Background:

Post-dural puncture headache is a common complication after neuraxial anesthesia and is frequent in obstetrics. The persistence of headache despite adequate treatment, however,should alert us to the possibility of other more serious causes. 

Case report:

A 27-year old primigravida who received uneventful epidural analgesia during childbirth. Twelve hours after delivery, she presented moderate fronto-occipital headache, whose intensity increased when she was in the sitting position. She was diagnosed with post-dural puncture headache (PDPH) due to accidental dural puncture and was treated with paracetamol, metamizole, caffeine and hydrocortisone, with a good response. After 24-h, incapacitating headache, with no other symptoms, reappeared, and an epidural blood patch (EBP) was performed. As a result, the headache improved.
Twenty-four hours later, she was readmitted for headache without other symptoms. We performed a second EBP, but the symptoms failed to improve. Because the persistence of the headache a cranial magnetic resonance (MR) was requested, which evidenced a subdural hematoma (SDH) in the right hemisphere with alterations of cerebrospinal fluid hypotension. The patient was hospitalized for a week and given conservative treatment, with improvement of the symptoms. 
Two months later, a second MR was performed, which showed the disappearance of SDH.

Discussion:
Epiduralis used routinely and serious complications are infrequent. After a dural puncture, there is a risk of intracranial SDH. PDPH may be the only symptom and its persistence despite multiple treatments requires that other causes be ruled out with imaging studies.
It is important to be aware of the risk factors for PDPH and to make a differential diagnosis so that a SDH may be diagnosed and treated quickly.
Early suspicion can prevent neurological consequences.

Learning points:

Intracranial SDH is an infrequent complication of epidural.
It may present as persistent PDPH and necessitates differential diagnosis with MR.
Early differential diagnosis is important to avoid severe sequelae.

References:

Turnbull DK,et.al. Br J Anaesth 2003;91:718-729
Bleeker CP,et.al. Br J Anaesth 2004;93:461-464

Intracranial subdural hematoma following epidural analgesia in obstetrics