Beyond the Typical Headache: A Case of Bilateral Subdural Hygroma Complicated by Hemorrhage Following Obstetric Dural Puncture

This report details the case of a 28-year-old parturient who developed bilateral intracranial subdural collections after an accidental dural puncture during combined spinal-epidural anesthesia for elective cesarean delivery. The dural tear occurred at the L3–L4 interspace, accompanied by observable cerebrospinal fluid leakage; anesthesia was subsequently successfully achieved via single-shot spinal administration at L2–L3. The patient initially presented on postoperative day (POD) 2 with orthostatic headaches, consistent with classic post-dural puncture headache. However, between POD 3 and 7, her symptoms evolved into severe, non-positional cephalalgia that proved refractory to conventional analgesics. magnetic resonance imaging (MRI) performed on POD 8 confirmed extensive bilateral subdural fluid collections with a minor hemorrhagic component, totaling approximately 200 mL in volume. Given the eventual resolution of symptoms with conservative management, the patient was discharged and later demonstrated complete neurological recovery during follow-up evaluations.This case underscores two critical insights: First, the paradoxical clinical trajectory—from positional to non-positional headaches—serves as a key indicator for neuroimaging to exclude subdural hematoma, a very rare complication. Moreover, prophylactic enoxaparin initiated on postoperative day 4 may have exacerbated bleeding, highlighting that anticoagulant administration requires prior neuroimaging when post-dural puncture headache (PDPH) persists. These findings advocate for vigilant monitoring in obstetric neuraxial anesthesia, particularly when multiple attempts or anticoagulants are involved, to prevent permanent neurological sequelae.