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Superior Sagittal Sinus Thrombosis and Posterior Parietal Intracerebral Hemorrhage following an Accidental Dural Puncture
Abstract Number: S 76
Abstract Type: Case Report/Case Series
Accidental dural puncture (ADP) occurs in ~0.19-3.6% of parturients during attempts at epidural analgesia. Intrathecal catheterization following ADP is one measure that may be performed to reduce the incidence of post-dural puncture headaches. According to some studies, this technique may represent an effective and safe method to manage this complication. With this case report, we review the management of a 29-year-old healthy parturient who sustained an ADP with intrathecal catheterization and subsequently developed a superior sagittal sinus thrombus and right posterior parietal intracerebral hemorrhage.
A 29-year-old G3P1011 active labor requested epidural analgesia for labor. The procedure was complicated by ADP. An intrathecal catheter was threaded and remained in place for the duration of her labor course (< 12hrs). She underwent an otherwise unremarkable labor, delivery, and postpartum hospital course. Three days following hospital discharge, the patient presented to the emergency department (ED) with symptoms of altered mentation, headaches, and left-sided gait dysfunction. She was subsequently discharged with supportive care and caffeine. Two days later, she presented again to the ED with symptoms of seizures and worsening altered mental status; intubation was required for airway protection and appropriate anti-epileptic medications were administered. CT/CTA/MRA of the head were obtained revealing a superior sagittal sinus thrombus and right posterior parietal intracerebral hemorrhage. The patient was extubated and discharged 5 days later. Due to the intracerebral hemorrhage, anticoagulation was not started. To date, the patient has remained asymptomatic and free of further seizure activity.
Superior sagittal sinus thrombosis is an uncommon complication of ADP; it is even rarer to have a coinciding intracerebral hemorrhage. The incidence of these complications is unknown. Diagnosis may be challenging and treatment requires a multidisciplinary approach. This case reviews the current literature on this topic with similar complications and the role of anesthesia providers in the management of this rare complication. In particular, this case highlights the difficulty in the diagnosis and workup of this patient who did not have classic PDPH or symptoms.
1. Ellen M. Lockhart, M.D., Curtis L. Baysinger, M.D., Intracranial Venous Thrombosis in the Parturient, Anesthesiology, 2007; 107:652–8 2007
2. S. Ghatge, S. Uppugonduri, Z. Kamarzaman, Cerebral venous sinus thrombosis following accidental dural puncture and epidural blood patch, International Journal of Obstetric Anesthesia, 2008; 17, 267–270
3. Benzon HT, Iqbal M, Tallman MA, Boehlke L, Russell EJ, Superior sagittal sinus thrombosis in a patient with postdural puncture headache, Regional Analgesia and Pain Medicine, 2003 Jan-Feb;28(1):64-7