Bakar Bulent, Ozer Esra, Tekkok Ismail Hakki
Department of Neurosurgery, Faculty of Medicine, Kirikkale University, Kirikkale, Turkey.
Department of Anaesthesiology and Reanimation, TOBB-ETU Hospital, Ankara, Turkey.
Braz J Anesthesiol. 2015 Sep-Oct;65(5):417-20. doi: 10.1016/j.bjane.2013.07.002. Epub 2013 Oct 16.
Only few reports in literature have pointed out to the possibility of a cranial subdural haematoma formation associated with dural puncture during spinal or epidural analgesia. We herein describe such a rare case who was diagnosed to have acute subdural haematoma after combined spinal-epidural anaesthesia used in labour.
A 34-year-old, primigravid women with a gestation of 38 weeks underwent caesarean section under combined spinal-epidural anaesthesia and gave birth to a healthy boy. Thirty-two hours after delivery, her moderate headache progressed to a severe headache associated with nausea and vomiting and later was more complicated with a generalized tonic-clonic seizure and ensuing lethargy. Computed tomography of the brain demonstrated a right-sided fronto-temporo-parietal acute subdural haematoma with diffuse cerebral oedema. She underwent urgent FTP craniotomy and evacuation of the haematoma. Early postoperative cranial computed tomography showed a clean operative site. Eight days after subdural haematoma surgery, she became lethargic again, and this time cranial computed tomography disclosed an extradural haematoma under the bone flap for which she had to undergo surgery again. Two days later, she was discharged home with Karnofsky performance score of 90/100. At follow-up exam, she was neurologically intact and her cranial computed tomography and magnetic resonance were normal.
As conclusion, with the use of this combined spinal-epidural anaesthesia, it should be kept in mind that headache does not always mean low pressure headache associated with spinal anaesthesia and that a catastrophic complication of subdural haematoma may also occur.
文献中仅有少数报道指出，在脊髓或硬膜外镇痛期间进行硬膜穿刺可能会形成颅内硬膜下血肿。我们在此描述了这样一例罕见病例，该患者在分娩时使用腰麻-硬膜外联合麻醉后被诊断为急性硬膜下血肿。
一名34岁初产妇，妊娠38周，在腰麻-硬膜外联合麻醉下行剖宫产术，产下一名健康男婴。产后32小时，她中度头痛进展为伴有恶心呕吐的严重头痛，随后更并发全身性强直阵挛发作及随之而来的嗜睡。脑部计算机断层扫描显示右侧额颞顶叶急性硬膜下血肿伴弥漫性脑水肿。她接受了紧急额颞顶开颅血肿清除术。术后早期脑部计算机断层扫描显示手术部位干净。硬膜下血肿手术后8天，她再次出现嗜睡，此次脑部计算机断层扫描显示骨瓣下硬膜外血肿，为此她不得不再次接受手术。两天后，她以卡氏评分90/100出院回家。在随访检查中，她神经功能完好，脑部计算机断层扫描和磁共振成像均正常。
总之，使用这种腰麻-硬膜外联合麻醉时，应牢记头痛并不总是意味着与脊髓麻醉相关的低压性头痛，硬膜下血肿这种灾难性并发症也可能发生。
