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Tonic-clonic seizure after unrecognized unintentional dural puncture: A case report
Abstract Number: FCC-314
Abstract Type: Case Report Case Series
Unintentional dural puncture is associated with a high risk of headache, but neurological complications have also been reported. We present a case of tonic-clonic seizure in a parturient who suffered an unrecognized unintentional dural puncture during placement of an epidural catheter for labor analgesia.
A 21 yo primigravid woman presented for induction of labor at 39w5d gestation. Her pregnancy was complicated by Crohn’s disease, obesity, anemia, and depression. She requested labor epidural analgesia approximately 24 hours after her induction began. Two unsuccessful attempts were made by a resident, the first resulting in an intravascular catheter. The attending physician subsequently made two attempts using ultrasound guidance, and an epidural catheter was placed successfully on the second attempt with negative aspiration. The patient first reported neck pain during epidural placement that continued throughout her peripartum course. Her remaining labor was uneventful and she had a vaginal delivery of a vigorous neonate on induction day two. On post-partum day (PPD) 1, the patient endorsed neck pain and a non-positional headache. Postdural puncture headache was not diagnosed and she was not offered an epidural blood patch (EBP). She was discharged on PPD 2.
She was re-admitted on PPD 5 with post-partum headache. Her headache remained non-positional, but tinnitus was noted to be worse when sitting up. She also endorsed blurry vision. She was evaluated by both anesthesiology and neurology teams. An MRI showed marked intracranial hypotension including bilateral subdural effusions and a 6 mm cerebellar tonsillar herniation. There was no evidence of venous thrombosis. The neuroradiology team was consulted for the placement of an urgent EBP. While awaiting this intervention, the patient developed a tonic-clonic seizure and her trachea was intubated for airway protection. An emergent CT demonstrated findings consistent with earlier MRI findings. An EBP was placed that evening using 20mL of autologous blood. An EEG overnight uncovered temporal seizure activity spreading to both hemispheres. The patient was extubated the following morning, and a follow-up EEG demonstrated no seizure activity though she continued to report headache that improved when the head of her bed was lowered. On PPD 7, persistent SVT in conjunction with hypoxia prompted a CT chest that demonstrated pulmonary embolism and therapeutic enoxaparin was started. She was transitioned to unfractionated heparin and a second EBP using 20mL of autologous blood was performed by neuroradiology on PPD 10 for continued headache. She was discharged home on PPD 11 without headache, and has had no long-term sequelae.
Discussion: We report a case of seizure following intracranial hypotension caused by an unrecognized unintentional dural puncture. Prompt recognition and treatment with an EBP may prevent further seizure activity and neurological decompensation.