Seizures after epidural blood patch in a postpartum patient later diagnosed with hypertension and proteinuria: a diagnostic conundrum

Seizures are a rare, but documented, consequence of accidental dural puncture and epidural blood patch. They are also the cardinal feature of eclampsia. We present a postpartum patient who suffered a tonic-clonic seizure within 1 hour of an epidural blood patch procedure for a suspected post-dural puncture headache. Investigations also revealed hypertension, proteinuria and subdural collections. This case demonstrates the diagnostic dilemma associated with postpartum headache and late postpartum eclampsia. We illustrate the importance of a thorough clinical assessment of postpartum patients presenting with headache, highlighting the possibility of more than one underlying pathological cause. We also consider the role of epidural blood patch in both precipitating, and preventing, complications of accidental dural puncture.

Don't Forget Rare Causes of Postpartum Headache! Cases Report and Literature Review

Headache is a common finding in the postpartum period, caused by a spectrum of different conditions. Most headaches in the postpartum period are self-limiting and benign in etiology, but there are some potentially serious causes to be considered. We disclose two cases of postpartum headache, initially considered as post-dural puncture headache (PDPH), that evolved into a harmful condition and showed that an expanded differential diagnosis for headache in the postpartum is mandatory, requiring a high level of attention from health professionals. In fact, a careful examination of the medical history, physical examination, and the recognition for the need for early neuroradiological imaging should increase diagnostic accuracy.

Severe Postpartum Headache and Hypertension Caused by Reversible Cerebral Vasoconstriction Syndrome: A Case Report

Reversible cerebrovascular vasoconstriction syndrome is an uncommon condition that presents as severe headache and hypertension. Recent literature suggests a 1% incidence in postpartum headache cases. It can cause subarachnoid hemorrhages, cerebral ischemia, and seizures. It is often misdiagnosed as postdural puncture headache or preeclampsia. In this case, a postpartum woman, who had received epidural anesthesia for labor, presented 5 days postpartum with severe headache that did not resolve with an epidural blood patch. She then became more hypertensive and suffered a grand mal seizure. When treatment for eclampsia failed to resolve her symptoms, magnetic resonance angiography was performed. It demonstrated the pathognomic signs of reversible cerebrovascular vasoconstriction syndrome. Her symptoms resolved with nimodipine.

Reversible cerebral vasoconstriction syndrome and posterior reversible encephalopathy syndrome associated with intracranial hypotension

BACKGROUND

Reversible cerebral vasoconstriction syndrome (RCVS) and posterior reversible encephalopathy syndrome (PRES) are both rare disorders. The pathophysiology of both diseases is not yet fully understood.

METHODS

We report the unique case of a 19-year-old comatose woman who was brought to the ER after a series of generalized tonic-clonic seizures 6 days post peridural anesthesia for cesarean section. Vital signs and initial laboratory testing including urine analysis and drug screening were unremarkable. Initial cranial CT scan showed an acute small subdural hematoma (17 mm length × 6 mm width × 30 mm height), cerebral edema with slit ventricles, and slight cerebellar tonsillar herniation as signs of intracranial hypotension. CT angiography depicted narrowing of the proximal intracranial vessels consistent with RCVS. MR imaging was also suggestive of both intracranial hypotension and RCVS and showed, in addition, vasogenic edema consistent with PRES. An extensive CSF leakage involving T1 to L2/L3 was confirmed by spinal MRI.

RESULTS

The patient underwent conservative therapy for intracranial hypotension (e.g., head-down position) as well as epidural blood patch, which led to regression of the clinical symptoms within a few days. Follow-up MRI showed complete resolution of all radiological changes.

CONCLUSIONS

In summary, our patient developed clinical and neuroradiological signs of intracranial hypotension and a combination of PRES and RCVS associated with a CSF leakage caused by peridural anesthesia; by treating the intracranial hypotension, the other syndromes resolved. From a clinical point of view, it is important to look for CSF leakage as a treatable possible cause of PRES and/or RCVS triggered by intracranial hypotension as in our patient postpartum. Moreover, it is vital to obtain a good history as, in cases of suspected CSF leakage with classic postural headache, a recent spinal/cranial procedure is typically present.

Epidural Anesthesia Complicated by Subdural Hygromas and a Subdural Hematoma

Inadvertent dural puncture during epidural anesthesia leads to intracranial hypotension, which if left unnoticed can cause life-threatening subdural hematomas or cerebellar tonsillar herniation. The highly variable presentation of intracranial hypotension hinders timely diagnosis and treatment. We present the case of a young laboring adult female, who developed subdural hygromas and a subdural hematoma following unintentional dural puncture during initiation of epidural anesthesia.

Pituitary apoplexy with reversible cerebral vasoconstrictive syndrome after spinal anaesthesia for emergency caesarean section: an uncommon cause for postpartum headache

Pituitary apoplexy is a rare condition involving pituitary necrosis following either pituitary haemorrhage or infarction. Similarly, reversible cerebral vasoconstrictive syndrome is a cerebrovascular disorder characterised by diffuse, multifocal narrowing of cerebral arteries. Both may present with an acute, intense headache and associated neurological deficits. In postpartum women, these conditions should be considered in the differential diagnosis of post-dural puncture headache following regional anaesthesia, as serious morbidity may ensue if they are left untreated. We report the case of a patient who developed pituitary apoplexy during an emergency caesarean section under spinal anaesthesia. It was further complicated by the development of reversible cerebral vasoconstriction syndrome and stroke.

Post-dural puncture headache and posterior reversible encephalopathy syndrome: a misdiagnosis or co-presentation?

Posterior reversible encephalopathy syndrome (PRES) is a rare neurological condition associated with a variety of underlying conditions, including preeclampsia. The headache associated with PRES may be indistinguishable from post-dural puncture headache, which may result in diagnostic delay. We report a case of PRES that was initially diagnosed as post-dural puncture headache. The case was unique because there were no features of preeclampsia, initial presentation was typical of post-dural puncture headache, and there was a five-day interval between the onset of headache and the development of seizures and cortical blindness, pathognomonic of PRES. It remains unclear whether this was an atypical presentation of PRES, initially misdiagnosed as post-dural puncture headache, or whether delayed treatment of headache triggered PRES.