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Patient with Cerebral Venous Sinus Thrombosis and Postdural Puncture Headache treated successfully with Epidural Blood Patch and Anticoagulation
Abstract Number: T-47
Abstract Type: Case Report/Case Series
Postdural puncture headache (PDPH) is considered the most probable cause of headaches occurring after delivery under regional anesthesia, especially when a postural component is reported. We report a case of a parturient whose workup and follow-up of PDPH revealed underlying concurrence of cerebral venous sinus thrombosis (CVST).
A 35-year-old G6P2 at 40 weeks gestation, with history of chronic headaches (negative head CT)and previous C-section presented with anhydramnios at term. After induction of labor, epidural analgesia was requested and the placement of an epidural catheter was uncomplicated. She achieved excellent analgesia for 10 subsequent hours of labor utilizing a continuous infusion of Hydromorphone 3 mcg/ml and Bupivacaine 0.05% in NS. She then went on to have an uneventful vaginal delivery of a male infant with apgars 8/10. Headache wwas first reported 2-3 minutes following removal of epidural catheter. It was bifrontal and periorbital in location with a strong postural component. An unrecognized dural puncture was suspected and conservative treatment for PDPH was initiated. She only achieved partial relief of her symptoms and was offered an Epidural Blood Patch (EBP) prior to discharge but she chose to continue conservative management at home. Patient returned on post partum day (PPD) 8 with intractable headaches that had progressed in severity. She again described bifrontal and periorbital headaches with radiation to occiput that was 5/10 in severity when recumbent and 10/10 when upright. Nausea and photosensitivity were also present. Neurology was consulted and urgent imaging was done. CT/MRI/MRV of brain showed bilateral subdural collections measuring 2 mm and nonocclusive right transverse sinus thrombosis extending into sagittal sinus with radiologic signs of intracranial hypotension. An EBP was requested by neurology to prevent exacerbation of a low CSF state before starting anticoagulation for the CVST. An EBP was performed on PPD 10 and anticoagulation with heparin was started 5 hours following EBP. The patient reported progressive improvement of symptoms with complete resolution of her headaches in 4 days. Repeat imaging showed resolution of right SDH and she was discharged on Coumadin to be continued for 6-12 months.
The concurrence of CVST and PDPH is rare. In this case, CVST concurring with PDPH was diagnosed early and treated successful with EBP and anticoagulation.
1.Gonen KA, Taskapilioglu O, Dusak A, Hakyemez B. Persistent headache in a postpartum patient: the investigation and management. BMJ Case Rep. 2013 Jun 21;2013
2.Lockhart EM, Baysinger CL. Intracranial Venous Thrombosis in the Parturient. Anesthesiology. 2007 Oct;107(4):652-8