AAO 2008 Grand Rounds Outline
Kelly A. Malloy, O.D., F.A.A.O. (PCO)
“ LABOR PAINS ”
An 18 year-old girl reports diplopia, headache, tiredness and fatigue, beginning about 1 week after giving birth in
October 2007. She had not sought any care until presenting for an eye exam in January 2008. She was found to
have a right abduction deficit, and her optic discs were suspicious for inferior fullness in the left eye. Urgent
neuro-imaging shows a large sub-dural hematoma, with midline shift to the right, and what is getting close to
uncal herniation. This was likely a complication of pregnancy and/or epidural anesthesia for delivery of her baby.
CASE REPORT:
A. Case History
a. Patient Demographics: - 18 year-old, 5 ft 3 in, 119 lb right-handed girl
b. Chief Complaint:
horizontal diplopia x 3 months, worse at distance and in right gaze
eye pain, headache, fatigue, tiredness
all symptoms began about a week after giving birth with spinal epidural anesthesia in late
October 2007.
Ocular / Medical History: - status post 3 pregnancies. There were 2 full term births. Her first
child was born January 2006, and her second child was born in October 2007. Between those 2, she
was pregnant and had an abortion. She has no history of blood clots. During her first pregnancy she
had high blood pressure. She does not recall if she had eclampsia or preeclampsia. Otherwise, the
patient indicates she has had some bumps or sores on her tongue, which have been present ever
since having her first child in 2006. The patient indicates that when she was young her family always
told her that she had a lazy eye. In speaking with some of her family members today, they indicate
that by this they meant that the right eyelid seemed to be somewhat more droopy when she was
young as compared to the left eyelid. However, they never noted any misalignment of the eyes as is
present now.
Medications: - She is now on Depo-Provera, and began this medication last week.
Other Salient Information: - Social history is apparently noncontributory. Family history is remarkable for
hypertension and hypercholesterolemia .
-
B. Pertinent Findings:
a. Clinical: (photos included in presentation where appropriate)
-
VA 20/20 OD and 20/20 OS. No dyschromatopsia; Confrontation fields full bilaterally
Pupils isocoric ; no evidence of RAPD
palpebral apertures: 9 mm OD and 9 mm OS Post-fatigue: 9 mm OD and 5 mm OS
apparent orbicularis oculi weakness OU
evident limitation (70% of normal) of abducting capacity OD
Negative forced duction testing
Slit lamp examination unremarkable OU
Applanation tensions: normal OU Blood pressure: 108/56
Dilated fundus examination:
a. Optic discs: .20/.20 OU, no evidence of pallor,
b. Questionable indistinct disc margin/mild edema inferiorly OS
b. Physical:
- Neurologic examination: cranial nerves V, VII - XII intact
- Motor, sensory, and coordination testing:
a. Question of some extremity weakness on right side, patient falling asleep
c. Radiology Studies: (photos included)
- Urgent MRI of brain and orbits, with and out gadolinium administration
- MRI findings: - large left sub-dural hematoma, 2.5 cm
a. mass effect on left hemisphere
b. 8 mm midline shift
c. some findings to suggest possible early uncal herniation
d. MRI findings were discussed while patient was still at imaging facility
e. Patient was sent directly to the adjacent ER, for direct admission and
transfer to main hospital for neuro-surgical consult
C. Differential Diagnoses:
- Initially of abduction deficit (possible complication of epidural anesthesia, complication of pregnancy,
increased intracranial pressure, mass, thyroid, inflammatory, infectious, MG)
- Postpartum headache
a. Complication of Pregnancy
i. Elevated blood pressure
b. Complication of epidural anesthesia
i. Postdural puncture (puncture of dura during epidural anesthesia)
1. Headache
2. Potential sub-dural hemorrhage (rare complication) may be related
to intracranial hypotension
3. Potential sub-arachnoid hemorrhage (rare complication)
ii. Meningitis
c. Migraine
d. Tension headache
- Cranial Nerve VI Palsy ( and mild incipient papilledema) Secondary to Increased Intracranial
Pressure
a. Post-dural puncture with sub-dural hemorrhage
b. Meningitis
- After MRI – evidence of large sub-dural hematoma, likely secondary to complications of dural
puncture during epidural anesthesia 3 months prior
D. Diagnosis and Discussion
a. Subdural Hematoma As A Complication of Anesthesia During Childbirth
i. Subdural hemorrhage has been documented as a rare complication of pregnancy,
spinal anesthesia from intracranial hypotension, and from postdural puncture during
administration of the epidural or spinal anesthesia
ii. This is a very rare presentation
E. Treatment / Management:
a.
Treatment / Response:
- Emergent Neuro-surgical Consultation and emergency neuro-surgery
a. craniotomy vs. craniectomy
b. drain accumulated blood, relieve mass effect
- this is an ongoing case – follow-up to be included in the presentation
b.
Bibliography / Literature Review:
F.
-
Acharya, R, Chhabra SS, Ratra M, et al. Cranial Subdural hematoma after spinal anesthesia. British J of
Anesthesia Vol 86, No 6, 893-895 (2001)
-
Ezri, T, Abouleish E, Lee, C, et al. Intracranial subdural hematoma following dural puncture in a parturient with
HELLP syndrome. Canadian J of Anesthesiai 49:820-823 (2002)
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Kelsaka E, Sarihasan B, Baris S, et al. Subdural hematoma as a late complication of spinal anesthesia. J NeuroSurg
Anesthesiol. 15(1):47-49 (2003)
-
Zeidan a, Farhat O, Maaliki H, et al. Does postdural puncture headache left untreated lead to subdural hematoma?
Case report and review of the literature. Int J Obstet Anesth. 15(1):50-8. (2006)
Conclusion:
a.
b.
c.
d.
Symptoms of headache and diplopia beginning after childbirth and/or epidural or spinal anesthesia need
to be considered very serious symptoms
These patients need to be emergently evaluated for potential subdural hemorrhage
Subdural hemorrhage is a rare, but very serious complication of postdural puncture during anesthesia
As this case demonstrates, cranial nerve VI palsy can be the first indication of this serious complication
after childbirth