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Subdural hygroma after dural puncture.

We report a case of subdural hygroma secondary to accidental dural puncture while inserting an epidural catheter for postoperative analgesia. A 72-year-old female was scheduled for a Whipple's procedure. Her past history included asthma and bronchiectasis. A combined general and epidural anaesthetic was planned with invasive monitoring. An attempt was made to insert the epidural using a 16 gauge Tuohy needle at the T10-11 interspace, but this was complicated by a dural puncture as diagnosed by the free flow of cerebrospinal fluid (CSF). The epidural was resited at the space above. Propofol and fentanyl were used to induce and maintain general anaesthesia. A bolus of 8 ml of 0.25% levobupivacaine with 100 [micro]g of fentanyl was administered into the epidural catheter intraoperatively. An infusion of 0.1% levobupivacaine was then commenced and continued postoperatively, The patient was extubated at the end of the procedure. The epidural provided satisfactory analgesia and the patient was able to breathe adequately with normal gas exchange, confirmed by arterial blood gas analysis. However, the patient became drowsy in the immediate postoperative period and on the first postoperative day. This prompted the withdrawal of fentanyl from the epidural infusion. The epidural catheter was removed on day six and the patient was commenced on regular tramadol and diclofenac. On the eighth postoperative day it was noticed that the patient was intermittently confused. This persisted and on the 13th postoperative day there was a sudden decline in her level of consciousness to a Glasgow Coma Score of 11 (E 2 V 3 M 6). The patient was admitted to a high-dependency neurocritical care unit and an urgent CT head was performed. This demonstrated bilateral low-density subdural collections (Figure 1). Some mass effect on the cerebral hemispheres and compression of the lateral ventricles was also seen. A diagnosis of bilateral subdural hygroma was made.

[FIGURE 1 OMITTED]

A neurosurgical opinion was sought and the decision was made to manage her conservatively with surgical intervention only if further neurological deterioration occurred. She improved with complete bed rest and her Glasgow Coma Score returned to 15 two days later.

Subdural hygroma is a rare complication of dural puncture and is probably due to the excessive loss of CSF from a dural leak lower in the spinal canal. Increased interstitial fluid of the pachymeninges forms as a result of compensatory meningeal vasodilatation (1). The major concern is that this may progress to a chronic subdural hematoma. Lee et al in their review of traumatic subdural hygroma found that in 8.2% of patients, subdural hygroma subsequently led to the formation of chronic subdural haematoma (2). The presentation may range from mild confusion and drowsiness to unstable gait, severe headache and grand mal convulsion(3,4). Most patients experience immediate post dural puncture headache, which in some cases may persist despite a blood patch.

Our patient was unusual in that she did not have a post dural puncture headache and her symptoms developed almost two weeks after the dural puncture. Nevertheless, we believe that the most likely cause for her subdural hygroma was leakage of CSF through a persistent dural breach.

This case serves to illustrate that dural puncture may be associated with rare but serious neurological complications. Even trivial symptoms like intermittent confusion should not be overlooked in a patient with iatrogenic or traumatic dural puncture. Neurological signs such as persistent headache or a change in level of consciousness should alert the clinician to the possibility of subdural collection and always warrants further investigation.

References

(1.) van den Berg JS, Sijbrandy SE, Meijer AH, Oostdijk AH. Subdural hygroma: A rare complication of spinal anesthesia. Anesth Analg 2002; 94:1625-1627.

(2.) Lee KS, Bae WK, Park YT, Yon IG. The pathogenesis and fate of traumatic subdural hygroma. Br J Neurosurg 1994; 8:551558.

(3.) Kampe S, Hunseler U. Subdural Hygroma: A rare complication of spinal anesthesia diagnosed after a grand mal convulsion. Anesth Analg 2003; 96:907.

(4.) Aragones N, Arxer A, Vieito M, Ros J, Villalonga A, Ustrell X. The diagnosis and treatment of a patient with puerperal infection and subdural hygromas. Anesth Analg 2004; 99:12181220.

A. SINHA

L. O'SHEA

Cambridge, United Kingdom
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Article Details
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Title Annotation:Correspondence
Author:Sinha, A.; O'Shea, L.
Publication:Anaesthesia and Intensive Care
Article Type:Case study
Geographic Code:4EUUK
Date:Jan 1, 2008
Words:694
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