Bilateral interhemispheric subdural hematoma after inadvertent lumbar puncture in a parturient

Abstract

Interhemispheric subdural hematomas (ISH) are rare in adults and occur most often after cranial trauma. We describe a parturient who developed bilateral acute ISH after inadvertent dural puncture associated with placement of an epidural catheter for labour analgesia. We discuss the features, pathophysiology, and management of this type of subdural hematoma. A 38-yr-old woman requested epidural analgesia for relief of labour pain. An inadvertent dural puncture occurred during placement of a 17G Tuohy needle. After labour and delivery, the patient developed symptoms of a postdural puncture headache, which responded only partially to an epidural blood patch. The patient's headache subsequently became less position-dependent and was associated with episodes of sharp pain radiating down her legs and paresthesias on the left side of her body. A computed tomography (CT) scan showed right frontal and left parietal acute ISH without an intracranial mass effect. The patient was monitored in the intensive care unit and treated conservatively because of the relatively small size of the ISH and the absence of progressive neurological deficits on serial examinations. Daily CT scans showed gradual decreases in the size of the ISH concomitant with improvement of the headache. Rupture of bridging veins between the cerebral cortex and the superior sagittal sinus is the usual mechanism by which ISH occur. Nearly one-quarter of patients with ISH do not survive, although those with smaller hematomas have a better outcome. If the hematoma is < 1 cm in thickness, a conservative approach to ISH is recommended in the absence of mental status changes, seizure activity, or focal deficits, but with larger ISH or evidence of progressive neurological deterioration, surgical evacuation is most often required to prevent mortality.