Pituitary Apoplexy Mimicking Post-Dural Puncture Headache
Abstract Number: S-60
Abstract Type: Case Report/Case Series
Post-dural puncture headache (PDPH), a common complication of parturients undergoing neuroaxial blockade, is thought to be due to loss of CSF into epidural space causing traction and irritation of meninges. In this case report we are describing a rare clinical syndrome presented as postpartum headache resembling the clinical picture of PDPH. A 21 year-old morbidly obese female at 34 weeks gestation presented to the L&D Unit with history of hypertension, proteinuria, and headache. Following admission she had a witnessed seizure that lasted approximately for a minute. Intravenous magnesium was started and she was brought to the operating room for an emergent cesarean section. After several attempts, a successful subarachnoid block was achieved with a 22 ga. spinal needle using 7.5 mg of bupivacaine with 20 mcg fentanyl and 150 mcg of morphine. The delivery of the infant was uneventful. On her second post-operative day, the patient complained of severe frontal headache that worsened with sitting and improved after lying down. The history was consistent with PDPH and conservative management with bed rest, caffeine and cosyntropin was initiated. The management failed to improve her symptoms and an MRI of the head was ordered the next day. The MRI revealed a 1.8 x 1.1 x 0.9 cm enlargement of the pituitary gland due to macro-adenoma and hemorrhage that consistent with the diagnosis of pituitary apoplexy. Pituitary apoplexy is a life threatening emergency that occurs after hemorrhage or infarction of a normal or adenomatous pituitary gland. Blood and tissue edema within the hypophyseal fossa causes compression and results in swelling of the contents in the sella turcica. It produces severe headache, visual changes, hypopituitarism and altered mental status (1). Our patient had no known history of pituitary adenoma but displayed multiple predisposing factors for pituitary apoplexy. During pregnancy, the pituitary gland normally hypertrophies in size but pituitary tumors can also grow rapidly during this time that can lead to ischemia and apoplexy. Modest hypertension of 140/70 mm Hg in younger patients during preeclampsia and eclampsia can cause cerebral edema and hemorrhage further increasing the risk of pituitary apoplexy. On the other hand, hypotension induced by her spinal anesthesia can cause tumor ischemia contributing to the development of apoplexy. Although there are reports (2) of pituitary apoplexy after spinal anesthesia, this is the first case report of pituitary apoplexy presenting as post-puncture headache after neuroaxial anesthesia.