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 Table of Contents  
Year : 2021  |  Volume : 41  |  Issue : 2  |  Page : 92-95

Intracranial subdural hematoma following spinal anesthesia: A case report and literature review

1 Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei; Department of Anesthesiology, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
2 Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
3 Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei; Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
4 Department of Orthopedic Surgery, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan

Date of Submission23-Apr-2020
Date of Decision12-Aug-2020
Date of Acceptance14-Sep-2020
Date of Web Publication06-Oct-2020

Correspondence Address:
Dr. Wei-Cheng Tseng
Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, No. 325, Section 2, Chenggong Road, Neihu District 114, Taipei
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmedsci.jmedsci_104_20

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Intracranial subdural hematoma (ICSH) is a rare complication of spinal anesthesia (SA). Because of similar characteristics with postdural puncture headache (PDPH), the definitive diagnosis of ICSH is usually delayed or masked, which potentially results in morbidity or mortality. Herein, we report the case of a young male who developed ICSH following SA and emphasize the differences between ICSH and PDPH in terms of atypical presentations. Furthermore, this report aims to identify the criteria for performing an epidural blood patch in patients with ICSH after dural puncture.

Keywords: Epidural blood patch, intracranial subdural hematoma, lumbar puncture, postdural puncture headache, spinal anesthesia

How to cite this article:
Lin SL, Yeh CC, Wu ZF, Pan RY, Tseng WC. Intracranial subdural hematoma following spinal anesthesia: A case report and literature review. J Med Sci 2021;41:92-5

How to cite this URL:
Lin SL, Yeh CC, Wu ZF, Pan RY, Tseng WC. Intracranial subdural hematoma following spinal anesthesia: A case report and literature review. J Med Sci [serial online] 2021 [cited 2023 Feb 7];41:92-5. Available from: https://www.jmedscindmc.com/text.asp?2021/41/2/92/297427

  Introduction Top

Spinal anesthesia (SA) is a commonly used technique for orthopedic, urological, obstetric, gynecological, and lower abdominal surgeries. Although SA is a safe and simple procedure, it really causes many complications including hypotension, back pain, postdural puncture headache (PDPH), spinal or epidural hematoma, and nerve injury.[1] Furthermore, SA may lead to rare but life-threatening complications, such as intracranial subdural hematoma (ICSH) or cardiac arrest, with an incidence rate of approximately 0.0%.[1],[2],[3] Among these dreadful consequences, the incidence rate of ICSH after neuraxial anesthesia is 0.0002% in the obstetric population.[1],[4] Because ICSH and PDPH have similar characteristics, it is difficult to promptly recognize and treat ICSH. Once immediate interventions are delayed, the clinical outcome of ICSH can be devastating. Herein, we present the case of a 26-year-old male who developed ICSH after SA for knee arthroscopic surgery. In this case, we emphasize the importance of close follow-up and differential diagnoses in patients with headache following SA or lumbar puncture. Moreover, the requirements for performing an epidural blood patch (EBP) when ICSH develops after dural puncture (DP) are presented.

  Case Report Top

A 26-year-old male (height, 175 cm; weight, 65 kg; and body mass index, 21.2 kg/m2), classified as physical status Class I by the American Society of Anesthesiologists, was scheduled for arthroscopic surgery due to a tear in the right anterior cruciate ligament. Preoperatively, he denied any significant medical history, and routine examination results were not remarkable.

Before surgery, SA was attempted only once (BD spinal needle, 26G × 3½”) with a median approach at the L4/L5 interspace while the patient was in the left lateral decubitus position. After verifying the leakage of clear cerebrospinal fluid (CSF), the patient received 15 mg of 0.% isobaric bupivacaine intrathecally. No flashing pain or other abnormalities were observed during the injection of bupivacaine. Ten minutes after SA, the pinprick test revealed bilateral symmetric sensory block cephalad to T10. The 90-min arthroscopic procedure was performed in the supine position and was uneventful. Then, he was transferred to the postanesthesia care unit and discharged to the ward under stable vital signs.

Seventeen hours after the surgery, the patient complained of severe postural headache with a numerical rating scale (NRS) of 7–8 in the bilateral frontal regions. No concomitant neurological signs and symptoms were observed. Owing to the strong suspicion of PDPH, the patient received conservative treatment with analgesics and intravenous hydration and was instructed to take bed rest. After 2 days, he was discharged from our hospital with partial relief of headache (NRS of 3–4).

However, 3 days after discharge, the patient presented to our emergency department with persistent and diffuse headache (NRS of 6–7), which progressively changed from postural to nonpostural headache, and his headache became unresponsive to medical treatment. No fever, chills, nausea, vomiting, or other neurological deficits were observed at that time. To rule out intracranial pathologies, he underwent computed tomography scan, which revealed a 5-mm-thick subdural hematoma along the left falx cerebri and tentorium [Figure 1]. Without any history of trauma or hematological abnormalities, it was speculated that the development of ICSH may result from DP-related massive CSF leakage and subsequent overstretches of the subdural bridging veins (SBVs) during postural changes. Because the patient had stable vital signs and did not present with any neurological symptoms, except for intolerable headache, emergent surgical intervention was not indicated. On the next day, a brain computed tomography scan was performed again, and the size of the hematoma did not change. To prevent repeated stretches in the ruptured SBVs, an EBP was performed using an epidural needle (Tuohy epidural needle, 16G × 80 mm), and 20 mL of autologous blood was administered through the L4/L5 epidural space. No remarkable events were observed during the procedure.
Figure 1: A 26-year-old male with nonpostural headache following spinal anesthesia. The transverse view of brain computed tomography in the emergency department showed a thin layer of subdural hematoma (arrowhead) along the left falx cerebri and tentorium, measuring up to 5 mm in thickness.

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Although the patient still presented with moderate nonpostural headache immediately after the EBP, the degree of severity of headache improved gradually in the next 2 days with conservative treatment. The patient was then discharged when his headache subsided (NRS of 1–2), and no neurological deficits developed. The 1-month follow-up was uneventful, and the ICSH diminished in the succeeding neuroimaging.

  Discussion Top

PDPH is a frequent complication of neuraxial anesthesia and lumbar puncture. According to the latest diagnostic criteria of the International Headache Society,[5] PDPH is defined as a postural headache that occurs within 5 days after DP. It is usually accompanied by other symptoms such as neck stiffness, nausea, vomiting, and vertigo.[5],[6] Moreover, its symptoms often resolve spontaneously within 2 weeks[5] or 48 h when conservative therapies or EBPs are provided.[2]

The primary mechanism underlying ICSH after DP, which is similar to PDPH, may be the excessive leakage of CSF, causing intracranial hypotension and subsequent caudal displacement of the brain with gravitational traction on pain-sensitive structures including the SBVs.[1],[2],[3],[4],[6],[7],[8],[9],[10] If the traction force is substantial, it may cause the rupture of the weakest point of the SBVs.[1],[4],[6],[10] The extravasation of blood can accumulate over time and result in the symptoms of ICSH including headache or other focal neurological deficits associated with increased intracranial pressure (IICP) and mass effect.

Because headache is the most common symptom of both ICSH and PDPH,[8] early differentiation is extremely important to provide immediate management. The time interval from the initial symptoms to the definitive diagnosis of ICSH varies from 4 h to 29 weeks with a mean of 22 days,[2],[4] which depends on age, comorbidities, size and location of hematoma, and speed of hematoma formation.[2] Acute bleeding may rapidly become symptomatic; nevertheless, subacute or chronic ICSH can be easily confused with PDPH due to initial orthostatic headache and responsiveness to common treatment.[2],[7],[10] The increase in intracranial pressure from the progression of ICSH may also compensate for the decreased intracranial pressure attributed to CSF leakage, which probably causes temporary improvement or disappearance of headache.[9] Then, the persistent increase in intracranial pressure from ICSH may gradually cause headache again, which loses postural relation as well as efficacy to conservative therapy and accompanies other neurological deteriorations.[2],[7]

Although there are similar presentations between ICSH and PDPH, they have four major different characteristics. First, ICSH usually causes nonpostural headache,[1],[2],[3],[4],[7],[8],[10] unilaterally or bilaterally involving the frontal, parietal, and temporal regions alone or in combination.[7] However, PDPH almost always causes postural headache,[2],[3],[5],[7],[8] which is located in the bilateral frontal or occipital region.[8] Second, headache caused by ICSH may last for more than 5–7 days,[1],[2],[3],[4],[10] which is longer than the common course of PDPH. Third, ordinary therapies often do not improve the symptoms of patients with ICSH,[1],[2],[3],[7] and performing an EBP may worsen headache due to an increase in intracranial pressure.[2],[4] Fourth, ICSH may develop, besides headache, other neurological abnormalities such as conscious disturbance, convulsion, and paresis or plegia.[2],[3],[4],[7],[8],[10]

The major risk factors associated with ICSH following DP are pregnancy,[1],[2],[3],[4],[6] dehydration,[3],[4],[6] multiple dural penetrations,[1],[2],[3],[4],[6] use of large needle,[1],[3],[4],[8] use of anticoagulants,[2],[3] cerebral vascular abnormalities,[2],[3],[4] and brain atrophy.[2],[3],[4] In addition, other contributing factors in terms of comorbidities include coagulopathy,[1],[3],[4] chronic alcoholism, cardiovascular disease, and diabetes mellitus.[1] As a result, careful follow-up in high-risk patients presenting with an atypical headache after DP is also crucial. If ICSH is suspected, neuroimaging should be carried out as early as possible to confirm the diagnosis and provide prompt treatment.

The management of ICSH includes either conservative follow-up or surgical decompression, which depends on the severity of symptoms and the size of the hematoma. If the hematoma is <5 mm in thickness with minimal or mild neurological manifestations, it can be treated conservatively with close follow-up and usually resolves spontaneously.[1],[8],[10] Once progressive neurological deficits are observed, surgical decompression may be required to reduce intracranial pressure and preserve brain function.[1],[3],[4],[6],[8],[10]

In general, EBP is an effective treatment for PDPH.[4],[6] Because performing an EBP may cause a sudden increase in the intraspinal and intracranial pressure,[6],[9],[10] it may lead to further neurological deteriorations and is not usually recommended in patients with significant intracranial space-occupying lesions. However, early EBP may prevent excessive and repeated meningeal stretch and rebleeding in patients having small ICSH after DP without IICP signs. Although the level of pain relief after EBP may not be satisfactory in patients with ICSH, this modality can be effective in preventing the expansion of hematoma and speeding the patients' recovery. Based on our experiences and previous reports,[4],[9],[10] some criteria must be met before performing an EBP in patients with ICSH. First, patients should not initially present with neurological symptoms, or, if symptoms are observed, they should be minimal to mild. Second, there is no significant shift in the midline of the cerebral structures based on the current neuroimaging. Finally, acute aggravation of symptoms does not develop within a short period (<24 h) after diagnosis. Moreover, when performing an EBP, sedation should be avoided because it may interfere with judgment about patients' consciousness, which may be exacerbated by IICP.

  Conclusion Top

Due to similarities of clinical characteristics, ICSH is easily confused with PDPH. Once patients complain of atypical headache following DP, including prolonged and nonpostural headache, nonresponsiveness to standard treatment for PDPH, and development of neurological symptoms, physicians should always consider the diagnosis of ICSH to prevent subsequent mortalities and morbidities. In suspected cases of ICSH, neuroimaging is the most effective and easiest method that can validate such a condition. If the diagnosis is confirmed, patients should be managed conservatively or surgically based on clinical symptoms and hematoma size. Furthermore, the criteria for performing an EBP in patients with ICSH are extremely crucial. Early EBP can be effective in preventing the aggravation of ICSH in patients without IICP and in promoting patients' recovery.


We thank the patient for signing the informed consent for publication.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Metin KM, Güzel II, Oskovi A, Guzel AI. Chronic subdural hematoma following spinal anesthesia for cesarean section. J Exp Ther Oncol 2017;11:97-9.  Back to cited text no. 1
Amorim JA, Remígio DS, Damázio Filho O, de Barros MA, Carvalho VN, Valença MM. Intracranial subdural hematoma post-spinal anesthesia: Report of two cases and review of 33 cases in the literature. Rev Bras Anestesiol 2010;60:620-9, 344-9.  Back to cited text no. 2
Moradi M, Shami S, Farhadifar F, Nesseri K. Cerebral subdural hematoma following spinal anesthesia: Report of two cases. Case Rep Med 2012;2012:352028.  Back to cited text no. 3
Szeto V, Kosirog J, Eilbert W. Intracranial subdural hematoma after epidural anesthesia: A case report and review of the literature. Int J Emerg Med 2018;11:36.  Back to cited text no. 4
Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia 2018;38:1-211.  Back to cited text no. 5
Cuypers V, van de Velde M, Devroe S. Intracranial subdural haematoma following neuraxial anaesthesia in the obstetric population: A literature review with analysis of 56 reported cases. Int J Obstet Anesth 2016;25:58-65.  Back to cited text no. 6
Schweiger V, Zanconato G, Lonati G, Baggio S, Gottin L, Polati E. Intracranial subdural hematoma after spinal anesthesia for cesarean section. Case Rep Obstet Gynecol 2013;2013:253408.  Back to cited text no. 7
Kale A, Emmez H, Pişkin Ö, Durdağ E. Postdural puncture subdural hematoma or postdural puncture headache? Two cases report. Korean J Anesthesiol 2015;68:509-12.  Back to cited text no. 8
Domoto S, Suzuki M, Suzuki S, Bito H. Subdural hematoma after cesarean delivery without symptoms: A case report. JA Clin Rep 2018;4:18.  Back to cited text no. 9
Zekaj E, Saleh C, Minichiello M, Perazzo P, Servello D. How to treat repeated subdural hematomas after lumbar puncture? Asian J Neurosurg 2019;14:249-52.  Back to cited text no. 10
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