|Year : 2013 | Volume
| Issue : 2 | Page : 154-155
Subarachnoid hemorrhage after central neuroaxial blockade: An accidental finding
N Ratan Singh1, T Hemjit Singh1, M Rameshwar Singh2, PKS Laithangbam1
1 Department of Anesthesiology, Regional Institute of Medical Sciences, Imphal, Manipur, India
2 Department of Obstetrics and Gynecology, Regional Institute of Medical Sciences, Imphal, Manipur, India
|Date of Web Publication||19-Nov-2013|
T Hemjit Singh
Department of Anesthesiology, Regional Institute of Medical Sciences, Imphal - 795 004, Manipur
Source of Support: None, Conflict of Interest: None
Subarachnoid hemorrhage (SAH) may occur as a serious co-incidental finding of spinal anesthesia (SA). A case of SAH in a case of lower segment caesarean section following SA is reported in this paper, and it emphasizes the need for early recognition and proper management of such a case as delay in diagnosis may lead to mismanagement.
Keywords: Headache, Lower segment caesarean section, Spinal anesthesia, Subarachnoid hemorrhage
|How to cite this article:|
Singh N R, Singh T H, Singh M R, Laithangbam P. Subarachnoid hemorrhage after central neuroaxial blockade: An accidental finding. J Med Soc 2013;27:154-5
|How to cite this URL:|
Singh N R, Singh T H, Singh M R, Laithangbam P. Subarachnoid hemorrhage after central neuroaxial blockade: An accidental finding. J Med Soc [serial online] 2013 [cited 2021 Aug 1];27:154-5. Available from: https://www.jmedsoc.org/text.asp?2013/27/2/154/121603
| Introduction|| |
Severe headache following spinal anesthesia (SA) in the lower segment caesarean section (LSCS) may be due to varieties of causes viz. postdural puncture headache (PDPH), pre-eclampsia migraine, drug induced headache and intra cranial pathology which includes hemorrhage, venous sinus thrombosis and post-partum cerebral angiopathy.  However, persistent non-postural headache after SA may indicate the presence of serious intracranial lesion.  Classically, the headache from an aneurysmal rupture develops in seconds  and PDPH in 6 h after SA and the incidence of which may vary with the size of the needle used.
| Case report|| |
A 27-year-old, primiparous woman with cephalo-pelvic disproportion and acute foetal distress was presented for emergency LSCS under SA at Regional Institute of Medical Sciences Hospital, Imphal. The patient did not give any significant past history of illness nor had she undergone surgery under SA. She was premedicated with injection ranitidine 50 mg and injection ondansetron 4 mg I.V. The anesthetic procedure was uneventful with administration of 2 ml of 0.5% bupivacaine (heavy) in the L3, 4 spaces in a single puncture attempt in sitting position using 25 G Quincke spinal needle under aseptic condition. At 5 min, a sensory block of T6 was achieved and a live healthy male baby weighing 3.5 kg was delivered by LSCS. The hemodynamic parameters were within the permissible limits and no vasopressors were required. The procedure was uneventful and when the block level subsided, the patient was sent to post anesthetic care unit. Approximately after 1½ h of the procedure, the patient complained of a sudden onset of severe, pounding occipital headache radiating to the frontal region. The neurological examination revealed photophobia; however, no meningism, no additional motor or sensory deficits were found and Glasgow comma scale GCS score was 15. The systolic blood pressure and diastolic blood pressure were 142 and 86 mm Hg respectively and no electrocardiography changes were noted. Neurological consultation was sought and a cranial tomogram (CT) was performed which showed a collection of blood in the falx cerebri and diagnosis of subarachnoid hemorrhage (SAH) was confirmed [Figure 1]. The patient made an uneventful recovery after 48 h with bed rest and analgesics.
| Discussion|| |
The leakage of cerebrospinal fluid following lumbar puncture (LP) is usually of a minor degree and seldom gives rise to any symptoms.  The incidence of spontaneous SAH is increased five-fold in a pregnant woman compared to a non-pregnant woman, but no reliable data exist.  Spontaneous SAH is a rare event, ruptured intracranial aneurysms being the main cause (51-80%) followed by hypertensive diseases (10-15%) and arteriovenous malformations (5-10%).  In our patient, severe headache occurred after the operative procedure, i.e., beyond the LA effect duration. After ruling out the common causes of headache, a CT scan showed the small SAH. Only three cases of intracerebral hemorrhages and two cases of SAH alone have been reported after SA.  The combination of labor, spinal anesthetic and SAH may be purely coincidental in our patient as the hemorrhage may occur without any strenuous activity.  Prolonged and non-postural PDPH with a history of LP should be regarded as a warning sign and prompt immediate diagnosis for treatment before development of neurological symptoms is recommended.
| Conclusion|| |
Cerebral SAH as a serious co-incidental finding of SA must be kept in mind as it may mimic PDPH.
| References|| |
|1.||Eggert SM, Eggers KA. Subarachnoid haemorrhage following spinal anaesthesia in an obstetric patient. Br J Anaesth 2001;86:442-4. |
|2.||Benzon HT. Intracerebral hemorrhage after dural puncture and epidural blood patch: Nonpostural and noncontinuous headache. Anesthesiology 1984;60:258-9. |
|3.||Van Gijn J, Rinkel GJ. Subarachnoid haemorrhage: Diagnosis, causes and management. Brain 2001;124:249-78. |
|4.||Bjärnhall M, Ekseth K, Boström S, Vegfors M. Intracranial subdural haematoma: A rare complication following spinal anaesthesia. Acta Anaesthesiol Scand 1996;40:1249-51. |
|5.||Mas JL, Lamy C. Stroke in pregnancy and the puerperium. J Neurol 1998;245:305-13. |
|6.||Edlow JA, Caplan LR. Avoiding pitfalls in the diagnosis of subarachnoid hemorrhage. N Engl J Med 2000;342:29-36. |