A rare and immediate onset of pneumocephalus following neuraxial needle insertion: A case report and review of the literature.

RATIONALE: Pneumocephalus is a rare but potentially serious complication of neuraxial anesthesia, often misdiagnosed as post-dural puncture headache (PDPH) in obstetric settings. This case is unique for its immediate onset following a single epidural attempt using the loss-of-resistance to air (LORA) technique during labor. The report emphasizes the importance of vigilance, early imaging, and the potential advantage of using the loss-of-resistance to saline method to minimize the risk of intracranial air entry.

PATIENT CONCERNS: A 25-year-old woman in active labor developed sudden severe headache, neck pain, and upper back discomfort during the first epidural attempt. Despite reassurance and analgesics, symptoms persisted postpartum, causing significant distress and concern for neurological complications.

DIAGNOSES: While PDPH was initially suspected, the headache's persistence, partial non-postural nature, and poor analgesic response prompted further investigation. Non-contrast brain computed tomography revealed multiple intracranial gas locules in the lateral, third, and fourth ventricles and interpeduncular cistern, confirming post-dural puncture pneumocephalus.

INTERVENTIONS: An epidural blood patch provided rapid but short-lived relief, with symptoms recurring within 30 minutes. The patient was transferred to the surgical intensive care unit for conservative management, including high-flow oxygen therapy, supine positioning, intravenous fluids, analgesics, and high-caffeine beverages. Serial assessments and repeat computed tomography scans monitored air resolution. On postpartum day 8, she developed transient chest pain and shortness of breath; cardiopulmonary investigations were negative.

OUTCOMES: The patient experienced gradual symptom improvement over 4 days, with a progressive reduction in headache intensity and no new neurological deficits. Follow-up imaging demonstrated near-complete resolution of pneumocephalus. She was discharged on postpartum day 10 with only mild, intermittent headaches, which fully resolved by outpatient follow-up, and she remained neurologically intact throughout, indicating a complete recovery.

LESSONS: Pneumocephalus should be considered in postpartum patients with acute or atypical headache after neuraxial anesthesia, particularly with LORA use. While symptoms can mimic PDPH, differences in onset and headache characteristics warrant early neuroimaging. Conservative measures, especially high-flow oxygen, are highly effective for non-tension pneumocephalus. Preference for the loss-of-resistance to saline technique over LORA may significantly reduce the risk of this complication, enhancing safety in obstetric anesthesia.