Hematoma subdural após punção inadvertida da dura-máter: relato de caso

Wallace Lage Duarte; Fabiano de Souza Araújo; Marcelo Figueiredo Almeida; Débora Grimberg Geber; Carlos Henrique Viana de Castro

doi:10.1590/S0034-70942008000400008

Clinical Information

Hematoma subdural após punção inadvertida da dura-máter: relato de caso

Subdural hematoma after inadvertent dura mater puncture: case report

Wallace Lage Duarte; Fabiano de Souza Araújo; Marcelo Figueiredo Almeida; Débora Grimberg Geber; Carlos Henrique Viana de Castro

http://dx.doi.org/10.1590/S0034-70942008000400008 Braz J Anesthesiol, vol.58, n4, p.387-390, 2008

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Resumo

JUSTIFICATIVA E OBJETIVOS: A cefaléia pós-punção da dura-máter é complicação bastante conhecida das anestesias subaracnóidea e peridural, e o tratamento mais difundido é o tampão sangüíneo. O tampão sangüíneo alivia totalmente a cefaléia na grande maioria dos pacientes, e nos demais não há melhora ou, apenas, melhora parcial. Nesses casos, é prudente buscar diagnósticos diferenciais, como o hematoma subdural ou pneumoencéfalo. Os métodos de imagem são extremamente úteis nessas situações. O objetivo deste relato foi apresentar o caso de um paciente que desenvolveu hematoma subdural intracraniano após punção inadvertida da dura-máter em anestesia peridural. RELATO DO CASO: Paciente do sexo masculino, 47 anos, 147 kg, 1,90 m, estado físico ASA II, foi admitido para realização de dermolipectomia abdominal, após ter-se submetido à gastroplastia redutora. Durante anestesia peridural, houve perfuração acidental da dura-máter. O paciente evoluiu com sintomas de cefaléia pós-punção da dura-máter que foram tratados com tampão sangüíneo, com melhora parcial. Houve, posteriormente, piora da cefaléia, e a ressonância nuclear magnética de encéfalo mostrou hematoma subdural intracraniano, que foi tratado clinicamente. Houve melhora progressiva, com recuperação total após 30 dias. CONCLUSÕES: A ocorrência de hematoma subdural é complicação rara, mas grave da perfuração de dura-máter. O diagnóstico é difícil e deve ser sempre cogitado quando a cefaléia pós-punção da dura-máter não se resolve com o tampão sangüíneo ou piora com sua realização. No esclarecimento diagnóstico é fundamental o auxílio de um método de imagem.

Palavras-chave

COMPLICAÇÕES, TÉCNICAS ANESTÉSICAS, Regional

Abstract

BACKGROUND AND OBJECTIVES: Post-dural puncture headache is a well-known complication of epidural and subarachnoid blockades and the blood patch is the treatment used more often. In most patients, the blood patch relieves the headache completely, but for the remaining there is no improvement or only partial relief of the symptom. In those cases, it is prudent to look for other differential diagnosis, such as subdural hematoma or pneumoencephalus. In those situations, imaging exams are extremely useful. The objective of this report was to present the case of a patient who developed subdural hematoma after accidental puncture of the dura mater during epidural block. CASE REPORT: A 47-year old male patient, 147 kg, 1.90 m, physical status ASA II, was admitted for abdominal dermolipectomy after undergoing gastroplasty. The dura mater was accidentally punctured during the epidural block. The patient developed post-dural puncture headache treated with an epidural blood patch, with partial improvement of his symptoms. However, it was followed by worsening of the headache and an MRI showed the presence of an intracranial subdural hematoma, which was treated clinically. The patient evolved with progressive improvement of the symptom and full recovery after 30 days. CONCLUSIONS: Subdural hematoma is a rare, but severe, complication of dura mater puncture. It is difficult to diagnose, but it should always be remembered when post-dural puncture headache shows no resolution or even worsens after an epidural blood patch. An imaging exam is fundamental for the diagnosis of this rare complication.

Keywords

ANESTHETIC TECHNIQUE, Regional, COMPLICATIONS

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Hematoma subdural após punção inadvertida da dura-máter: relato de caso

Subdural hematoma after inadvertent dura mater puncture: case report

Wallace Lage Duarte; Fabiano de Souza Araújo; Marcelo Figueiredo Almeida; Débora Grimberg Geber; Carlos Henrique Viana de Castro

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