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Delayed Diagnosis of Central Venous Sinus Thrombosis due to Postdural Puncture Headache
Abstract Number: S2C-5
Abstract Type: Case Report/Case Series
Introduction: Central Venous Sinus Thrombosis (CSVT) is a challenging diagnosis due to a highly variable clinical presentation and a low annual incidence (5 per million). Pregnancy and puerperium are known risk factors.1 The diagnosis can be further complicated by post dural puncture headache (PDPH). PDPH is a much more common (1:100) cause of postpartum headache. There are several cases of patients being initially treated for PDPH and the diagnosis of CSVT is not made until further clinical deterioration or treatment failure.2
Case: 41 year old multiparous female with no significant past medical history underwent uncomplicated combined spinal epidural for labor analgesia with resultant uncomplicated vaginal delivery. Several hours after delivery she complained of a 10 out 10 headache. The headache was determined to be positional and likely due to PDPH. She was prescribed acetaminophen with caffeine resulting in improvement of the headache. She was discharged postpartum day 1 with a prescription for butalbital/acetaminophen/caffeine capsules.
On postpartum day 9 she presented to the ED with continued headache and progressive confusion. Her neuro exam noted significant dysfunction of higher integrative functions but no motor or sensory deficits. CT brain showed an acute venous thrombosis of the superior sagittal sinus along with an acute venous infarct in the parieto-occipital region. MR brain revealed a left subdural hematoma likely secondary to CSF hypotension. The risk of spread of the venous thrombosis was deemed to outweigh the risk of worsening subdural so a heparin drip was started with eventual bridging to warfarin. On outpatient follow-up, she had complete resolution of her headache and confusion.
Discussion: This case illustrates the potential complications in the diagnosis of CVST in the setting of PDPH. This patient likely had PDPH given the positive response to caffeine and acetaminophen and the presence of a subdural hematoma on imaging. The initial improvement in headache however delayed the diagnosis of CVST. Patients presenting with persistent headache symptoms along with confusion or motor weakness may indicate a more concerning diagnosis of CVST.
1. Kashkoush AI, et al. Cerebral venous sinus thrombosis in pregnancy and puerperium. J Clin Neurosci. 2017 May; 39: 9-15.
2. Borum SE, et al. Postpartum dural venous sinus thrombosis after postdural puncture headache and epidural blood patch. Anesthesiology. 1997 Feb;86(2):487-90.