Headache with warning signs associated with subdural hematoma post-spinal anesthesia

a case report of a rare complication

Abstract

Introducion: Post-spinal anesthesia headache is a common complication, but the occurrence of a subdural hematoma is rare and may present with warning signs that require immediate attention. Objectives: The objective of this report is to present a case of headache with warning signs associated with a subdural hematoma, diagnosed after spinal anesthesia performed with a fine-gauge needle and a single puncture, emphasizing the importance of early recognition and appropriate management of this rare complication. Case Report: A 50-yearold female patient with uterine cancer, undergoing radiotherapy, developed actinic cystitis and urethrorrhagia without hemodynamic or hematimetric alterations. She underwent spinal anesthesia for intra-vesical cauterization using a 27G Quincke needle with a single puncture. The surgical procedure was uneventful. After 48 hours, she developed a sudden onset of severe bilateral occipital headache (8/10), associated with nausea and vomiting. This was interpreted as a post-dural puncture headache (hypotension) and was treated with fluids, caffeine, and analgesics by the medical team. She returned to the emergency department 13 days later with a worsening headache, decreased level of consciousness, and dense brachiocrural hemiparesis on the left side. A cranial CT scan revealed a chronic right frontoparietal subdural hematoma with mass effect and midline shift. She was taken to the operating room for hematoma drainage. After trepanation, hypertensive hematoma drainage was observed. The procedure was uneventful, and the patient remained hospitalized for 5 days for monitoring and was discharged with complete recovery from deficits. Discussion: This case highlights the importance of differentiating benign headaches from serious secondary conditions. We reviewed the literature on the incidence, pathophysiology, and management of post-spinal anesthesia subdural hematomas. However, intracranial subdural hematoma constitutes a rare complication, with an incidence ranging from 1:500.000 to 1:1.000.000. The pathophysiological mechanism remains uncertain, though the leading hypothesis suggests that the loss of cerebrospinal fluid through the needle puncture causes a volumetric and pressure decrease in the dynamics of the closed circulatory system, leading to gravity-dependent brain displacement. This results in traction of cerebral structures and rupture of bridging veins. Consequently, the case illustrates a rare complication with nonspecific symptoms, making the early diagnosis of subdural hematoma challenging, which, if neglected, can result in a fatal outcome. This case emphasizes the importance of distinguishing benign headaches from serious secondary conditions. We review the literature on the incidence, pathophysiology, and management of subdural hematomas following spinal anesthesia. Conclusion: Early recognition of warning signs in patients with headaches following spinal anesthesia is crucial to prevent adverse outcomes. Subdural hematoma should be considered in the differential diagnosis of headaches with warning signs.