Post-Dural Puncture Headache Evolving to a Subdural Hematoma: A Case Report.

INTRODUCTION: Cervical epidural corticosteroid injections are frequently used for the treatment of subacute cervicobrachial pain. This therapy is considered safe, with the vast majority of the complications being minor and transient. CASE REPORT: We present a case of a woman in her fifties who suffered from cervicobrachialgia and received 2 cervical epidural corticosteroid infiltrations. On day 3 after the second infiltration, a new headache appeared and on day 16 a bilateral subdural hematoma was visualized on CT scan. Complete resorption of the hematoma was seen on day 25 without surgical intervention. DISCUSSION: Up until now, only 1 case report of an intracranial subdural hematoma after a cervical epidural steroid injection has been published. But several cases of an intracranial subdural hematoma after spinal, epidural, or combined spinal and epidural anesthesia have been reported. Physicians should be aware of this potentially dramatic complication since post-dural puncture headache after any type of procedure can evolve into a subdural hematoma. Clinical differentiation between the two can be difficult; post-dural puncture headache is characterized by relief of symptoms in the supine position and photophobia/phonophobia. A subdural hematoma should be considered if the headache changes in character, does not respond to treatment, or there are neurological signs such as nausea/vomiting and blurred vision. Immediate medical imaging should then be performed.

Thrombin generation and platelet activation in cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy - A prospective cohort study.

BACKGROUND AND OBJECTIVES: Cytoreductive surgery (CRS) with hyperthermic intraperitoneal peroperative chemotherapy (HIPEC), indicated for patients with peritoneal metastases from digestive or gynecological malignancies alike, demonstrates a considerable impact on hemostatic metabolism, both on platelet and on coagulation level. The potential hemostatic interference in CRS and HIPEC is phase dependent. The hypothesis of this prospective cohort study is that the procedure exposed an increased thrombotic risk, resulting in a faster and increased thrombin generation and hyper platelet function. METHODS: This study explores the combined use of ROTEM (rotational thromboelastometry), PACT (platelet activation test) and CAT (thrombin generation test) assays during CRS and HIPEC with a follow-up of 7 days postoperative in 27 patients with confirmed histological diagnosis of peritoneal disease. RESULTS: Platelet reactivity (relative to before incision values) to CRP (collagen-related peptide) (p value 0.02) and TRAP (thrombin receptor activator peptide) (p value 0.048) seems to be slightly reduced during CRS and HIPEC with regard to αIIbß3 activation, while P-selectin expression is not affected. During surgery, CAT demonstrates that, the LT (lagtime) (p value 0.0003) and TTP (time-to-thrombin peak) values (p value 0.002) decrease while and the TP (thrombin peak) (p value 0.004) and ETP (endogenous thrombin potential) (p value 0.02) increase. Subsequently, after surgery, the LT and TTP increase and ETP and TP decrease in time. ROTEM EXTEM (extrinsic) MCF (maximum clot firmness) (p value 0.005), INTEM (intrinsic) MCF (p value 0.003) and FIBTEM (fibrinogen) MCF (p value <0.001) decreased during CRS. At day 7 INTEM and FIBTEM MCF values (p values of 0.004 and <0.001) were significantly higher than before surgery. No considerable changes in platelet count and hemoglobin concentration and absence of leukopenia are noticed. CONCLUSION: This approach detects changes in coagulation much earlier than noticed by standard coagulation tests.