///2009 Abstract Details
2009 Abstract Details2018-05-01T17:45:11+00:00

Seizure reveals Subdural Hematoma and Posterior Reversible Encephalopathy Syndrome (PRES) in Post-partum Patient

Abstract Number: 214
Abstract Type: Case Report/Case Series

Mariam M. El-Baghdadi B.S., M.D.1 ; Manuel C. Vallejo M.D.2

Introduction

Posterior Reversible Encephalopathy Syndrome (PRES) is a clinicoradiological diagnosis characterized by headaches and further neurological deterioration including confusion, seizures, or cortical visual disturbances. PRES has occurred in patients with hypertensive encephalopathy, immunosuppresion, renal failure, electrolyte imbalance, pre-eclampsia, and eclampsia. PRES occurs due to elevated blood pressure which exceeds autoregulatory capacity of brain vasculature. This case report describes a postpartum woman who developed PRES ten minutes after receiving an epidural blood patch. Her postpartum history is complicated by postdural puncture headache preceding blood patch as well as a seizure and subdural hematoma.

Case Report

A 28 yr old 150kg G1P1001 woman with unremarkable pregnancy underwent cesarean section for macrosomia under combined spinal epidural (CSE). Her past medical history included asthma, migraines, and type 2 diabetes mellitus. The CSE was performed with a Gertie Marx needle through a 19 gauge Tuohy needle using a midline approach at the L2-3 level. On first attempt, clear CSF was obtained. Slow injection of fentanyl 20mcg, morphine 200mcg, and bupivacaine 12mg resulted in a T4 sensory level for surgery. Delivery of baby boy, Apgar 8/9, was uneventful. Motor and sensory block wore off after 3 hrs.

On post-operative day (POD) 3, the patient complained of a headache. The headache was frontal and associated with photosensitivity. At that time, the patient was advised to increase fluid intake and report change in symptoms. Reporting alleviation of headache, the patient was discharged on POD 4. She returned on POD 6 to the hospital complaining of headache. Epidural blood patch was performed at the L2-3 level with 15ml of autologous blood. After 10 minutes, the medical team was called to patients bedside. Patient appeared post-ictal; she had a bloody mouth from a tongue laceration and was confused. She was stabilized and received diagnostic workup. Significant findings include 10g in 24 hr urine protein consistent with pre-eclampsia. The MRI revealed parafalcine subdural hematoma and MRA revealed pruning of bilateral posterior cerebral arteries and branches consistent with PRES.

Discussion

In this patient, it is unclear as to the sequence of events leading to neurological deterioration. The lumbar puncture or leakage of CSF could have caused the subdural hematoma. The subdural hematoma may have been the powerful stimuli for cerebral vasoconstriction resulting in PRES. On the other hand, the diagnosis of pre-eclampsia alone is enough to have caused PRES. The epidural blood patch could have been a trigger for the seizure as there may have been a CSF leak causing traction of the dura. Regardless of the cause of PRES, the mainstay of treatment is addressing the vasospasm; this patient received her treatment in a timely fashion and irreversible brain damage from PRES was prevented.

SOAP 2009