Intractable Cerebral Vein Thrombosis during Pregnancy
Abstract Number: 139
Abstract Type: Case Report/Case Series
Introduction: Cerebral vein thrombosis (CVT) occurs in 12/100,000 deliveries, with a mortality rate of up to 10% (1). Diagnosis can be difficult due to nonspecific symptoms. The anesthetic management must be tailored to address issues associated with increased intracranial pressure, timing of anticoagulation, and method of delivery.
Case: A 31 year-old G1P0 presented at 23 weeks with persistent headache for one month. PMH was significant for migraines on sumatriptan and DVT/PE while on oral contraceptive. Workup revealed MTHFR gene mutation, platelets of 70,000, and MRI showed mastoiditis and cerebral vein thrombosis with complete occlusion of the left transverse and sigmoid sinus and partial occlusion of the superior sagittal sinus. Following a month of anticoagulation with LMWH, cerebral flow was somewhat improved, but the clot had not resolved significantly. She used a fentanyl patch and hydomorphone for persistent headaches. At 27 weeks, after being off LMWH for 24 hrs, the patient had a cesarean section for IUFD. Epidural anesthesia was uneventful. The patient had transient headache with each 5 ml injection of epidural lidocaine 2% to a total dose of 30 ml with stable hemodynamics. Post-op LMWH was scheduled to be restarted 24 hours after surgery. At 17 hours post-op, an acute change in mental status occurred, and stat CT angiogram revealed a new bilateral transverse sinus thrombus and full anticoagulation with heparin was restarted. Interventional radiologist removed thrombus from the left internal jugular, sigmoid and partially in the transverse sinus. In spite of heroic efforts, the patient died 24 hours later.
Discussion: Cerebral vein thrombosis during pregnancy can prove to be a fatal complication. Risk factors in this patient included mastoiditis, pregnancy, history of DVT and PE, and the MTHFR mutation(2). Diagnosis of CVT may be delayed given the nonspecific nature of the symptoms including constant or positional headache, dizziness, nausea and vomiting, blurred vision, lateralizing neurologic signs, lethargy, seizures, and coma(3) Also CVT usually occurs in the puerperium and not during pregnancy as in this patient(4). Treatment with heparin is often recommended although 40% of CVT patients have a hemorrhagic component (2). Both the method of delivery and anesthetic technique provide challenges in anticoagulation timing and avoiding intracranial pressure changes. Dural puncture from spinal anesthesia can cause herniation in the presence of intracranial mass effect, while an epidural anesthetic can transiently increase ICP. Regardless of technique, maintaining stable hemodynamics for cerebral perfusion pressure is important. CVT should be included in the differential diagnosis for headache and once diagnosed, aggressive treatment and vigilance should be undertaken.
References: 1)Lanska Stroke 2000:31:1274-82. 2) Stam NEJM 2005:352:1791-8. 3)Lockhart Anesthesiology 2007:107:652-8. 4)Cantu Stroke 1993:24:1880-8