Bilateral subdural intracranial hematoma after accidental dural puncture.

A 29-YR-OLD healthy parturient developed positional frontoparietalheadacheafteraccidentalduralpuncture during attempted placement of an epidural catheter. The headache improved with hydration, bed rest, and analgesics. However, it persisted (without postural component) at the 2week interval. Neurologic examination was normal. Magnetic resonance imaging showed the presence of bilateral frontoparietal subdural intracranial hematoma. Subdural intracranial hematoma is a very rare consequence of accidental dural puncture. The bleeding results from cerebrospinal fluid loss (cerebral hypotension) related to traction on the intracranial bridging veins. Postdural puncture headache may complicate the diagnosis. Atypical headache (absence of postural component, persistence for more than 7 days, unresponsiveness to analgesics), signs of increased intracranial pressure, or mass effect on brain parenchyma (vomiting, seizures, altered level of consciousness, focal motor and sensory deficits) should lead to consideration of subdural intracranial hematoma. Presence of semilunar extraparenchymal liquid over the convexity on computed tomography (more sensitive in acute situations) or magnetic resonance imaging (more sensitive in older “denser” hematomas) scans confirms the diagnosis (arrows). In view of the small size of the hematomas, in our case conservative management was deemed appropriate. However, when there is mass effect, compression, and midline shift, surgical evacuation of the hematoma is the treatment of choice. Epidural blood patch (treatment of postdural puncture headache) when performed in the presence of intracranial hemorrhage may lead to rebound intracranial hypertension andneurologicdeterioration. Ourpatientwasdischargedhomewithout anyneurologic sequelae.A follow-upmagnetic resonance imaging showedspontaneous resolution.Subdural intracranialhematomashouldbeconsidered in thedifferentialdiagnosisofpostpartumheadache.