American Journal of Emergency Medicine xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Subarachnoid hemorrhage and pneumocephalus due to epidural anesthesia; a rare case Abstract Epidural analgesia is an extremely effective and popular treatment for pain during labor. Subarachnoid hemorrhage and pneumocephaly is a serious but rare complication of puncture of the dura mater in epidural anesthesia. To best of our knowledge, intracranial subarachnoid hemorrhage together with pneumocephaly hasn’t been reported as a complication after the lumbar puncture so far. Our purpose is to increase awareness for serious complications such as subarachnoid hemorrhage and pneumocephaly following regional procedures (See Fig.). Our case was a 32-years old woman. The patient presented to emergency department with severe headache 3 days after delivery with epidural anesthesia. On CT scan, pneumocephaly and subarachnoid hemorrhage were detected. Our case was discharged to home on the day 20 after presentation, although there are life-threatening complications related to epidural and/or spinal anesthesia. Clinicians should be aware that serious complications such as pneumocephaly or subarachnoid hemorrhage may present in patients presenting with headache following epidural anesthesia and these patients should be assessed by CT imaging in case of clinical suspicion. Epidural anesthesia is a widely accepted technique with a rather low incidence of serious complications [1]. Epidural analgesia still is the most effective way to alleviate pain during labor pain [2,3]. Lifethreatening complications related to epidural anesthesia or analgesia are rare entities. Subarachnoid hemorrhage is an extremely rare complication after lumbar puncture and generally associated with intracranial aneurysms [4,5]. Pneumocephaly is a well-known but rare complication of spinal and epidural anesthesia that can occur after accidental dural puncture during lumbar epidural anesthesia [6,7]. To best of our knowledge, intracranial subarachnoid hemorrhage together with pneumocephaly hasn’t been reported as a complication after the lumbar puncture so far. A 34-years old woman presented to emergency department with severe headache and irritability. In her history, it was found out that she delivered her second baby by normal spontaneous vaginal delivery under epidural anesthesia in another facility 3 day ago and that she had headache since epidural anesthesia which didn’t respond to analgesics. It was also found that she delivered her first baby by normal spontaneous vaginal delivery without complication. The patient reported that she occasionally uses drugs for migraine but there was no history of hypertension or coagulopathy. Platelet count and prothrombin and activated partial thromboplastin times were normal in the patient. Three days ago, she had given birth to a boy under epidural anesthesia on the gestational week 32 due to premature rupture of membranes. In epidural, Marcaine (bupivacaine
HCl) had been used. On physical examination, the patient was conscious, cooperated with normal orientation. Meningeal irritation findings were negative including nuchal rigidity, Brudzinski’s sign and Kernig’s sign. Body temperature was 37°C. Pupil reflex was normal and pupillary light reflex was positive. In the patient, headache didn’t respond to paracetamol and non-steroid anti-inflammatory drug. Headache was persisting both during supine and sitting positions. Due to persistent headache during follow-up, cranial CT scan was scheduled. However, she had generalized, tonic-clonic seizures before CT scan; thus, the patient underwent CT scan after control of seizure with diazepam. On cranial CT scan, hyperdense lesions compatible with subarachnoid bleeding were observed on parietal sulci on the right and frontal sulci and tentorial level on the left and left occipital sulci. There was mild edema at cerebral parenchyma. Air density was observed in frontal cornua of lateral ventricle. The patient was
Fig. White colored arrows show that air densities are observed in frontal cornuas of lateral ventricle, black colored arrows show that subarachnoid hemorrhage is observed on parietal and occipital sulci and on the left tentorial level.
0735-6757/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Güzel M, et al, Subarachnoid hemorrhage and pneumocephalus due to epidural anesthesia; a rare case, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.01.029
2
M. Güzel et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
admitted to intensive care unit and an antiepileptic agent was initiated in the ICU. On 3-dimensional images from CT angiography, it was seen that right anterior communicating artery was markedly thinner when compared to left anterior communicating artery and that there were some irregularities in the walls of middle communication artery and its branches. However, no arteriovenous malformation or signs of pathological vascularization was observed. No additional seizure developed during follow-up. A repeat CT scan showed that the intracranial air had been absorbed. However, patients stayed in ICU for 28 days due to pulmonary problems; then, she was discharged to home. Cranial CT scan 2 weeks after discharge was considered as normal. No problem was observed during 6-months follow-up. Complications after spinal puncture are well known, including subdural epidural or subarachnoid hemorrhage, epidural abscess, anterior spinal artery thrombosis following prolonged hypotension, arachnoiditis or myelitis, and acute prolapse of an intervertebral disc [8,10]. Intracranial hemorrhage is an even rarer complication [4,5,11,12]. Subarachnoid hemorrhage, is extremely rare and generally associated with intracranial aneurysms [4,5]. The etiology of complications related to lumbar puncture includes iatrogenic and idiopathic causes, coagulopathy, blood dyscrasia, cranial vascular anomalies, and spinal vascular anomalies [13]. Though mechanisms of SAH hasn’t been fully understood, the most likely mechanism seems that attempts for spinal puncture caused spinal vessel rupture, either directly or indirectly by inducing differential pressure changes between CSF and intravascular spaces [10,14], and also the risk of an SAH increases with gestational age; probably because of hormonal and hemodynamic changes of pregnancy. Although one would assume that labor itself poses a particular risk, only 2% of SAHs occur during labor [15]. In our patient, there was no bleeding disorder or intracranial vascular anomaly. We concluded that SAH development in our patient resulted from both predisposition to SAH caused by pregnancy and pressure alteration in CSF and intravascular space. Pneumocephaly with subsequent headache is a relatively rare but well-described complication of unintentional dural puncture [16,17] resulting from the injection of air into the subarachnoid or subdural space and cranial migration [18] Pneumocephaly may occur due to many reasons. Pneumocephaly following lumbar puncture is related to failed attempts for obtaining CSF [19]. Pneumocephaly occurring after epidural block is usually caused by either dural puncture or loss of resistance technique using air. Thus, CSF can be immediately seen, when dural puncture is achieved [20]. We believe that air injected can enter to subarahnoid space directly, causing pneumocephaly. Although pneumocephaly and subarachnoid bleeding cases have been individually reported in the literature, there is no report about association of pneumocephaly and subarachnoid bleeding so far. Postdural puncture headache (PDPH) is the most common complication following epidural or spinal procedure. Because most physicians now use fine spinal needles, these headaches have become less common. Patients usually describe headache symptoms that worsen after sitting or standing from a recumbent position [21]. Postdural puncture headache may develop within few hours to several days after LP. The headache is frequently localized to frontal or occipital regions. The symptoms may radiate downwards. PDPH may be accompanied by several other symptoms. The pathophysiology of the PDPH has not been fully elucidated [22]. In our patient, severe headache had onset first. It developed within minutes after establishment of epidural anesthesia and persisted for several days without responding analgesics. Given the etiology of PDPH, we thought that headache was caused by widely known complications of lumbar puncture in association with SAH and pneumocephaly. In conclusion, it should be taken into account that subarachnoid hemorrhage and pneumocephaly may develop following epidural
anesthesia, even rarely. Clinicians should be aware of these rare but life-threatening complications. It should be kept in mind that these complications may develop without presence of any risk factor in the patient. Potential neurological damage can be managed by early treatment by performing CT scan in patients with persistent headache which onset after epidural anesthesia. Murat Güzel MD Department of Emergency Medicine Samsun Training and Research Hospital Samsun, Turkey E-mail address: [email protected] Ömer Salt MD Depatment of Emergency Medicine Yozgat State Hospital Yozgat, Turkey Ali K. Erenler MD Ahmet Baydın MD Mehmet T. Demir MD Anil Yalcin MD Department of Emergency Medicine Samsun Training and Research Hospital Samsun, Turkey Zahide Doganay MD Department of Reanimation Samsun Training and Research Hospital Samsun, Turkey http://dx.doi.org/10.1016/j.ajem.2014.01.029
References [1] Dahlgren N, Törnebrandt K. Neurological complicationsafter anaesthesia. A follow-up of 18,000 spinal and epidural anaesthetics performed over three years. Acta Anaesthesiol Scand 1995;39:872–80. [2] Renehan EM, Peterson RA, Penning JP, Rosaeg OP, Chow D. Visualization of a looped and knotted epidural catheter with a guidewire. Can J Anaesth 2000;47: 329–33. [3] Gozal D, Gozal Y, Beilin B. Removal of knotted epidural catheters. Case reports. Reg Anesth 1996;21:71–3. [4] Bottiger BW, Diezel G. Acute intracranial subarachnoid hemorrhage following repeated spinal anesthesia. Anaesthesist 1992;41:152–7. [5] Wells JB, Sampson IA. Subarachnoid hemorrhage presenting as post-dural puncture headache: a case report. Mt Sinai J Med 2002;69:109–10. [6] Gonzalez-Carrasco FJ, Aguilar JL, Llubia C, et al. Pneumocephalus after accidental dural puncture during epidural anesthesia. Reg Anesth 1993;18: 193–5. [7] Laviola S, Kirvelä M, Spoto MR, Tschuor S, Alon E. Pneumocephalus with intense headache and unilateral pupillary dilatation after accidental duralpuncture during epidural anesthesia for cesarean section. Anesth Analg 1999;88(3):582–3. [8] Aromaa U, Lahdensuu M, Cozanitis DA. Severe complications associated with epidural and spinal anaesthesias in Finland 1987–1993. A study based on patient insurance claims. Acta Anaesthesiol Scand 1997;41:445–52. [9] Auroy Y, Narchi P, Messiah A, et al. Serious complications related to regional anaesthesia, Results of a prospective survey in France. Anesthesiology 1997;87: 479–86. [10] Kreppel D, Antoniadis G, Seeling W. Spinal hematoma: a literature survey with meta-analysis of 613 patients. Neurosurg Rev 2003;26:1–49. [11] Ben-Nakhi A, Muttikkal TJE, Ashebu SD, Keluth Chavan VN. Bilateral subdural hemorrhage following lumbar puncture in a case of suspected meningitis. A case report. NRJ Neuroradiol J 2008;21:178–82. [12] Lee SJ, Lin YY, Hsu CW, Chu SJ, Tsai SH. Intraventricular hematoma, subarachnoid hematoma and spinal epidural hematoma caused by lumbar puncture: an unusual complication. Am J Med Sci 2009;337:143–5. [13] Harvey SC, Roland PJ, Cure JK, et al. Spinal epidural hematoma detected by lumbar epidural puncture. Anesth Analg 1997;84(5):1136–9. [14] Liu WH, Lin JH, Lin JC, Ma HI. Severe intracranial and intraspinal subarachnoid hemorrhage after lumbar puncture: a rare case report. Am J Emerg Med 2008;26: 633.e1–3. [15] Mas JL, Lamy C. Stroke in pregnancy and the puerparium[review]. J Neurol 1998;245:305–13. [16] Kuczkowski KM. Post-dural puncture headache, intracranial air and obstetric anesthesia. Anaesthesist 2003;52:798–800.
Please cite this article as: Güzel M, et al, Subarachnoid hemorrhage and pneumocephalus due to epidural anesthesia; a rare case, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.01.029
M. Güzel et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx [17] Hawley JS, Ney JP, Swanberg MM. Subarachnoid pneumocephalus from epidural steroid injection. Headache 2005;45:247–8. [18] Nafiu OO, Urquhart JC. Pneumocephalus with headache complicating labour epidural analgesia: Should we still be using air? Int J Obstet Anesth 2006;15: 237–9. [19] Flora GS, Tuchschmidt JA, Sharma OP. Pneumocephalus in association with lumbar punctures. Chest 1990;98:1041.
3
[20] Kim YD, Lee JH, Cheong YK. Pneumocephalus in a patient with no cerebrospinal fluid leakage after lumbar epidural block - a case report -. Korean J Pain 2012;25(4):262–6. [21] Vincent Jr RD, Chestnut DH. Epidural analgesia during labor. Am Fam Physician 1998;58(8):1785–92. [22] Bezov D, Lipton RB, Ashina S. Post-dural puncture headache: Part Idiagnosis, epidemiology, etiology and pathophysiology. Headache 2010;50:1144–52.
Please cite this article as: Güzel M, et al, Subarachnoid hemorrhage and pneumocephalus due to epidural anesthesia; a rare case, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.01.029
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Subarachnoid hemorrhage and pneumocephalus due to epidural anesthesia; a rare case Abstract Epidural analgesia is an extremely effective and popular treatment for pain during labor. Subarachnoid hemorrhage and pneumocephaly is a serious but rare complication of puncture of the dura mater in epidural anesthesia. To best of our knowledge, intracranial subarachnoid hemorrhage together with pneumocephaly hasn’t been reported as a complication after the lumbar puncture so far. Our purpose is to increase awareness for serious complications such as subarachnoid hemorrhage and pneumocephaly following regional procedures (See Fig.). Our case was a 32-years old woman. The patient presented to emergency department with severe headache 3 days after delivery with epidural anesthesia. On CT scan, pneumocephaly and subarachnoid hemorrhage were detected. Our case was discharged to home on the day 20 after presentation, although there are life-threatening complications related to epidural and/or spinal anesthesia. Clinicians should be aware that serious complications such as pneumocephaly or subarachnoid hemorrhage may present in patients presenting with headache following epidural anesthesia and these patients should be assessed by CT imaging in case of clinical suspicion. Epidural anesthesia is a widely accepted technique with a rather low incidence of serious complications [1]. Epidural analgesia still is the most effective way to alleviate pain during labor pain [2,3]. Lifethreatening complications related to epidural anesthesia or analgesia are rare entities. Subarachnoid hemorrhage is an extremely rare complication after lumbar puncture and generally associated with intracranial aneurysms [4,5]. Pneumocephaly is a well-known but rare complication of spinal and epidural anesthesia that can occur after accidental dural puncture during lumbar epidural anesthesia [6,7]. To best of our knowledge, intracranial subarachnoid hemorrhage together with pneumocephaly hasn’t been reported as a complication after the lumbar puncture so far. A 34-years old woman presented to emergency department with severe headache and irritability. In her history, it was found out that she delivered her second baby by normal spontaneous vaginal delivery under epidural anesthesia in another facility 3 day ago and that she had headache since epidural anesthesia which didn’t respond to analgesics. It was also found that she delivered her first baby by normal spontaneous vaginal delivery without complication. The patient reported that she occasionally uses drugs for migraine but there was no history of hypertension or coagulopathy. Platelet count and prothrombin and activated partial thromboplastin times were normal in the patient. Three days ago, she had given birth to a boy under epidural anesthesia on the gestational week 32 due to premature rupture of membranes. In epidural, Marcaine (bupivacaine
HCl) had been used. On physical examination, the patient was conscious, cooperated with normal orientation. Meningeal irritation findings were negative including nuchal rigidity, Brudzinski’s sign and Kernig’s sign. Body temperature was 37°C. Pupil reflex was normal and pupillary light reflex was positive. In the patient, headache didn’t respond to paracetamol and non-steroid anti-inflammatory drug. Headache was persisting both during supine and sitting positions. Due to persistent headache during follow-up, cranial CT scan was scheduled. However, she had generalized, tonic-clonic seizures before CT scan; thus, the patient underwent CT scan after control of seizure with diazepam. On cranial CT scan, hyperdense lesions compatible with subarachnoid bleeding were observed on parietal sulci on the right and frontal sulci and tentorial level on the left and left occipital sulci. There was mild edema at cerebral parenchyma. Air density was observed in frontal cornua of lateral ventricle. The patient was
Fig. White colored arrows show that air densities are observed in frontal cornuas of lateral ventricle, black colored arrows show that subarachnoid hemorrhage is observed on parietal and occipital sulci and on the left tentorial level.
0735-6757/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Güzel M, et al, Subarachnoid hemorrhage and pneumocephalus due to epidural anesthesia; a rare case, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.01.029
2
M. Güzel et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
admitted to intensive care unit and an antiepileptic agent was initiated in the ICU. On 3-dimensional images from CT angiography, it was seen that right anterior communicating artery was markedly thinner when compared to left anterior communicating artery and that there were some irregularities in the walls of middle communication artery and its branches. However, no arteriovenous malformation or signs of pathological vascularization was observed. No additional seizure developed during follow-up. A repeat CT scan showed that the intracranial air had been absorbed. However, patients stayed in ICU for 28 days due to pulmonary problems; then, she was discharged to home. Cranial CT scan 2 weeks after discharge was considered as normal. No problem was observed during 6-months follow-up. Complications after spinal puncture are well known, including subdural epidural or subarachnoid hemorrhage, epidural abscess, anterior spinal artery thrombosis following prolonged hypotension, arachnoiditis or myelitis, and acute prolapse of an intervertebral disc [8,10]. Intracranial hemorrhage is an even rarer complication [4,5,11,12]. Subarachnoid hemorrhage, is extremely rare and generally associated with intracranial aneurysms [4,5]. The etiology of complications related to lumbar puncture includes iatrogenic and idiopathic causes, coagulopathy, blood dyscrasia, cranial vascular anomalies, and spinal vascular anomalies [13]. Though mechanisms of SAH hasn’t been fully understood, the most likely mechanism seems that attempts for spinal puncture caused spinal vessel rupture, either directly or indirectly by inducing differential pressure changes between CSF and intravascular spaces [10,14], and also the risk of an SAH increases with gestational age; probably because of hormonal and hemodynamic changes of pregnancy. Although one would assume that labor itself poses a particular risk, only 2% of SAHs occur during labor [15]. In our patient, there was no bleeding disorder or intracranial vascular anomaly. We concluded that SAH development in our patient resulted from both predisposition to SAH caused by pregnancy and pressure alteration in CSF and intravascular space. Pneumocephaly with subsequent headache is a relatively rare but well-described complication of unintentional dural puncture [16,17] resulting from the injection of air into the subarachnoid or subdural space and cranial migration [18] Pneumocephaly may occur due to many reasons. Pneumocephaly following lumbar puncture is related to failed attempts for obtaining CSF [19]. Pneumocephaly occurring after epidural block is usually caused by either dural puncture or loss of resistance technique using air. Thus, CSF can be immediately seen, when dural puncture is achieved [20]. We believe that air injected can enter to subarahnoid space directly, causing pneumocephaly. Although pneumocephaly and subarachnoid bleeding cases have been individually reported in the literature, there is no report about association of pneumocephaly and subarachnoid bleeding so far. Postdural puncture headache (PDPH) is the most common complication following epidural or spinal procedure. Because most physicians now use fine spinal needles, these headaches have become less common. Patients usually describe headache symptoms that worsen after sitting or standing from a recumbent position [21]. Postdural puncture headache may develop within few hours to several days after LP. The headache is frequently localized to frontal or occipital regions. The symptoms may radiate downwards. PDPH may be accompanied by several other symptoms. The pathophysiology of the PDPH has not been fully elucidated [22]. In our patient, severe headache had onset first. It developed within minutes after establishment of epidural anesthesia and persisted for several days without responding analgesics. Given the etiology of PDPH, we thought that headache was caused by widely known complications of lumbar puncture in association with SAH and pneumocephaly. In conclusion, it should be taken into account that subarachnoid hemorrhage and pneumocephaly may develop following epidural
anesthesia, even rarely. Clinicians should be aware of these rare but life-threatening complications. It should be kept in mind that these complications may develop without presence of any risk factor in the patient. Potential neurological damage can be managed by early treatment by performing CT scan in patients with persistent headache which onset after epidural anesthesia. Murat Güzel MD Department of Emergency Medicine Samsun Training and Research Hospital Samsun, Turkey E-mail address: [email protected] Ömer Salt MD Depatment of Emergency Medicine Yozgat State Hospital Yozgat, Turkey Ali K. Erenler MD Ahmet Baydın MD Mehmet T. Demir MD Anil Yalcin MD Department of Emergency Medicine Samsun Training and Research Hospital Samsun, Turkey Zahide Doganay MD Department of Reanimation Samsun Training and Research Hospital Samsun, Turkey http://dx.doi.org/10.1016/j.ajem.2014.01.029
References [1] Dahlgren N, Törnebrandt K. Neurological complicationsafter anaesthesia. A follow-up of 18,000 spinal and epidural anaesthetics performed over three years. Acta Anaesthesiol Scand 1995;39:872–80. [2] Renehan EM, Peterson RA, Penning JP, Rosaeg OP, Chow D. Visualization of a looped and knotted epidural catheter with a guidewire. Can J Anaesth 2000;47: 329–33. [3] Gozal D, Gozal Y, Beilin B. Removal of knotted epidural catheters. Case reports. Reg Anesth 1996;21:71–3. [4] Bottiger BW, Diezel G. Acute intracranial subarachnoid hemorrhage following repeated spinal anesthesia. Anaesthesist 1992;41:152–7. [5] Wells JB, Sampson IA. Subarachnoid hemorrhage presenting as post-dural puncture headache: a case report. Mt Sinai J Med 2002;69:109–10. [6] Gonzalez-Carrasco FJ, Aguilar JL, Llubia C, et al. Pneumocephalus after accidental dural puncture during epidural anesthesia. Reg Anesth 1993;18: 193–5. [7] Laviola S, Kirvelä M, Spoto MR, Tschuor S, Alon E. Pneumocephalus with intense headache and unilateral pupillary dilatation after accidental duralpuncture during epidural anesthesia for cesarean section. Anesth Analg 1999;88(3):582–3. [8] Aromaa U, Lahdensuu M, Cozanitis DA. Severe complications associated with epidural and spinal anaesthesias in Finland 1987–1993. A study based on patient insurance claims. Acta Anaesthesiol Scand 1997;41:445–52. [9] Auroy Y, Narchi P, Messiah A, et al. Serious complications related to regional anaesthesia, Results of a prospective survey in France. Anesthesiology 1997;87: 479–86. [10] Kreppel D, Antoniadis G, Seeling W. Spinal hematoma: a literature survey with meta-analysis of 613 patients. Neurosurg Rev 2003;26:1–49. [11] Ben-Nakhi A, Muttikkal TJE, Ashebu SD, Keluth Chavan VN. Bilateral subdural hemorrhage following lumbar puncture in a case of suspected meningitis. A case report. NRJ Neuroradiol J 2008;21:178–82. [12] Lee SJ, Lin YY, Hsu CW, Chu SJ, Tsai SH. Intraventricular hematoma, subarachnoid hematoma and spinal epidural hematoma caused by lumbar puncture: an unusual complication. Am J Med Sci 2009;337:143–5. [13] Harvey SC, Roland PJ, Cure JK, et al. Spinal epidural hematoma detected by lumbar epidural puncture. Anesth Analg 1997;84(5):1136–9. [14] Liu WH, Lin JH, Lin JC, Ma HI. Severe intracranial and intraspinal subarachnoid hemorrhage after lumbar puncture: a rare case report. Am J Emerg Med 2008;26: 633.e1–3. [15] Mas JL, Lamy C. Stroke in pregnancy and the puerparium[review]. J Neurol 1998;245:305–13. [16] Kuczkowski KM. Post-dural puncture headache, intracranial air and obstetric anesthesia. Anaesthesist 2003;52:798–800.
Please cite this article as: Güzel M, et al, Subarachnoid hemorrhage and pneumocephalus due to epidural anesthesia; a rare case, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.01.029
M. Güzel et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx [17] Hawley JS, Ney JP, Swanberg MM. Subarachnoid pneumocephalus from epidural steroid injection. Headache 2005;45:247–8. [18] Nafiu OO, Urquhart JC. Pneumocephalus with headache complicating labour epidural analgesia: Should we still be using air? Int J Obstet Anesth 2006;15: 237–9. [19] Flora GS, Tuchschmidt JA, Sharma OP. Pneumocephalus in association with lumbar punctures. Chest 1990;98:1041.
3
[20] Kim YD, Lee JH, Cheong YK. Pneumocephalus in a patient with no cerebrospinal fluid leakage after lumbar epidural block - a case report -. Korean J Pain 2012;25(4):262–6. [21] Vincent Jr RD, Chestnut DH. Epidural analgesia during labor. Am Fam Physician 1998;58(8):1785–92. [22] Bezov D, Lipton RB, Ashina S. Post-dural puncture headache: Part Idiagnosis, epidemiology, etiology and pathophysiology. Headache 2010;50:1144–52.
Please cite this article as: Güzel M, et al, Subarachnoid hemorrhage and pneumocephalus due to epidural anesthesia; a rare case, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.01.029
