* Corresponding author: Serafino Ricci, serafino.ricci@uniroma1.it DOI: 10.3269/1970-5492.2017.12.34 All rights reserved. ISSN: 2279-7165 - Available on-line at www.embj.org EUROMEDITERRANEAN BIOMEDICAL JOURNAL 2017,12 (34) 159–162 (FORMERLY: CAPSULA EBURNEA) Case Report CEREBRAL SINUS THROMBOSIS AFTER SPINAL ANAESTHESIA: PREDISPOSING FACTORS, OPERATING DIFFICULTIES AND DIAGNOSTIC PROBLEMS. Edoardo De Robertis 1 , Serafino Ricci 2 *, Maria Pieri 3 , Angela Silvestre 3 , Gennaro Scibelli 4 , Francesco Massoni 2 , Giuseppe Vacchiano 5 1 Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples “Federico II” 2 Department of Anatomy, Histology, Legal Medicine and Orthopedics. “Sapienza” University, Rome 3 Department of Advanced Biomedical Science-Legal Medicine Section. University of Naples “Federico II” 4 Department of Anaesthesiology and Intensive Care, Local Healthcare Unit “Naples 1”, S. Paolo Hospital, Naples 5 Department of Law, Economics and Mathematical Methods. University of Sannio, Benevento A R T I C L E I N F O Article history: Received 15 June 2017 Revised 08 September 2017 Accepted 30 September 2017 Keywords: Cerebral sinus thrombosis, spinal anaesthesia, medico legal considerations A B S T R A C T The authors describe a case of cerebral venous sinus thrombosis following subarachnoid anaesthesia, characterized by operative difficulties and lack of patient collaboration. After anaesthesia, the patient reported a positional headache and on the 5 th day following surgery, he developed a frontal tensive headache with dysphoric and depressive symptoms. On the 9 th day he presented with emesis, hypostenia of the upper left limb and ipsilateral positive Babinsky. The diagnosis was made only on the 10 th day. Genetic analyses showed a homozygous mutation of methylene-tetrahydrofolate-reductase associated to hyperhomocysteinemia (21,7μM). The recurrence of post-dural puncture headaches is very frequent in patients undergoing subarachnoid anesthesia, but special attention is required in the event of headache, as well as associated clinical signs and other risk factors, in order to achieve a precocious diagnosis and allow the physician to start a suitable therapy. © EuroMediterranean Biomedical Journal 2017 1. Introduction Thrombosis of the cerebral venous sinuses is a major acute, fortunately rare, cerebrovascular event, associated with many conditions. The etiology of this disease remains unknown (1) . Diagnosis of the disease is not always easy. As cerebral thrombosis can result in serious encephalic complications, early diagnosis and timely anticoagulant therapy, which will positively influence its clinical course, are essential. 2. Case presentation Patient: male, aged 28, had undergone knee arthroscopy due to a meniscal lesion. Preoperative investigations (ECG, laboratory examinations and chest x-rays) did not show significant pathological abnormalities. Anesthesiologic risk was classified as ASA II, as the patient was a smoker and had mild hypertension. The anesthesia technique adopted was a neuraxial subarachnoid block using hyperbaric 0.5% marcaine and a 22 gauche spinal needle. Due to operational difficulties and lack of patient collaboration, the anesthesiologist had to insert the needle at L2-L3 level several times before successfully performing the procedure.