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A Sellar Mass revealed after a Post-Dural Puncture Headache and an Epidural Blood Patch
Abstract Number: S 56
Abstract Type: Case Report/Case Series
Post dural puncture headaches (PDPH) are not uncommon in obstetric anesthetic practice. However, PDPH has also been misdiagnosed with other causes of postpartum headaches ranging from benign conditions to more severe neurologic pathology. We report a rare case in which the resolution of a PDPH with an Epidural Blood Patch (EBP) revealed an underlying dissimilar headache, which when investigated, disclosed a previously undiagnosed sellar mass.
A 22 year old, healthy patient at 39+6 weeks gestation Gravida 3 para 0 was admitted for labor. After an initial accidental dural puncture with a 17 gauge Tuohy needle, successful epidural analgesia was achieved and the patient subsequently had an uneventful labor and vaginal delivery. In the postpartum period, she complained of a severe, postural, occipital headache. Despite conservative management, her severe headache persisted along with photophobia necessitating an EBP. The patient had a resolution of headache with no other symptoms. The next day she developed a non-postural, frontal headache which was less intense with persistent vomiting, and developed intermittent somnolence. An urgent CT of the brain and neurology consult were obtained. The CT – and follow up MRI – revealed a 1.4 cm complex mass within the sella extending into the suprasellar region. The patient’s symptoms resolved completely with conservative management. The patient was discharged home and scheduled for appropriate follow up visits.
DISCUSSION: PDPH treatment is a common part of obstetric anesthesia practice. It is well recognized that this treatment of a complication engenders its own set of risks. Though the risks of EBP are mostly minor , the temporal relationship between the PDPH and EBP in this presentation might suggest a causal significance. Sellar masses may present with a headache but the fleeting presentation in this patient limits the possible reasons . Both sub-acute apoplexy and a vascular headache might fit with this presentation. The intracranial pressure effects from changes in cerebral spinal fluid (CSF) dynamics resulting from both an initial loss of CSF and subsequent increased pressure from the EBP could be postulated as influencing the evolution of this pathology.
CONCLUSION: This case describes the occurrence of a PDPH following an accidental dural puncture which was treated with an EBP. However, persistent symptoms which could have been attributed to ongoing PDPH, instead, led to the diagnosis of a large sellar mass.
1. Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth 91 (5), 718, 2003
2. Peter N Riskind. Pituitary Tumors and Headaches, Neuroendocrine Newsletter; Volume 19, Issue 1, Spring 2012