Beyond the Typical Headache: A Case of Bilateral Subdural Hygroma Complicated by Hemorrhage Following Obstetric Dural Puncture

Beyond the Typical Headache: A Case of Bilateral Subdural Hygroma Complicated by Hemorrhage Following Obstetric Dural Puncture | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Beyond the Typical Headache: A Case of Bilateral Subdural Hygroma Complicated by Hemorrhage Following Obstetric Dural Puncture Linlin Wang, Yuzhi Wei, Siyi Yan, Mengzhuo Guo, Yi Guo, Huan Zhang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7565090/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract This report details the case of a 28-year-old parturient who developed bilateral intracranial subdural collections after an accidental dural puncture during combined spinal-epidural anesthesia for elective cesarean delivery. The dural tear occurred at the L3–L4 interspace, accompanied by observable cerebrospinal fluid leakage; anesthesia was subsequently successfully achieved via single-shot spinal administration at L2–L3. The patient initially presented on postoperative day (POD) 2 with orthostatic headaches, consistent with classic post-dural puncture headache. However, between POD 3 and 7, her symptoms evolved into severe, non-positional cephalalgia that proved refractory to conventional analgesics. magnetic resonance imaging (MRI) performed on POD 8 confirmed extensive bilateral subdural fluid collections with a minor hemorrhagic component, totaling approximately 200 mL in volume. Given the eventual resolution of symptoms with conservative management, the patient was discharged and later demonstrated complete neurological recovery during follow-up evaluations. This case underscores two critical insights: First, the paradoxical clinical trajectory—from positional to non-positional headaches—serves as a key indicator for neuroimaging to exclude subdural hematoma, a very rare complication. Moreover, prophylactic enoxaparin initiated on postoperative day 4 may have exacerbated bleeding, highlighting that anticoagulant administration requires prior neuroimaging when post-dural puncture headache (PDPH) persists. These findings advocate for vigilant monitoring in obstetric neuraxial anesthesia, particularly when multiple attempts or anticoagulants are involved, to prevent permanent neurological sequelae. Subdural hygroma accidental dural puncture case report postpartum headache neuroimaging Figures Figure 1 Figure 2 Introduction Intracranial subdural hematoma (SDH) or hygroma is a rare but serious neurological complication following neuraxial anesthesia[ 1 ], with an estimated incidence of between 1:500,000 and 1:1,000,000[ 2 ]. It most commonly arises as a consequence of persistent cerebrospinal fluid (CSF) leakage leading to intracranial hypotension, brain sag, and traction on bridging veins or the arachnoid membrane[ 3 – 6 ]. While post-dural puncture headache (PDPH) is a well-known complication, the progression to SDH is less common and requires a high index of clinical suspicion for diagnosis. This case report describes a patient who developed a bilateral subdural collection with hemorrhage after an accidental dural puncture during elective cesarean delivery. Furthermore, it highlights the diagnostic challenge posed by the evolution of headache characteristics and discusses the potential role of prophylactic anticoagulation in exacerbating this condition. Case Presentation A 28-year-old primigravida, with a height of 156 cm and weight of 66 kg, was admitted at 37 + 1 weeks' gestation with a diagnosis of transverse fetal lie. The patient presented without abdominal pain, vaginal bleeding, or fluid leakage, reporting normal fetal movements. An elective cesarean delivery was planned. Her medical history included subclinical hypothyroidism managed with oral levothyroxine, with recent thyroid function tests confirming euthyroid status. Admission diagnoses were term singleton pregnancy in a nulliparous woman with transverse fetal presentation and subclinical hypothyroidism. She denied any neurological disorders. Preoperative investigations revealed sinus arrhythmia at 67 beats per minute on electrocardiogram. Chest radiography revealed segmentation anomalies at T5-T7 thoracic vertebrae with associated bilateral rib developmental abnormalities. Laboratory findings included hemoglobin of 102 g/L (mild anemia), platelet count 207×10⁹/L, and normal coagulation parameters: prothrombin time 11.3 s (seconds), activated partial thromboplastin time 29.1 s, and INR (international normalized ratio) 1.01. During anesthesia induction, the alert and oriented patient maintained vital signs at blood pressure (BP) 120/90 mmHg, heart rate (HR) 96 bpm, and peripheral oxygen saturation (SpO₂) 98% following peripheral intravenous (IV) catheter placement. Combined spinal-epidural (CSE) anesthesia was initiated in the right lateral decubitus position. During needle insertion at the L3-L4 interspace using a 14-gauge epidural needle (Fornia Medical, Zhuhai, China), accidental dural puncture occurred with cerebrospinal fluid (CSF) leakage. The needle was immediately withdrawn. Successful single-shot spinal anesthesia was subsequently achieved at the L2-L3 interspace, confirmed by free CSF reflux through the spinal needle. A 2.5 mL solution of 0.5% ropivacaine mixed with CSF was administered intrathecally. Following needle removal, the patient was repositioned supine with 15° left lateral tilt. Sensory blockade to the T6 dermatome developed within three minutes with stable hemodynamics. Surgery commenced promptly, delivering a live female infant with Apgar scores of 10 at one and five minutes approximately six minutes after incision. Estimated intraoperative blood loss was 500 mL with urine output of 400 mL and intravenous fluid administration totaling 1200 mL. The procedure concluded uneventfully with a final sensory blockade level at T8. Postoperative analgesia was provided via intravenous patient-controlled infusion containing 100 µg sufentanil citrate and 20 mg ondansetron in 100 mL normal saline, programmed with a continuous basal rate of 3 mL/hour, 2 mL demand doses, and a 20-minute lockout interval between doses. On POD 1, the patient remained bedbound without flatus or bowel movement. Cardiopulmonary and gynecological examinations were unremarkable. She received intravenous antibiotics and approximately 3000 mL fluid replacement while maintaining supine positioning without pillows, with encouragement for gradual ambulation. The intravenous analgesic pump was discontinued after 24 hours upon exhaustion of medication. Resting incisional pain registered 3–4 on the Visual Analog Scale without effective demand dose utilization. No headache or other discomfort was reported. By POD 2, the patient described mild positional headaches localized to frontal and occipitoparietal regions, scoring 2–3 on the Visual Analog Scale (VAS). Symptoms exacerbated in upright positions and alleviated supine, without nausea, vomiting, or neurological deficits. Vital signs remained stable. Management continued with bed rest and daily 3000 mL intravenous hydration. From POD 3 to 7, headaches intensified to VAS 4–7, becoming position-independent and unrelieved by recumbency. Neurological examination revealed no focal signs. The patient declined epidural blood patch therapy. Oral acetaminophen provided partial symptomatic relief. Concurrently, enoxaparin 4000 units subcutaneously once daily was initiated on POD 4 for deep vein thrombosis prophylaxis during prolonged immobilization. Serial blood tests demonstrated declining hemoglobin, reaching a nadir of 78 g/L. Transfusion of four units of packed red blood cells elevated hemoglobin to 98 g/L with subsequent stabilization. Platelet counts and coagulation parameters remained within normal limits. On POD 8, the patient reported significant headache relief. Brain MRI identified bilateral subdural collections with mixed signal intensity: linear areas of T1 hypointensity and T2 hyperintensity, suggestive of a predominantly fluid-filled space with suspended hemorrhagic products. The ventricular system appeared normal in size and configuration, with midline structures maintained, and sulci showing no widening (Figs. 1 – 2 ). Neurology consultation recommended conservative management with close monitoring, reserving surgical intervention if clinically indicated. Given symptomatic improvement, the patient requested and was discharged that same day. During follow-up obstetric visits, headache resolution was documented without recurrence. Repeat neuroimaging or specialized neurological care was not pursued. Discussion Neuraxial anesthesia remains the cornerstone technique for cesarean deliveries, with post-dural puncture headache representing a well-documented complication. Current literature indicates accidental dural puncture occurs in 0.4%-6% of obstetric neuraxial procedures [ 1 ], with 50%-80% of affected parturients developing post-dural puncture headache (PDPH) [ 7 ]. The patient developed postoperative headache as a complication, which was diagnosed as PDPH. Notably, imaging studies revealed the presence of subdural fluid accumulation accompanied by minor hemorrhagic components, with a total volume of approximately 200 ml. This finding has drawn our particular attention due to its potential clinical implications. The accumulation of subdural fluid results from cerebrospinal fluid entering the subdural space through a one-way valvular tear in the arachnoid membrane. This condition is most commonly observed following traumatic brain injury[ 8 ]. Cases of intracranial subdural fluid accumulation following dural puncture during spinal anesthesia have rarely been reported in the literature globally. The underlying mechanism is hypothesized to be related to intracranial hypotension resulting from insufficient cerebrospinal fluid volume[ 9 ]. This low-pressure state causes the brain to sag and shift downward, exerting traction on the intracranial arachnoid membrane and the adjacent bridging veins—particularly at their vulnerable subdural segments[ 6 ]. Such traction may lead to tears in both the arachnoid and venous walls, allowing cerebrospinal fluid and blood to collect within the subdural space, thereby forming a subdural effusion accompanied by hemorrhage[ 10 ]. Mounting evidence links PDPH to intracranial subdural hematoma formation. Albert R. Moore et al. established this association in obstetric populations, a finding corroborated by Cuypers V et al.'s systematic analysis[ 11 ]. Subdural hematoma constitutes a rare but serious consequence of unintentional dural tears during spinal or epidural anesthesia with estimated incidence between, a retrospective study indicated that the time interval from symptom onset to diagnosis varied widely, ranging from 4 hours to 29 weeks, with a mean of 22 days (standard deviation: 35 days) and a median of 14 days[ 2 , 12 ]. Subdural hematoma (SDH) typically manifests as progressive, position-independent headaches refractory to conventional PDPH therapies or blood patching. Neurological deficits may accompany this presentation[ 13 ]. Our patient exhibited headache as the sole symptom throughout her PDPH-to-SDH progression, contrasting with the broader symptom profile documented in a 35-case review where headaches affected 74.3% of patients, while altered consciousness (40.0%), vomiting (31.4%), hemiparesis (22.9%), cranial nerve palsies (14.3%), and speech disturbances (11.4%) were also reported. That cohort demonstrated 11.4% neurological sequelae and equivalent mortality[ 12 ]. Significant risk factors encompass pregnancy status, multiple neuraxial attempts, anticoagulant administration, intracranial vascular anomalies, and cerebral atrophy. On POD 2, the patient developed positional headache consistent with post-dural puncture headache. Between POD 3 and 7, the headache intensified, became refractory to common analgesics, and was no longer positional. Magnetic resonance imaging of the brain performed on POD 8 revealed subdural fluid accumulation accompanied by minor hemorrhage, with an estimated total volume of 200 ml. The mechanism is presumed to be related to cerebrospinal fluid loss after dural puncture, which resulted in significantly decreased intracranial pressure. This subsequent intracranial hypotension likely led to brain sagging, causing traction and tearing of the intracranial arachnoid mater and bridging veins that connect the superficial cerebral veins and dural venous sinuses, ultimately resulting in subdural effusion and hemorrhage. Despite the detailed clinical insights presented, this case report has several inherent limitations. The findings are derived from a single patient encounter, which precludes broad generalizations to the broader obstetric population. Furthermore, intracranial vascular malformations—a potential predisposing factor for subdural hemorrhage—could not be entirely ruled out, as advanced vascular imaging was not performed. The temporal association between enoxaparin administration and symptom progression suggests a possible aggravating role of anticoagulation, though causation remains speculative. Finally, medium- to long-term neurological follow-up was limited after discharge, and repeat neuroimaging was not obtained, leaving some uncertainty regarding complete resolution of the collections. Future prospective studies with systematic imaging and larger sample sizes are needed to better characterize risk factors and natural history of this rare complication. Conclusions These observations support the following clinical considerations: In patients with post-dural puncture headache (PDPH) following neuraxial anesthesia, urgent neuroimaging such as MRI or contrast-enhanced CT should be considered if the headache persists beyond one week, does not respond to conventional therapy or epidural blood patch, changes from positional to non-positional, or is accompanied by new neurological symptoms. Obstetric patients who undergo multiple neuraxial procedures and elderly males using anticoagulants may be at increased risk for subdural hygroma or hematoma and thus might require closer monitoring. Early intervention is recommended upon identification of an effusion or hematoma to mitigate the potential risks of intracranial hypertension or chronic mass effect that could lead to permanent neurological deficits. Abbreviations BP Blood pressure CSF Cerebrospinal fluid CT Computed tomography CSE Combined spinal-epidural anesthesia HR Heart rate INR International normalized ratio IV Intravenous MRI Magnetic resonance imaging PDPH Post-dural puncture headache POD Postoperative day SDH Subdural hematoma SpO₂ Peripheral oxygen saturation VAS Visual Analog Scale Declarations Ethics approval and consent to participate Not applicable. Consent for publication The patient provided written informed consent for publication of their personal/clinical details and any identifying images to be published in this study. Availability of data and materials The datasets used during the current study are available from the corresponding author on reasonable request. Competing Interests The authors declare that they have no competing interests. Funding None. Authors' contributions L.W. and Y.W. contributed equally to this work as co-first authors. L.W. was responsible for data collection and analysis, and drafted the initial manuscript. Y.W. managed the literature review and contributed to the case description. S.Y. and M.G. were involved in patient care and data interpretation. Y.G. performed the radiological analysis and image preparation. H.Z. as the corresponding author supervised the entire study, provided critical revisions, and approved the final manuscript. All authors reviewed and approved the final manuscript. Acknowledgements Not applicable. Clinical trial number Not applicable Conflict of interest statement The authors declare no competing interests. Consent for publication Not applicable. Informed consent The patient has provided written informed consent for the participation and publication of this research. References Nepomuceno R, Herd A. Bilateral subdural hematoma after inadvertent dural puncture during epidural analgesia. J Emerg Med. 2013;44(2):e227–230. Machurot PY, Vergnion M, Fraipont V, Bonhomme V, Damas F. Intracranial subdural hematoma following spinal anesthesia: case report and review of the literature. Acta Anaesthesiol Belg. 2010;61(2):63–6. Colamaria A, Sacco M, Iodice S, Fochi NP, Carbone F. Cerebrospinal fluid leak as a driving factor in chronic subdural hematoma formation: A histological study. Surg Neurol Int. 2021;12:578. Cutsforth-Gregory JK, Steel SJ, Schievink WI, Madhavan AA. Causes of Intracranial Hypotension: Spontaneous, Traumatic, and Iatrogenic Cerebrospinal Fluid Leaks. Neuroimaging Clin N Am. 2025;35(1):123–32. Kumar R, Cutsforth-Gregory JK, Brinjikji W. Cerebrospinal Fluid Leaks, Spontaneous Intracranial Hypotension, and Chiari I Malformation. Neurosurg Clin N Am. 2023;34(1):185–92. Schievink WI. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA. 2006;295(19):2286–96. Buddeberg BS, Bandschapp O, Girard T. Post-dural puncture headache. Minerva Anestesiol. 2019;85(5):543–53. Lee KS. Chronic Subdural Hematoma in the Aged, Trauma or Degeneration? J Korean Neurosurg Soc. 2016;59(1):1–5. Epstein NE. Neurological complications of lumbar and cervical dural punctures with a focus on epidural injections. Surg Neurol Int. 2017;8:60. Wilkinson BM, Oh JY, Swarnkar AS, Galgano M. Dramatic Resolution of Symptomatic Thoracolumbar Traumatic Spinal Subdural Hygroma with Lumbar Puncture: A Literature Review and Case Illustration. World Neurosurg. 2020;135:19–22. Moore AR, Wieczorek PM, Carvalho JCA. Association Between Post-Dural Puncture Headache After Neuraxial Anesthesia in Childbirth and Intracranial Subdural Hematoma. JAMA Neurol. 2020;77(1):65–72. Amorim JA, Remígio DS, Damázio Filho O, de Barros MA, Carvalho VN, Valença MM. Intracranial subdural hematoma post-spinal anesthesia: report of two cases and review of 33 cases in the literature. Rev Bras Anestesiol. 2010;60(6):620–9. Zeidan A, Farhat O, Maaliki H, Baraka A. Does postdural puncture headache left untreated lead to subdural hematoma? Case report and review of the literature. Middle East J Anaesthesiol. 2010;20(4):483–92. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 26 Oct, 2025 Reviewers agreed at journal 21 Oct, 2025 Reviewers agreed at journal 18 Oct, 2025 Reviewers agreed at journal 16 Oct, 2025 Reviewers agreed at journal 15 Oct, 2025 Reviewers agreed at journal 09 Oct, 2025 Reviewers invited by journal 09 Oct, 2025 Editor assigned by journal 06 Oct, 2025 Editor invited by journal 16 Sep, 2025 Submission checks completed at journal 15 Sep, 2025 First submitted to journal 15 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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1","display":"","copyAsset":false,"role":"figure","size":159388,"visible":true,"origin":"","legend":"\u003cp\u003eAxial T2-weighted MRI of the brain demonstrating bilateral subdural hyperintensities (arrows).\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7565090/v1/d2a3a31bd923881108cdf630.png"},{"id":94204652,"identity":"2dbb1685-8371-40f1-80ac-84ab0f649294","added_by":"auto","created_at":"2025-10-23 14:24:42","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":115124,"visible":true,"origin":"","legend":"\u003cp\u003eAxial T1-weighted MRI of the brain demonstrating bilateral subdural hypointensities (arrows).\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-7565090/v1/e74eec496b464b166bed8f64.png"},{"id":94205139,"identity":"613d662d-439b-4389-96c7-06962353c73c","added_by":"auto","created_at":"2025-10-23 14:32:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":720915,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7565090/v1/15e6c7a4-ad90-4575-a611-517e8665cebb.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Beyond the Typical Headache: A Case of Bilateral Subdural Hygroma Complicated by Hemorrhage Following Obstetric Dural Puncture","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIntracranial subdural hematoma (SDH) or hygroma is a rare but serious neurological complication following neuraxial anesthesia[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], with an estimated incidence of between 1:500,000 and 1:1,000,000[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It most commonly arises as a consequence of persistent cerebrospinal fluid (CSF) leakage leading to intracranial hypotension, brain sag, and traction on bridging veins or the arachnoid membrane[\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. While post-dural puncture headache (PDPH) is a well-known complication, the progression to SDH is less common and requires a high index of clinical suspicion for diagnosis. This case report describes a patient who developed a bilateral subdural collection with hemorrhage after an accidental dural puncture during elective cesarean delivery. Furthermore, it highlights the diagnostic challenge posed by the evolution of headache characteristics and discusses the potential role of prophylactic anticoagulation in exacerbating this condition.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 28-year-old primigravida, with a height of 156 cm and weight of 66 kg, was admitted at 37\u0026thinsp;+\u0026thinsp;1 weeks' gestation with a diagnosis of transverse fetal lie. The patient presented without abdominal pain, vaginal bleeding, or fluid leakage, reporting normal fetal movements. An elective cesarean delivery was planned. Her medical history included subclinical hypothyroidism managed with oral levothyroxine, with recent thyroid function tests confirming euthyroid status. Admission diagnoses were term singleton pregnancy in a nulliparous woman with transverse fetal presentation and subclinical hypothyroidism. She denied any neurological disorders.\u003c/p\u003e\u003cp\u003ePreoperative investigations revealed sinus arrhythmia at 67 beats per minute on electrocardiogram. Chest radiography revealed segmentation anomalies at T5-T7 thoracic vertebrae with associated bilateral rib developmental abnormalities. Laboratory findings included hemoglobin of 102 g/L (mild anemia), platelet count 207\u0026times;10⁹/L, and normal coagulation parameters: prothrombin time 11.3 s (seconds), activated partial thromboplastin time 29.1 s, and INR (international normalized ratio) 1.01.\u003c/p\u003e\u003cp\u003eDuring anesthesia induction, the alert and oriented patient maintained vital signs at blood pressure (BP) 120/90 mmHg, heart rate (HR) 96 bpm, and peripheral oxygen saturation (SpO₂) 98% following peripheral intravenous (IV) catheter placement. Combined spinal-epidural (CSE) anesthesia was initiated in the right lateral decubitus position. During needle insertion at the L3-L4 interspace using a 14-gauge epidural needle (Fornia Medical, Zhuhai, China), accidental dural puncture occurred with cerebrospinal fluid (CSF) leakage. The needle was immediately withdrawn. Successful single-shot spinal anesthesia was subsequently achieved at the L2-L3 interspace, confirmed by free CSF reflux through the spinal needle. A 2.5 mL solution of 0.5% ropivacaine mixed with CSF was administered intrathecally.\u003c/p\u003e\u003cp\u003eFollowing needle removal, the patient was repositioned supine with 15\u0026deg; left lateral tilt. Sensory blockade to the T6 dermatome developed within three minutes with stable hemodynamics. Surgery commenced promptly, delivering a live female infant with Apgar scores of 10 at one and five minutes approximately six minutes after incision. Estimated intraoperative blood loss was 500 mL with urine output of 400 mL and intravenous fluid administration totaling 1200 mL. The procedure concluded uneventfully with a final sensory blockade level at T8.\u003c/p\u003e\u003cp\u003ePostoperative analgesia was provided via intravenous patient-controlled infusion containing 100 \u0026micro;g sufentanil citrate and 20 mg ondansetron in 100 mL normal saline, programmed with a continuous basal rate of 3 mL/hour, 2 mL demand doses, and a 20-minute lockout interval between doses.\u003c/p\u003e\u003cp\u003eOn POD 1, the patient remained bedbound without flatus or bowel movement. Cardiopulmonary and gynecological examinations were unremarkable. She received intravenous antibiotics and approximately 3000 mL fluid replacement while maintaining supine positioning without pillows, with encouragement for gradual ambulation. The intravenous analgesic pump was discontinued after 24 hours upon exhaustion of medication. Resting incisional pain registered 3\u0026ndash;4 on the Visual Analog Scale without effective demand dose utilization. No headache or other discomfort was reported.\u003c/p\u003e\u003cp\u003eBy POD 2, the patient described mild positional headaches localized to frontal and occipitoparietal regions, scoring 2\u0026ndash;3 on the Visual Analog Scale (VAS). Symptoms exacerbated in upright positions and alleviated supine, without nausea, vomiting, or neurological deficits. Vital signs remained stable. Management continued with bed rest and daily 3000 mL intravenous hydration.\u003c/p\u003e\u003cp\u003eFrom POD 3 to 7, headaches intensified to VAS 4\u0026ndash;7, becoming position-independent and unrelieved by recumbency. Neurological examination revealed no focal signs. The patient declined epidural blood patch therapy. Oral acetaminophen provided partial symptomatic relief. Concurrently, enoxaparin 4000 units subcutaneously once daily was initiated on POD 4 for deep vein thrombosis prophylaxis during prolonged immobilization. Serial blood tests demonstrated declining hemoglobin, reaching a nadir of 78 g/L. Transfusion of four units of packed red blood cells elevated hemoglobin to 98 g/L with subsequent stabilization. Platelet counts and coagulation parameters remained within normal limits.\u003c/p\u003e\u003cp\u003eOn POD 8, the patient reported significant headache relief. Brain MRI identified bilateral subdural collections with mixed signal intensity: linear areas of T1 hypointensity and T2 hyperintensity, suggestive of a predominantly fluid-filled space with suspended hemorrhagic products. The ventricular system appeared normal in size and configuration, with midline structures maintained, and sulci showing no widening (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Neurology consultation recommended conservative management with close monitoring, reserving surgical intervention if clinically indicated. Given symptomatic improvement, the patient requested and was discharged that same day. During follow-up obstetric visits, headache resolution was documented without recurrence. Repeat neuroimaging or specialized neurological care was not pursued.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eNeuraxial anesthesia remains the cornerstone technique for cesarean deliveries, with post-dural puncture headache representing a well-documented complication. Current literature indicates accidental dural puncture occurs in 0.4%-6% of obstetric neuraxial procedures [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], with 50%-80% of affected parturients developing post-dural puncture headache (PDPH) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The patient developed postoperative headache as a complication, which was diagnosed as PDPH. Notably, imaging studies revealed the presence of subdural fluid accumulation accompanied by minor hemorrhagic components, with a total volume of approximately 200 ml. This finding has drawn our particular attention due to its potential clinical implications.\u003c/p\u003e\u003cp\u003eThe accumulation of subdural fluid results from cerebrospinal fluid entering the subdural space through a one-way valvular tear in the arachnoid membrane. This condition is most commonly observed following traumatic brain injury[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Cases of intracranial subdural fluid accumulation following dural puncture during spinal anesthesia have rarely been reported in the literature globally. The underlying mechanism is hypothesized to be related to intracranial hypotension resulting from insufficient cerebrospinal fluid volume[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This low-pressure state causes the brain to sag and shift downward, exerting traction on the intracranial arachnoid membrane and the adjacent bridging veins\u0026mdash;particularly at their vulnerable subdural segments[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Such traction may lead to tears in both the arachnoid and venous walls, allowing cerebrospinal fluid and blood to collect within the subdural space, thereby forming a subdural effusion accompanied by hemorrhage[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMounting evidence links PDPH to intracranial subdural hematoma formation. Albert R. Moore et al. established this association in obstetric populations, a finding corroborated by Cuypers V et al.'s systematic analysis[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Subdural hematoma constitutes a rare but serious consequence of unintentional dural tears during spinal or epidural anesthesia with estimated incidence between, a retrospective study indicated that the time interval from symptom onset to diagnosis varied widely, ranging from 4 hours to 29 weeks, with a mean of 22 days (standard deviation: 35 days) and a median of 14 days[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSubdural hematoma (SDH) typically manifests as progressive, position-independent headaches refractory to conventional PDPH therapies or blood patching. Neurological deficits may accompany this presentation[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Our patient exhibited headache as the sole symptom throughout her PDPH-to-SDH progression, contrasting with the broader symptom profile documented in a 35-case review where headaches affected 74.3% of patients, while altered consciousness (40.0%), vomiting (31.4%), hemiparesis (22.9%), cranial nerve palsies (14.3%), and speech disturbances (11.4%) were also reported. That cohort demonstrated 11.4% neurological sequelae and equivalent mortality[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Significant risk factors encompass pregnancy status, multiple neuraxial attempts, anticoagulant administration, intracranial vascular anomalies, and cerebral atrophy.\u003c/p\u003e\u003cp\u003eOn POD 2, the patient developed positional headache consistent with post-dural puncture headache. Between POD 3 and 7, the headache intensified, became refractory to common analgesics, and was no longer positional. Magnetic resonance imaging of the brain performed on POD 8 revealed subdural fluid accumulation accompanied by minor hemorrhage, with an estimated total volume of 200 ml. The mechanism is presumed to be related to cerebrospinal fluid loss after dural puncture, which resulted in significantly decreased intracranial pressure. This subsequent intracranial hypotension likely led to brain sagging, causing traction and tearing of the intracranial arachnoid mater and bridging veins that connect the superficial cerebral veins and dural venous sinuses, ultimately resulting in subdural effusion and hemorrhage.\u003c/p\u003e\u003cp\u003eDespite the detailed clinical insights presented, this case report has several inherent limitations. The findings are derived from a single patient encounter, which precludes broad generalizations to the broader obstetric population. Furthermore, intracranial vascular malformations\u0026mdash;a potential predisposing factor for subdural hemorrhage\u0026mdash;could not be entirely ruled out, as advanced vascular imaging was not performed. The temporal association between enoxaparin administration and symptom progression suggests a possible aggravating role of anticoagulation, though causation remains speculative. Finally, medium- to long-term neurological follow-up was limited after discharge, and repeat neuroimaging was not obtained, leaving some uncertainty regarding complete resolution of the collections. Future prospective studies with systematic imaging and larger sample sizes are needed to better characterize risk factors and natural history of this rare complication.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThese observations support the following clinical considerations: In patients with post-dural puncture headache (PDPH) following neuraxial anesthesia, urgent neuroimaging such as MRI or contrast-enhanced CT should be considered if the headache persists beyond one week, does not respond to conventional therapy or epidural blood patch, changes from positional to non-positional, or is accompanied by new neurological symptoms. Obstetric patients who undergo multiple neuraxial procedures and elderly males using anticoagulants may be at increased risk for subdural hygroma or hematoma and thus might require closer monitoring. Early intervention is recommended upon identification of an effusion or hematoma to mitigate the potential risks of intracranial hypertension or chronic mass effect that could lead to permanent neurological deficits.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBlood pressure\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCSF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCerebrospinal fluid\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eComputed tomography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCSE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCombined spinal-epidural anesthesia\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHeart rate\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eINR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInternational normalized ratio\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntravenous\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMagnetic resonance imaging\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePDPH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePost-dural puncture headache\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePOD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePostoperative day\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSDH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSubdural hematoma\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSpO₂\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePeripheral oxygen saturation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eVAS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eVisual Analog Scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient provided written informed consent for publication of their personal/clinical details and any identifying images to be published in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e None.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eL.W. and Y.W. contributed equally to this work as co-first authors. L.W. was responsible for data collection and analysis, and drafted the initial manuscript. Y.W. managed the literature review and contributed to the case description. S.Y. and M.G. were involved in patient care and data interpretation. Y.G. performed the radiological analysis and image preparation. H.Z. as the corresponding author supervised the entire study, provided critical revisions, and approved the final manuscript. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient has provided written informed consent for the participation and publication of this research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNepomuceno R, Herd A. Bilateral subdural hematoma after inadvertent dural puncture during epidural analgesia. J Emerg Med. 2013;44(2):e227\u0026ndash;230.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMachurot PY, Vergnion M, Fraipont V, Bonhomme V, Damas F. Intracranial subdural hematoma following spinal anesthesia: case report and review of the literature. Acta Anaesthesiol Belg. 2010;61(2):63\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eColamaria A, Sacco M, Iodice S, Fochi NP, Carbone F. Cerebrospinal fluid leak as a driving factor in chronic subdural hematoma formation: A histological study. Surg Neurol Int. 2021;12:578.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCutsforth-Gregory JK, Steel SJ, Schievink WI, Madhavan AA. Causes of Intracranial Hypotension: Spontaneous, Traumatic, and Iatrogenic Cerebrospinal Fluid Leaks. Neuroimaging Clin N Am. 2025;35(1):123\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKumar R, Cutsforth-Gregory JK, Brinjikji W. Cerebrospinal Fluid Leaks, Spontaneous Intracranial Hypotension, and Chiari I Malformation. Neurosurg Clin N Am. 2023;34(1):185\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchievink WI. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA. 2006;295(19):2286\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBuddeberg BS, Bandschapp O, Girard T. Post-dural puncture headache. Minerva Anestesiol. 2019;85(5):543\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLee KS. Chronic Subdural Hematoma in the Aged, Trauma or Degeneration? J Korean Neurosurg Soc. 2016;59(1):1\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEpstein NE. Neurological complications of lumbar and cervical dural punctures with a focus on epidural injections. Surg Neurol Int. 2017;8:60.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWilkinson BM, Oh JY, Swarnkar AS, Galgano M. Dramatic Resolution of Symptomatic Thoracolumbar Traumatic Spinal Subdural Hygroma with Lumbar Puncture: A Literature Review and Case Illustration. World Neurosurg. 2020;135:19\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMoore AR, Wieczorek PM, Carvalho JCA. Association Between Post-Dural Puncture Headache After Neuraxial Anesthesia in Childbirth and Intracranial Subdural Hematoma. JAMA Neurol. 2020;77(1):65\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAmorim JA, Rem\u0026iacute;gio DS, Dam\u0026aacute;zio Filho O, de Barros MA, Carvalho VN, Valen\u0026ccedil;a MM. Intracranial subdural hematoma post-spinal anesthesia: report of two cases and review of 33 cases in the literature. Rev Bras Anestesiol. 2010;60(6):620\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZeidan A, Farhat O, Maaliki H, Baraka A. Does postdural puncture headache left untreated lead to subdural hematoma? Case report and review of the literature. Middle East J Anaesthesiol. 2010;20(4):483\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Subdural hygroma, accidental dural puncture, case report, postpartum headache, neuroimaging","lastPublishedDoi":"10.21203/rs.3.rs-7565090/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7565090/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis report details the case of a 28-year-old parturient who developed bilateral intracranial subdural collections after an accidental dural puncture during combined spinal-epidural anesthesia for elective cesarean delivery. The dural tear occurred at the L3\u0026ndash;L4 interspace, accompanied by observable cerebrospinal fluid leakage; anesthesia was subsequently successfully achieved via single-shot spinal administration at L2\u0026ndash;L3. The patient initially presented on postoperative day (POD) 2 with orthostatic headaches, consistent with classic post-dural puncture headache. However, between POD 3 and 7, her symptoms evolved into severe, non-positional cephalalgia that proved refractory to conventional analgesics. magnetic resonance imaging (MRI) performed on POD 8 confirmed extensive bilateral subdural fluid collections with a minor hemorrhagic component, totaling approximately 200 mL in volume. Given the eventual resolution of symptoms with conservative management, the patient was discharged and later demonstrated complete neurological recovery during follow-up evaluations.\u003c/p\u003e\u003cp\u003eThis case underscores two critical insights: First, the paradoxical clinical trajectory\u0026mdash;from positional to non-positional headaches\u0026mdash;serves as a key indicator for neuroimaging to exclude subdural hematoma, a very rare complication. Moreover, prophylactic enoxaparin initiated on postoperative day 4 may have exacerbated bleeding, highlighting that anticoagulant administration requires prior neuroimaging when post-dural puncture headache (PDPH) persists. These findings advocate for vigilant monitoring in obstetric neuraxial anesthesia, particularly when multiple attempts or anticoagulants are involved, to prevent permanent neurological sequelae.\u003c/p\u003e","manuscriptTitle":"Beyond the Typical Headache: A Case of Bilateral Subdural Hygroma Complicated by Hemorrhage Following Obstetric Dural Puncture","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-23 14:24:38","doi":"10.21203/rs.3.rs-7565090/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-10-27T01:41:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"335799113962906952324007611951046628149","date":"2025-10-21T07:56:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"76736080130591849971944733279339699948","date":"2025-10-18T13:40:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"281460256916380408534358636731079210297","date":"2025-10-16T06:13:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"162647868511390355311210146221114406040","date":"2025-10-15T04:11:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"242261065470651499100646032467113436492","date":"2025-10-09T16:19:01+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-09T15:21:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-07T03:29:44+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-16T16:41:15+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-15T22:38:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Anesthesiology","date":"2025-09-15T22:36:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"91405f01-6f16-4449-adaf-11d45827df05","owner":[],"postedDate":"October 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-23T14:24:38+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-23 14:24:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7565090","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7565090","identity":"rs-7565090","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}