Subdural hematoma in two hematopoietic stem cell transplant patients with post-dural puncture headache and initially normal CT brain scan

Abstract

Subdural hematoma (SDH) is a rare complication in patients after lumbar puncture. We report two patients receiving hematopoietic stem cell transplantation (HSCT) who developed post-dural puncture headache (PDPH) and SDH following intrathecal methotrexate (MTX). Both patients initially had normal computed tomography (CT) scan findings at the onset of headache. The diagnosis was established only when a repeat CT brain scan was performed for deteriorating neurological signs coinciding with improving platelet counts. These cases demonstrate the importance of continued vigilance for the early recognition of this salvageable entity. A normal initial CT finding and platelet count do not exclude the occurrence of SDH. A repeat CT scan, or even magnetic resonance imaging (MRI), are indicated if the clinical suspicion remains strong.

Lumbar Puncture: It Is Time to Change the Needle

“…When the PLPH character changes and other neurologic sequels appear, the clinician must suspect the development of subdural hematoma or sinus vein thrombosis and perform an urgent MRI to exclude these diagnoses [3,4,5,6,7,8]. …”

“…Another group of patients at increased risk for complications associated with LP are the hematologic patients, including patients undergoing hematopoietic stem cell transplantation and those receiving intrathecal therapy with methotrexate and corticosteroids which are prone to life-threatening complications following LP such as subdural hematoma [6], cerebellar infarction [54] and superior sagittal sinus thrombosis [55]. The occurrence of additional signs and symptoms following PLPH should alert the clinician to the presence of more prominent intracranial pathology [3,56].…”

Haemostasis and Safety Measures before Lumbar Puncture in the Haematology Ward: The Danish Routines

“…Cranial subdural haematoma is a known complication of haematopoietic stem cell transplantation [7,8], diagnostic LP [12] and spinal anaesthesia [13]. Diagnosis is complicated by the fact that the symptoms resemble those of post-dural puncture headache, viral meningitis, cortical vein thrombosis and sinus headache [12] and by the fact that an initial normal brain imaging may not necessarily rule out a cranial subdural haematoma.…”

“…Diagnosis is complicated by the fact that the symptoms resemble those of post-dural puncture headache, viral meningitis, cortical vein thrombosis and sinus headache [12] and by the fact that an initial normal brain imaging may not necessarily rule out a cranial subdural haematoma. Repeated computed tomography has been shown to be necessary in haematology patients [7]. …”

“…Once present, permanent paraplegia can ensue even after surgical decompression [4], and permanent deficits have been reported in up to 90% of cases [5]. The haematology population, in particular patients treated by haematopoietic stem cell transplantation, may be at an increased risk of developing cranial subdural haematoma [7,8]. …”