches after spinal
anesthesia surgeries.

\textbf{Ref}

1. Amorim JA, Rem\selectlanguage{ngerman}ígio DSCdA, Damázio Filho O, Barros MAGd, Carvalho VN,
Valença MM. Intracranial subdural hematoma post-spinal anesthesia:
report of two cases and review of 33 cases in the literature. Revista
brasileira de anestesiologia. 2010;60:624-9.

2. Cuypers V, Van de Velde M, Devroe S. Intracranial subdural hematoma
following neuraxial anaesthesia in the obstetric population: a
literature review with analysis of 56 reported cases. International
journal of obstetric anesthesia. 2016;25:58-65.

3. Wang T-T, Sun S, Huang S-Q. Effects of epidural labor analgesia with
low concentrations of local anesthetics on obstetric outcomes: a
systematic review and meta-analysis of randomized controlled trials.
Anesthesia \& Analgesia. 2017;124(5):1571-80.

4. Thew M, Paech MJ. Management of postdural puncture headache in the
obstetric patient. Current Opinion in Anesthesiology. 2008;21(3):288-92.

5. Jespersen MS, Jaeger P, Ægidius KL, Fabritius ML, Duch P, Rye I, et
al. Sphenopalatine ganglion block for the treatment of postdural
puncture headache: a randomised, blinded, clinical trial. British
Journal of Anaesthesia. 2020;124(6):739-47.

6. Pozza DH, Tavares I, Cruz CD, Fonseca S. Spinal Cord Injury and
Complications Related to Neuraxial Anaesthesia Procedures: A Systematic
Review. International journal of molecular sciences. 2023;24(5):4665.

7. Cook T, Counsell D, Wildsmith J. Major complications of central
neuraxial block: report on the Third National Audit Project of the Royal
College of Anaesthetists. British journal of anaesthesia.
2009;102(2):179-90.

8. Meyer MJ, Krane EJ, Goldschneider KR, Klein NJ. Neurological
complications associated with epidural analgesia in children: a report
of 4 cases of ambiguous etiologies. Anesthesia \& Analgesia.
2012;115(6):1365-70.

9. Bi Y, Zhou J. Spinal subdural hematoma and subdural anesthesia
following combined spinal--epidural anesthesia: a case report. BMC
anesthesiology. 2021;21(1):130.

10. Bakar B, Ozer E, Tekkok IH. Life-threatening acute subdural
haematoma after combined spinal-epidural anaesthesia in labour. Revista
Brasileira de Anestesiologia. 2015;65:417-20.

11. Hoang VT, Hoang TH, Nguyen TTT, Chansomphou V, Hoang DT. Pituitary
Apoplexy and Subdural Hematoma after Caesarean Section. Case Rep Obstet
Gynecol. 2022;2022:3097949.

12. de Almeida SM, Shumaker SD, LeBlanc SK, Delaney P, Marquie\selectlanguage{english}-Beck J,
Ueland S, et al. Incidence of post\selectlanguage{english}-dural puncture headache in research
volunteers. Headache: The Journal of Head and Face Pain.
2011;51(10):1503-10.

13. Soofizadeh N, Farhadipour F, Rezayi M, Moradi M, Shojaa S. A Rare
Case Report of Cerebral Subdural Hematoma following Cesarean Section
under Spinal Anesthesia. The Iranian Journal of Obstetrics, Gynecology
and Infertility. 2012;15(17):25-9.\selectlanguage{english}
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