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Postdural Puncture Headache Masking Vertebral Artery Dissection in the Parturient
Abstract Number: S-59
Abstract Type: Case Report/Case Series
Introduction: Postpartum spontaneous vertebral artery dissection (sVAD) is a rare condition that may result in potentially devastating neurologic outcomes . Clinical presentation may include headache, neck pain, pulsatile tinnitus, cerebral ischemia and subarachnoid hemorrhage[2,3]. This case highlights the importance of including VAD in the differential diagnosis of persistent post epidural headache and nuchal pain in the setting of epidural blood patch therapy.
Case Report: Following uncomplicated spontaneous vaginal delivery of a healthy baby with epidural analgesia, a previously well 45 year old parturient (gravid 2, para 1) complained of a frontal headache 36 hours postpartum. Epidural catheter placement was uneventful without obvious dural puncture and second stage of labor was 6 minutes duration. The headache was initially positional in nature with no other symptoms, and settled with oral analgesia at time of discharge home. Over the course of 2 days the frontal headache extended occipital, remained positional and was associated with tinnitus. On admission the patient was apyrexic (temperature 36.2 oC, white cell count 5.3 x 109/L), normotensive (113/58 mmHg) and without evidence of meningism or focal neurology. An epidural blood patch (EBP) for suspected post-dural puncture headache was performed aseptically using 30 ml of autologous blood. This achieved temporary resolution of symptoms, but she represented 3 days later with return of tinnitus, occipital headache (minimal relief when supine) and new onset constant neck pain. On further questioning, the patient described an episode of excessive straining secondary to constipation prior to worsening of her symptoms. Neurological examination was again unremarkable. A second EBP was performed aseptically with 20 ml of autologous blood for which the patient noted little improvement in headache and worsening of neck pain. Subsequent to urgent Neurology consultation, magnetic resonance angiography (MRA) revealed bilateral extra-cranial vertebral artery dissection. The patient was immediately commenced on subcutaneous therapeutic dose low molecular weight heparin for 3 months with a follow-up MRA to be performed at the end of this treatment term. To date she remains fully active and neurologically intact. Residual symptoms include mild neck pain but full resolution of headache.
Conclusion: Persistence of postpartum headache or neck pain following repeated EBP for post-dural puncture headache warrants further neurology assessment and neuro-radiologic imaging to rule out sVAD as part of the differential diagnosis. Inciting events in the puerperium may include excessive valsalva manoeuvres associated with straining. Evidence suggests that early recognition and treatment of sVAD is associated with favorable clinical outcome .
1. Arnold M et al.Stroke 2008; 39(8):2377-2379
2. The CADISP Study. Neurology 2011; 77:1174-1181
3. Arnold M et al. Stroke 2006;37:2499-2