Subdural haemorrhage following epidural top-up for caesarean section

Background & aims

Subdural haemorrhage after epidural is a rare complication, which can pose diagnostic challenge given the varied differentials for intrapartum headache. We present a 30-year-old fit and well female at 40 weeks and 2 days gestation with an epidural uneventfully sited. Two top-ups were administered without issue before a category two caesarean was instigated for failure to progress and cardiotocography concerns.

Methods

A test dose of 3 mls of 2% lidocaine with 5 micrograms/ml of adrenaline resulted in rapid lightheadedness, followed by difficulty in breathing. Over 5 minutes there was progressive decrease in consciousness, becoming unresponsive, with a fixed, dilated right pupil, accompanied by desaturation but no cardiovascular instability. Emergency rapid sequence induction of general anaesthesia was performed, oxygenation improved and the right pupil resolved. Following delivery, the uterus was felt to be atonic, oxytocin and carboprost were administered, avoiding ergometrine in case of undiagnosed eclampsia.

Results

Whilst maintaining neuroprotection, CT head imaging showed a subdural haematoma, within the falx cerebri, with no other sites of haemorrhage. A neurosurgical referral advised no acute surgical intervention and the patient was successfully extubated with no residual neurology.

Magnetic resonance venography demonstrated no evidence of venous sinus thrombosis and neurology review suggested intracranial hypotension the likely trigger for subdural haemorrhage. The patient remained clinically well, although developed hypertension on day three, requiring labetalol, and occipital headache on day four. CSF was noted on epidural removal.

Conclusions

Despite being a rare complication, subdural haemorrhage is an important differential for post-epidural headache due to potentially catastrophic consequences.