Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited. Acute thalamic haemorrhagic stroke after combined spinal–epidural anaesthesia in pregnancy A case report Hamiyet O ¨ zcan, Serap Aktas ¸ and Ayda Tu ¨ rko ¨z From the Department of Anesthesiology, Emsey Hospital, I ˙ stanbul, Turkey (HO ¨ , SA), Department of Anesthesiology and Reanimation, BezmialemVakif University, Istanbul, Turkey (AT) Correspondence to Ayda Tu ¨ rko ¨ z, MD, Department of Anesthesiology and Reanimation, BezmialemVakif University, Istanbul, Turkey e-mail: aydaturkoz@gmail.com Editor, Intracerebral haematoma is an exceptionally rare but life- threating complication of lumbar puncture, myelography, spinal anaesthesia and spinal surgery. 1–5 Unless the pa- tient takes anticoagulants, the pathophysiology and cause of this condition are unknown. 3,4 We present a case of acute thalamic haemorrhage associated with nonpostural headache complaints starting 4 h after combined spinal– epidural (CSE) anaesthesia. A previously healthy 36-year-old pregnant woman was delivered of twin babies by caesarean section under CSE anaesthesia. There was no history of preeclampsia, antic- oagulation or haemorrhagic diathesis. The physical ex- amination and pre-operative blood tests including coagulation profile, urine analysis, chest radiograph and ECG were all within normal limits. When the patient arrived in the operating room, the L4 to L5 epidural space was accessed at the first attempt using a Tuohy 18-gauge needle; a 27-gauge needle was used to deliver bupiva- caine 12 mg with fentanyl 20 mg into the subarachnoid space, followed by the insertion of a 20-gauge epidural catheter for postoperative analgesia. During the opera- tion and in the postoperative recovery unit, her blood pressure (BP) and heart rate were within normal limits. Four hours after delivery, her moderate headache pro- gressed to a severe nonpostural headache associated with increased BP, numbness at the edge of the lips, left hemiplegia and aphasia. Computerised tomography (CT, Fig. 1) showed a thalamic haemorrhage consistent with the diagnosis of stroke. The patient was managed by careful neurological follow-up associated with conserva- tive treatment and physical therapy. After 6 months, there were no abnormalities in the CT scan (Fig. 2) and the patient recovered except that power in the upper left arm was reduced to 3/5. In the literature, we were not able to find any information on acute thalamic haemor- rhagic stroke after CSE anaesthesia. The incidence of intracranial intracerebral haematoma after epidural and spinal anaesthesia in obstetric practice has not been estimated because only a small number of cases have been reported. Until now, only four cases of intracerebral hematoma were reported, the first in 1981 and the last in 2002. 4,5 None of the four patients had an 828 Correspondence Fig. 1 Plain computerised tomography head scan: right-sided acute thalamic haematoma following combined spinal–epidural anaesthesia. Fig. 2 Computerised tomography scan showing resolution of the thalamic haematoma after 6 months. Eur J Anaesthesiol 2020; 37:824–835