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Reversible cerebral vasoconstriction syndrome presenting as postpartum headache
Abstract Number: F-37
Abstract Type: Case Report/Case Series
Introduction: Post-dural puncture headache (PDPH) is due to unintended dural puncture, which leads to low cerebrospinal fluid pressure. Although PDPH is a common cause of headache in the postpartum period, the differential diagnosis of post partum headache remains quite extensive. We report a case of possible reversible cerebral vasoconstriction syndrome, which presented as post partum headache.
Case Report: A 23 year-old female was admitted to our hospital eight days following an uneventful cesarean section. Her antepartum history was unremarkable. However, a few days after the surgery, she started having a headache followed by an episode of generalized seizure on the morning of admission. Her recent obstetric history was significant for two epidural placements for labor analgesia as well as a subarachnoid block for C-section. Upon examination, she was noted to have a frontal, orthostatic headache consistent with PDPH, along with nuchal rigidity. Imaging review revealed a normal CT scan of the head. An MRI and neurology consult were ordered and conservative management was undertaken for her headache. The MRI showed non- specific inflammatory changes suggestive of meningitis, but diagnostic lumbar puncture was noncontributory. She was started on IV antibiotics. Her headache resolved over the next several days, and she was discharged home.
Discussion: The incidence of postpartum headache is reported to be as high as 39% during the first week after delivery. Primary disorders, e.g. tension type headache and migraine, are common. Secondary causes include PDPH, subarachnoid hemorrhage, intracranial masses, meningitis, preeclampsia/eclampsia, and cerebral venous sinus thrombosis, among others. Iatrogenic meningitis due to break in sterile technique during epidural placement was a possible etiology in our patient, but the time of onset, absence of fever , and unremarkable CSF exam failed to support that diagnosis. However, the patient’s clinical findings, including headache, nuchal rigidity, and convulsion in the immediate puerperium, suggest reversible cerebral vasoconstriction syndrome (RCVS) or its variant, post partum angiopathy, as a plausible diagnosis. Cerebral angiography would have been helpful to confirm that diagnosis.
Definite therapeutic measures such as epidural blood patch should be avoided for patients in whom neurologic abnormalities superimpose the typical presentation of PDPH. Also, appropriate consultation and involvement by a neurologist is critical in the diagnosis and management of these patients.
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