Subarachnoid and intraventricular hemorrhage due to ruptured aneurysm after combined spinal-epidural anesthesia.

A patient received combined spinal-epidural anesthesia for a scheduled total knee arthroplasty. After an injection of spinal anesthetic and ephedrine due to a decrease in blood pressure, the patient developed a severe headache. The patient did not respond to verbal command at the completion of the operation. A brain CT scan revealed massive subarachnoid and intraventricular hemorrhages, and a CT angiogram showed a ruptured aneurysm. Severe headaches should not be overlooked in an uncontrolled hypertensive patient during spinal anesthesia because it may imply an intracranial and intraventricular hemorrhage due to the rupture of a hidden aneurysm.