Subdural haematoma following accidental dural puncture: a refresh and support protocol

Post-dural puncture headache (PDPH) is a common complication of accidental dural puncture during epidural analgesia. Although usually benign, it may rarely be associated with intracranial subdural haematoma (SDH), a potentially serious complication that can be difficult to distinguish from PDPH. We report the case of a 27-year-old primiparous woman with suspected accidental dural puncture during labour epidural analgesia. On postpartum day 1, she developed a persistent, non-postural headache associated with vomiting and tinnitus, despite conservative treatment. On postpartum day 4, right lower limb paresis prompted urgent neuroimaging. Brain MRI revealed bilateral SDHs measuring less than 5 mm, with signs of intracranial hypotension. Spinal MRI excluded spinal haematoma and cord compression. Surgical intervention was not indicated. Two epidural blood patches were performed, resulting in rapid clinical improvement. The patient was discharged on postpartum day 6 with planned neurological follow-up. This case highlights the importance of recognising atypical postpartum headaches and neurological warning signs following suspected accidental dural puncture. Persistent non-postural headaches, treatment failure or new neurological deficits should prompt urgent neurological assessment and neuroimaging. A structured decision-making algorithm may facilitate timely diagnosis and appropriate management.