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Postdural puncture headache complicated by intracranial hemorrhage
Abstract Number: F-50
Abstract Type: Case Report/Case Series
MM, a 38 yo G7 P5 Hispanic female @ 36 4/7 wks gestation, no significant medical history, presented to the obstetrical unit in early labor. Patient was augmented with oxytocin and requested an epidural for pain relief. A CLEA was placed, but complicated by an accidental dural puncture. Pt had an uneventful SVD.
Postpartum day (PPD) #2, the patient began to complain of a frontal headache (HA), 2-10/10 VAS that was positional. Exam revealed patient was normotensive, bradycardic in the 60’s (on admission: 75 BPM), and no focal neurological deficits. Evaluated by anesthesia service with recommendations for IV hydration, caffeine, and ibuprofen for pain. On PPD #3, her headache persisted and now involved the occiput. Again, no neurological deficits appreciated, normotensive, and bradycardic. Options were discussed with patient and she opted for an epidural blood patch. Early afternoon on PPD # 3, obstetrical team was notified of BP, 160/78; PIH labs were ordered. Thirty minutes later, obstetrical team was paged for a heart rate of 50 and the patient complained of neck pain in addition to HA. Patient was transferred to extended care unit for further management. This was not communicated to the anesthesia service.
Anesthesia service proceeded with an uneventful epidural blood patch of 23 mL with immediate relief of HA. Within 10 minutes, patient complained of severe right-sided face and neck pain. On exam per OB team, she was noted to have hives over her chest, Benadryl was ordered. Ten minutes later, the anesthesia service was called emergently to evaluate. Pt continued to c/o severe pain over the face and neck, BP was noted to be elevated, 160/90, and pulse 50 BPM. IV fluids, morphine, stat PIH labs, and stat CT of the head was ordered. Over the next two hours, patient remained hypertensive and bradycardic, treated with hydralazine per OB team; had a progressive decline in mental status to unresponsiveness, emesis, increased urine output, and right-sided facial droop. CT scan revealed a large left frontal intracerebral hemorrhage with involvement/compression of the motor strip and Broca's area (3 cm x 4 cm x 5 cm) with a 4 mm midline shift. Neurosurgery was consulted and patient transferred to the ICU. The following morning, PPD #4, patient’s neurological exam worsened, she was emergently intubated, and taken to the OR for an emergent craniectomy. Five-hundred (500 mL) of blood was evacuated. On POD #6 patient was transferred to the impatient stroke rehab unit and discharged home on POD #57. Eight months later, patient was discharged from physical therapy after meeting goals, independently performs ADLs, but remains with RUE weakness and speech deficits.
Hemorrhagic strokes are rare in obstetrical patients. However, this case highlights that despite a “classic” presentation of a disease, other pathologies may co-exist. Proper communication may have allowed this patient to be diagnosed earlier with immediate intervention.