A case of pneumocephalus following an labour epidural: A lesson learnt

Raja Rajesvari, Kayalvizhi, Vijayakumar

Department of Anesthesiology, Kauvery Hospital, Radial Road, Chennai

Abstract

Background

Epidural analgesia is a commonly administered method for painless labour. Headache following regional anesthesia (spinal or epidural) is often assumed as post dural puncture headache. We encountered a case of pneumocephalus causing headache following a labour epidural.

Key words: Pneumocephalus; Labour Epidural analgesia; Post-dural puncture headache; Headache.

Case Presentation

A 29-year-old primi gravida was admitted for safe confinement. She was a known case of gestational diabetes and hypothyroidism on treatment. Induction of labour done with misoprost and oxytocin and after 4-5cm cervical dilatation patient requested for epidural analgesia. After taking informed and written consent, labour epidural was performed by an experienced anesthesiologist at L3-L4 intervertebral space, in the sitting position using 18G Tuohy needle, by loss of resistance to air technique and the epidural catheter was fixed to skin at 12cm mark. The patient was monitored during the procedure with pulse oximetry, ECG, and non-invasive blood pressure monitoring. After giving test dose 3 ml of 1.5% lignocaine with adrenaline, she was commenced on infusion of Inj. 0.2% Ropivacaine at 5ml/hr for epidural analgesia. Patient delivered by vacuum assisted vaginal delivery after 4 hours, following which epidural catheter was removed.  Immediate Peripartum and post-partum period were uneventful. However, she complained of mild headache on day 2 just prior to discharge. Adequate hydration, bed rest and analgesics were prescribed and patient was discharged with stable hemodynamics.

The next day patient presented with complaints of headache with pain intensity of VAS 6/10, neck stiffness, and pain radiation to shoulder, which aggravated on sitting position. There was no history of fever, nausea, vomiting, giddiness or visual disturbance.  On examination, vitals, systemic and neurological examination were within normal limits. Despite no evidence of dural puncture, patient developed headache and to rule out other possible causes MRI brain was done which revealed air in the bilateral frontal horn of the lateral ventricle (right side – 4cc, left side 3cc). No evidence of acute infarct/ hemorrhage or signs of increased intracranial pressure. She was adequately hydrated, reassured and was advised to remain in supine position with supplemental oxygen support for next 24 hours. Repeat CT brain done which revealed interval reduction in Pneumoventricle.  Her symptoms improved gradually and was discharged on 3rd day.

Discussion

Pneumocephalus is presence of air in intracranial space. It’s a rare complication after epidural and results from accidental injection of air into intrathecal space especially when using loss of resistance with air technique, which is commonly used method to identify epidural space. Symptoms include severe headache not always associated with postural variation and other neurological changes. CT scan or MRI is used for diagnosis. The presence of air in ventricles is suggestive of migration of air from epidural space. Treatment is mostly conservative involving analgesics and bed rest, supplemental oxygen which aids reabsorption of air. Mostly air gets reabsorbed within a few days.

Every headache that occurs in the setting of epidural need not be labelled as post dural puncture headache and a low index of suspicion is required in seeking a CT brain as and when required.

References

  • Anwari JS, Hazazi AA. Another cause of headache after epidural injection. 2015;20(2):167–9.
  • Maira Ahmad1, Shannay Bellamy1*, William Ott1 and Rany Mekhail1 -Pneumocephalus secondary to epidural analgesia: a case report.
  • Reddi S, Honchar V, Robbins MS. Pneumocephalus associated with epidural and spinal anesthesia for labor. Neurol Clin Pract. 2015;5(5):376–82.
  • Nistal-Nuño B, Gómez-Ríos MÁ. Case report: pneumocephalus after labor epidural anesthesia. Res. 2014;3:166.
  • Vacca VM. Pneumocephalus assessment and management. Nurs CritCare. 2017;12(4):24–9.
  • Dabdoub CB, Salas G, Silveira Edo N, Dabdoub CF. Review of the management of pneumocephalus. Surg Neurol Int. 2015;6:155.

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