Subdural hematoma following head trauma and spinal anesthesia for elective cesarean delivery: a case report

Subdural hematoma is a rare but life-threatening complication of obstetric spinal anesthesia. We report a case of acute subdural hematoma following spinal anesthesia for elective cesarean delivery that likely promoted rebleeding from an unrecognized prepartum head trauma. A healthy 32-year-old primiparous patient (ASA II) underwent a cesarean delivery with spinal anesthesia performed with a 27-gauge Quincke needle. The perioperative course was uneventful; however thirty hours postoperatively, the patient developed a sudden severe fronto-orbital headache followed by progressive deterioration in consciousness and anisocoria. Emergency neuroimaging revealed an acute left temporal subdural hematoma with frontoparietal extension and mass effect. Further history-taking revealed a previously unreported minor head trauma one week prior to delivery. The patient underwent urgent surgical evacuation via craniectomy within one hour, resulting in rapid neurological improvement. By postoperative day three, the patient had made a full neurological recovery. This clinical presentation supports a two-hit mechanism: initial bridging-vein injury from minor trauma formed a pauci-symptomatic collection; spinal-induced cerebrospinal fluid hypotension then increased venous traction, precipitating rebleeding, amplifying mass effect. This case underscores the importance of meticulous pre-anesthetic history-taking, particularly regarding recent head trauma, in obstetric patients scheduled for neuraxial anesthesia. The use of pencil-point small-gauge spinal needles is recommended to minimize the risk of dural puncture and subsequent cerebrospinal fluid leakage. Vigilance for atypical post-dural puncture headache, prompt neuroimaging, and urgent neurosurgical intervention were key to the favorable neurological outcome observed.