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Postdural Puncture Headache Or Cerebral Venous Thrombosis?: A Headache For Anesthesiologist
Abstract Number: RF5AH-165
Abstract Type: Case Report Case Series
Headaches are a common neurological complain during pregnancy and the postpartum period. About 90% of headaches are primary and benign, but some rare types of headaches can be life-threatening and difficult to diagnosis. When a woman develops a positional headache after an inadvertent dural puncture, she often receives post-dural-puncture headache (PDPH) management. However, it is also important to consider the possibility of Dural venous sinus thrombosis (DVST), a cerebrovascular disease that may present with a headache, affecting approximately 0.002% of women, and accounting for 0.5% of strokes. This is the first report of a woman experiencing partial headache relief following sphenopalatine ganglion block (SPGB) and epidural blood patch (EBP) treatments and then being readmitted two days later with right-sided paralysis. Written informed consent was obtained from the patient for publication of this report.
A 23-year-old woman at 39 weeks’ gestation underwent epidural placement for labor analgesia. CSF was aspirated on the first attempt and the needle was reinserted at L3-L4. She had an uneventful delivery of a healthy male infant approximately 4 hours after catheter insertion. On postpartum day (PPD1), she reported a positional headache worse in the posterior region associated with nausea only. Oral medications, including Acetaminophen/Butalbital/Caffeine, SPGB and EBP treatments provided minimum relief. She was discharged on PPD 3 after reporting moderate symptom relief with oxycodone-acetaminophen. Several hours later, she presented to ED with a severe headache, and word finding difficulty. Non-contrast CT head was negative, and she received IV morphine and was discharged. About 24 hours after ED discharge, she presented to the ED with similar symptoms and new right-sided weakness. On physical exam, she had minimal strength in her right upper and lower extremities. A repeat head CT revealed multiple thrombi in the cerebral venous and arterial systems. She was started on IV heparin for anticoagulation and her weakness and headache improved dramatically. She was discharged to rehabilitation center four days after treatment with IV heparin.
This case emphasizes the importance of including DVST in the differential diagnosis of a headache after a dural puncture in the puerperium not responding to standard treatments. Such a diagnosis requires a high clinical suspicion. DVST in this patient can be attributed to the post-partum hypercoagulable state.
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