Symptomatic Pneumocephalus as a Complication of Lumbar Epidural Anaesthesia
Ana Filipa Pires, Teresa Martins Mendes, Ana Areia Reis, Ana Ferreira Pacheco, Vítor Fagundes, Mari Mesquita
Serviço de Medicina Interna, Hospital Padre Américo, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
Doi: 10.12890/2020_001425 - European Journal of Case Reports in Internal Medicine - © EFIM 2020
Received: 13/12/2019
Accepted: 18/12/2019
Published: 22/01/2020

How to cite this article: Pires AF, Martins Mendes T, Areia Reis A, Ferreira Pacheco A, Fagundes V, Mesquita M. Symptomatic pneumocephalus as a complication of lumbar epidural anaesthesia. EJCRIM 2020;7 doi:10.12890/2020_001425.

Conflicts of Interests: The authors declare there are no competing interests.
This article is licensed under a Commons Attribution Non-Commercial 4.0 License


Introduction: Lumbar epidural anaesthesia is a commonly used technique for analgesia during labour. One of the rare complications of this technique is pneumocephalus.
Case description: We report the case of a 35-year-old female admitted to the Emergency Department with severe headache associated with fast head movements. Five days previously she had a eutocic delivery and lumbar epidural anaesthesia was performed. A brain computed tomography (CT) scan showed pneumocephalus and she was admitted to the hospital ward. A brain CT scan on the fourth day of hospitalization showed resolution of ventricular pneumocephalus.
Discussion: The most frequently occurring symptom with pneumocephalus is headache associated with fast brain motion resulting from air injection and meningeal irritation. When there is clinical suspicion of pneumocephalus, a brain CT scan should be performed for the diagnosis.



Pneumocephalus, lumbar epidural anaesthesia, post-dural puncture headache


Lumbar epidural anaesthesia is a commonly used technique for analgesia during labour. The most common side effects include hypotension, pruritus, inadequate analgesia, post-puncture headache, nerve damage, infection and epidural haematoma[1,2].
Although commonly seen in neurosurgery and neuroradiology, pneumocephalus is rarely reported after epidural injection as a consequence of unintentional dural puncture, resulting from the introduction of air into the subarachnoid/subdural space and subsequent cranial migration[3,4].
The loss of resistance to air (LORA) technique is commonly employed for recognition of the epidural space. Cases of pneumocephalus following neuraxial anaesthesia have been described either after an epidural using the LORA technique or after spinal anaesthesia[5,6].
Symptoms of pneumocephalus are difficult to distinguish from those of post-dural puncture headache and the diagnosis is based on clinical impression and brain computed tomography (CT)[7].


On the 20th of January 2019, a 35-year-old healthy, Caucasian, female patient, who was postparturient, presented at the Emergency Department with severe headache not responsive to analgesics. The headache started first day postpartum, after she was given epidural anaesthesia, which was attempted for the first time. This process was incident-free, with the epidural analgesia working correctly and labour proceeding with normal evolution, and the patient was discharged at day 3 postpartum. The headache was exacerbated by movement, sitting and standing, and progressively worsening, motivating admission to the Emergency Department 5 days after the labour. She had no symptoms of vomiting, no fever and no confusion. On physical examination, the patient was alert and oriented, blood pressure was 130/80 mmHg. Heart rate was 81 beats/minute, with no fever, and neurological examination was normal. The site of the spinal anaesthesia had no signs of infection. A brain CT scan was performed and revealed supratentorial pneumoventricle, gas density being noted in the uppervermian cistern and the frontal horns of the lateral ventricles and in the temporal horn of the left lateral ventricle (Figs. 1 and 2).
The patient was treated conservatively for 4 days with total resolution of symptoms. A brain CT scan on the fourth day of hospitalization showed disappearance of ventricular pneumocephalus (Fig. 3). The follow-up was uneventful.

Figure 1 (click to enlarge)

Figure 2 (click to enlarge)

Figure 3 (click to enlarge)

Figure 1. CT scan showing gas density in the upper vermian cistern and lateral ventricles
Figure 2. Brain CT scan showing pneumoventricle
Figure 3. Brain CT scan at discharge, without the presence of gas


Pneumocephalus is the presence of air in the intracranial cavity. It is relatively common in patients submitted to neurosurgery[8] and treatments of interventional neuroradiology[9]. It can be caused by trauma[10] or infection[11]. The development of pneumocephalus after spinal or epidural anaesthesia is extremely infrequent. The incidence of pneumocephalus after epidural anaesthesia is unknown, and only a few cases per year are described in the literature [12,13].
The symptom most frequently reported with pneumocephalus is headache[14] associated with fast brain motion resulting from air injection and meningeal irritation. The onset is usually fast, in the same day after the cause, and it resolves in the first 5 days. It is exacerbated by motion and may not be alleviated by lying down[7].

  1. Silva M, Halpern SH. Epidural analgesia for labor: current techniques. Local Reg Anesth 2010;3:143–153.
  2. Pan PH, Bogard TD, Owen MD. Incidence and characteristics of failures in obstetric neuraxial analgesia and anesthesia: a retrospective analysis of 19,259 deliveries. Int J Obstet Anesth 2004;13:227–233.
  3. Wang JC, Tsai SH, Liao WI. Pneumocephalus after epidural anesthesia in an adult who has undergone lumbar laminectomy. J Neurosurg Anesthesiol 2014;26:261–263.
  4. Nafiu OO, Urquhart JC. Pneumocephalus with headache complicating labour epidural analgesia: should we still be using air? Int J Obstet Anesth 2006;15:237–239.
  5. Aida S, Taga K, Yamakura T, Endoh H, Shimoji K. Headache after attempted epidural block: the role of intrathecal air. Anesthesiology 1998;88(1):76–81.
  6. Alonso E, Parajua JL. [Iatrogenic pneumocephalus caused by epidural analgesia.] Neurologia 2000;15(9):418.
  7. Mateo E, López-Alarcón MD, Moliner S, Calabuig E, Vivó M, De Andrés J, et al. Epidural and subarachnoidal pneumocephalus after epidural technique. Eur J Anaesthesiol 1999;16(6):413–417.
  8. Reasoner DK, Todd MM, Scamman FL, Warner DS. The incidence of pneumocephalus after supratentorial craniotomy: observations on the disappearance of intracranial air. Anesthesiology 1994;80(5):1008–1012.
  9. Peterson HO, Kieffer SA. Neuroradiology. Volume 1. New York: Hayon and Row; 1984, p. 127–130.
  10. Finch MD, Morgan GA. Traumatic pneumocephalus following head injury. A complication of general anaesthesia. Anaesthesia 1991;46(5):385–387.
  11. Candan S, Katelioglu M, Ceylan S, Köksal I. Otogenic brain abscess with pneumocephalus. Infection 1990;18(3):191–192.
  12. Hawley JS, Ney JP, Swanberg MM. Subarachnoid pneumocephalus from epidural steroid injection. Headache 2005;45(3):247–248.
  13. Simopoulos T, Peeters-Asdourian C. Pneumocephalus after cervical epidural steroid injection. Anesth Analg 2001;92(6):1576–1577.
  14. Katz JA, Lukin R, Bridenbaugh PO, Gunzenhauser L. Subdural intracranial air: an unusual cause of headache after epidural steroid injection. Anesthesiology 1991;74(3):615–618.
  15. Benzon HT, Linde HW, Molloy RE, Brunner EA. Postdural puncture headache in patients with chronic pain. Anesth Analg 1980;59(10):772–774.