121 Postpartum postdural puncture headache: when things can go wrong…

Background and Aims We report a case of cerebral venous sinus thrombosis (CVST) after no obvious dural puncture in a postcesarean section patient Methods A 32-year old primigravida underwent cesarean section under a combined spinal-epidural. She had a medical history of panic attacks and depression. On the second postpartum day, the parturient developed orthostatic headache which was considered as postdural puncture headache and treated accordingly. Three days postdischarge, the headache returned, having lost its orthostatic component. The parturient however refused to return to hospital for reassessment. Over the next few days, the parturient started behaving strangely and refusing interaction with the newborn. A psychiatrist consulted by the family diagnosed anxiety disorder based on the parturient’s previous medical history and suggested anti-anxiety medication. Results On the seventh postpartum day, the parturient was urgently readmitted to hospital, unable to speak and looking catatonic. Major postpartum depression was diagnosed by the attending psychiatrist and antidepressive medication was initiated. However, on the first readmission night, the parturient developed tonic-clonic seizures and an urgent brain CT-scan revealed multiple left-sided infarcts with haemorrhagic foci. CVST was diagnosed, low-molecular weight heparin was started and the parturient’s situation improved dramatically Conclusions CVST is attributed to cerebral venous dilation and intracranial hypotension in the setting of postpartum hypercoagulability and can have a deleterious outcome if unsuspected and untreated. This case of misdiagnosis emphasizes the need for urgent neurological consultation in the puerperium in case of new or recurrent neurological symptoms. CVST should be considered in the differential diagnosis, especially in case of atypical clinical presentation.