Spontaneous Intracerebral Hemorrhage after Cesarean Section

Lower section cesarean section (LSCS) is the most commonly performed surgery today and spinal anesthesia is the preferred mode of anesthesia in most of the cases. Headache occurring during cesarean section (LSCS) can have many causes like stress or anxiety, post-dural puncture headache, hypotension, etc. We report a case of patient developing headache and left side weakness intraoperatively, which on further investigation found to be due to development of intracerebral hemorrhage (ICH).

A 34 years old American Society of Anesthesiologists grade II primigravida with twin pregnancy was admitted for an elective cesarean section. She was a booked patient and had an uneventful pregnancy. Her baseline heart rate inside the operation theater was 89 beats per minute and blood pressure was 116/74 mm Hg in supine position. All her blood investigations were within normal limits. She was administered 2.2 mL of injection bupivacaine (heavy) in lateral decubitus position using a 25 G Quinke's spinal needle in the first attempt. The intraoperative monitoring included continuous electrocardiography, oxygen saturation monitoring, and noninvasive blood pressure monitoring every 5 minutes. Two healthy female infants were delivered and she was administered 5 units of oxytocin intravenously. Around 20 minutes after delivery of the twins, the patient started complaining of severe headache. She was administered 1 g of intravenous paracetamol for control of headache; however, her headache was not relieved. Toward the end of surgery, the operating surgeon felt that the face of the patient was deviated toward the left side and she was still complaining of severe headache. On further examination, it was found that she was having difficulty in moving her left upper limb. At the end of surgery, her Glasgow Coma Scale (GCS) score was E4V4M5, and both pupils were equal and reactive to light. Throughout this period, there was no documented systolic blood pressure reading of over 150 mm Hg.

On the basis of these findings, a decision was taken to perform an urgent noncontrast computed tomography (CT) scan head in this patient, which revealed right basal ganglia bleed with intraventricular bleed ([Fig. 1]). A neurosurgery consultation was taken and they advised CT angiography of cerebral vessels. CT angiography did not show any evidence of arteriovenous malformation (AVM) or a cerebral aneurysm in the patient. On the basis of investigation findings, a decision to perform decompressive craniectomy was taken. Her perioperative course was uneventful. She was kept intubated and sedated overnight and was extubated the next day. She was shifted to ward after 2 days of extubation and discharged to home 10 days after surgery. At the time of discharge, her GCS was E4V5M6 and her motor power was ⅖ in the upper limb and ⅗ in the lower limb.

Fig. 1 Non-contrast CT head of the patient demonstrating right basal ganglia bleed with intraventricular extension.

ICH during pregnancy is a rare but catastrophic event. The incidence of stroke in pregnancy is 9 to 26 per 100,000 pregnancies; hemorrhagic strokes account to approximately 38% of the total strokes.[1] AVMs are the chief cause of ICH in pregnancy.[2] Other causes of ICH in pregnancy include cerebral aneurysms, cerebral venous thrombosis, trauma, pregnancy-induced hypertension, and coagulopathies.[3]

Development of ICH after cesarean section is even more rare, with only two reports available in literature.[4] [5] Sharma reported development of symptoms of ICH in a post-LSCS patient 4 hours after the surgery, while in a report by von Knobelsdorff and Paris, the symptoms of ICH developed 80 minutes after the LSCS.[4] [5] To our knowledge, this is the first report to demonstrate occurrence of symptoms of ICH intraoperatively. Dai and Diamond had reported development of spontaneous ICH in a pregnant female with pregnancy-induced hypertension.[6] They described advanced maternal age (in particular, age older than 35 years); African American race; preexisting hypertension (chronic hypertension), gestational hypertension, preeclampsia (or eclampsia), preexisting hypertension with superimposed preeclampsia/eclampsia, or coagulopathy; and tobacco abuse/dependence as risk factors for development of ICH. However, our patient did not have any of these predisposing factors for development of ICH. There was no history of preeclampsia in our patient and she had regular routine checkups during the pregnancy. Although variations in blood pressure are common during cesarean section, there was no documented systolic blood pressure reading of more than 150 mm Hg in our patient intraoperatively. However, noninvasive blood pressure monitoring has its limitations and is not able to document sudden surges in blood pressure. Also, the location of bleed in our patient points toward it being a hypertensive bleed. ICH after cesarean section is a rare but possible complication. A high index of suspicion should be there for any severe headache and newly developed motor deficit developing intraoperatively to diagnose ICH at the earliest.

Publikationsverlauf

Artikel online veröffentlicht:
09. September 2025

• References

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• 2 Liang CC, Chang SD, Lai SL, Hsieh CC, Chueh HY, Lee TH. Stroke complicating pregnancy and the puerperium. Eur J Neurol 2006; 13 (11) 1256-1260
• 3 Fairhall JM, Stoodley MA. Intracranial haemorrhage in pregnancy. Obstet Med 2009; 2 (04) 142-148
• 4 Sharma K. Intracerebral hemorrhage after spinal anesthesia. J Neurosurg Anesthesiol 2002; 14 (03) 234-237
• 5 von Knobelsdorff G, Paris A. Intrazerebrale Blutung nach Sectio ceasarea in SpinalanästhesieKoinzidenz oder Kausalität?. [Intracerebral hemorrhage after cesarean section under spinal anesthesia. Coincidence or causality?] Anaesthesist 2004; 53 (01) 41-44 German.
• 6 Dai X, Diamond JA. Intracerebral hemorrhage: a life-threatening complication of hypertension during pregnancy. J Clin Hypertens (Greenwich) 2007; 9 (11) 897-900