Pseudotumor Cerebri in Pregnancy and Labor
Abstract Number: 265
Abstract Type: Case Report/Case Series
Introduction: Postpartum headache is familiar to most anesthesiologists, but conditions producing severe antepartum headache may not be. We describe a case of pseudotumor cerebri presenting in the second trimester of pregnancy, and consider its implications.
Case: A 19-year-old G3P2 presented at 15 weeks gestation with 2 weeks of nonpostural severe headache, nausea, vomiting, photo/phonophobia, and stiff neck. She was on no medications. BMI was 31, and BP was 123/63. Physical exam and lab values were normal. Specialist evaluation and imaging ruled out vertebral artery dissection, cortical vein thrombosis, and intracranial mass lesion. She had bilateral papilledema and abducens nerve palsies, but visual fields were normal. Pseudotumor cerebri (PTC) was suspected and confirmed by lumbar puncture (LP) in the lateral decubitus position, with opening pressure 55 cm H2O (normal <25.)
Oral acetazolamide was begun. After 6 days, repeat LP showed opening pressure of 35 cm H20. Symptoms improved greatly thereafter and she went home on acetazolamide 500 mg po bid.
At 38 weeks she developed evidence of preeclampsia, with BP 180/108, 3+ proteinuria, recurrent headache, and blurred vision. Eye exam noted no papilledema or sixth nerve palsy. Labor was induced, with analgesia provided by continuous epidural infusion. A normal-appearing infant was born 15 hours later. There were no complaints of headache or blurred vision postpartum.
Discussion: PTC features signs and symptoms of increased intracranial pressure (ICP) without imaging abnormalities. The typical patient is an obese female of childbearing age but relationship to pregnancy is unclear. Headache occurs in >90% of all cases1 and neck stiffness may be seen.4 Ophthalmologic examination is vital to assess papilledema and track visual field defects. Permanent visual impairment is the most significant consequence of prolonged intracranial hypertension.2 Acetazolamide, a carbonic anhydrase inhibitor, variably decreases CSF production and ICP, and is the mainstay of treatment.2 Preserving maternal vision may justify risks of teratogenicity even if therapy is needed before 20 weeks. Optic nerve sheath fenestration or lumboperitoneal cerebrospinal fluid shunting may be indicated to prevent blindness, even during pregnancy.3,4
PTC does not contraindicate vaginal delivery or regional anesthesia. If lumboperitoneal shunt is present, epidural anesthesia may be preferable. A parturient with uncontrolled PTC and papilledema might benefit from an intrathecal catheter, which could be used to withdraw CSF and to provide anesthesia.5 We avoided dural puncture in this case, hoping to simplify the management of any postpartum headache in this complex patient. Happily, mother and baby both did well.
4.Neurol Clin N Am 2004;22:99-131