Post dural puncture headache and its potential to obscure sinister pathologies: A case report

doi:10.21203/rs.3.rs-5029425/v1

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Case Report

Post dural puncture headache and its potential to obscure sinister pathologies: A case report

https://doi.org/10.21203/rs.3.rs-5029425/v1

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Background

Cerebral venous sinus thrombosis (CVT) is a potentially fatal condition that can occur in postpartum period with the hypercoagulable state developed in pregnancy. Accidental dural puncture is found to be a risk factor for CVT. However, common occurrence of post-dural puncture headache (PDPH) following accidental dural puncture can mask the clinical presentation of other serious conditions such as CVT.

Case Presentation

We present a case of 29-year-old postpartum female who had accidental dural puncture during labour epidural insertion and managed for PDPH subsequently found to have CVT following further investigation due to persistent symptoms.

Conclusions

This case report would allow increasing awareness among perioperative clinicians to keenly exclude serious pathology in the presence of possible PDPH as this is a diagnosis of exclusion although there is a history of dural puncture.

cerebral venous sinus thrombosis

post-dural puncture headache

accidental dural puncture

case report

Pregnancy is a hypercoagulable state, preparing for blood loss at delivery by increasing the concentration of clotting factors. Therefore, pregnancy itself is a risk state for thrombosis once the Virchow’s triad is fulfilled due to other precipitant factors. Thrombosis can occur at any site of vascular system. Though, cerebral venous thrombosis (CVT) is rare, it has a significant mortality rate of 2–10% [1]. We present a case of a 29-year-old primi mother who was managed as post dural puncture headache following accidental dural puncture, which masked the underlying sinister diagnosis of cerebral venous thrombosis.

She is a 29-year-old primiparous mother who presented for labour induction at 40 weeks of gestation. Her past medical history was insignificant. She did not have personal or family history of clotting disorder or prior history of chronic headache.

After obtaining informed consent, epidural anaesthesia was attempted for labour and delivery during the first stage. The procedure was complicated by an unintentional dural puncture with an 18G Tuohy needle, resulting in cerebrospinal fluid (CSF) leakage. The epidural needle was re-sited at higher spinal level, and epidural infusion was continued according to protocol. Mother was transferred to the post-partum unit after uneventful vaginal delivery of the baby. The epidural catheter was removed the following day.

On the first day postpartum, she complained of a severe occipital headache involving the back of the neck, exacerbated in the upright position and relieved when lying down. She was afebrile and did not have any focal neurological signs or neck stiffness. Given the background of accidental dural puncture, a working diagnosis of post-dural puncture headache (PDPH) was made. She was treated with oral paracetamol, tramadol and diclofenac sodium with a target daily fluid intake of 2.5-3L.

On the second day, she experienced vomiting with persistent nausea and photophobia. The headache was debilitating, but she managed to carry out her self-care and feed the newborn.

As her symptoms were not improving, a multidisciplinary evaluation was sought. Neurological examination showed no neurological deficit. Full blood count and inflammatory markers were not suggestive of central nervous system infection. To exclude increased intracranial pressure before the CSF studies, a non-contrast computed tomography (NCCT) scan was performed, which revealed no evidence of cerebral oedema, but venous sinus thrombosis was suspected. This was followed by a cerebral contrast-enhanced computer tomography (CECT) venogram, which confirmed sagittal sinus thrombosis (Fig. 1).

With the hematologist’s opinion, a therapeutic dose of subcutaneous enoxaparin was started after obtaining a baseline clotting profile. By day 5, she showed improvement. Warfarin was started and bridging therapy was continued until target International Normalised Ratio (INR) of 2–3 achieved. On day 9, she was discharged home with a weekly follow-up plan at the hematology clinic.

Etiology of postpartum headache is multifactorial. 75% of headaches are benign [2], such as migraine or tension headache. Other causes include hypertensive disorders, vascular causes, infections and space occupying lesions. If the headache occurs after dural puncture, the first differential diagnosis would be PDPH, but other causes should not be overlooked.

PDPH can be caused by either accidental dural puncture during an epidural block or intentional puncture during a subarachnoid block, with the former being more common due to the use of a larger gauge needle and greater free flow of CSF. The exact pathophysiology of PDPH is not yet known, but two possible mechanisms have been proposed. Firstly, reduction in intracranial pressure with loss of CSF will result in traction of intracranial structures including meninges and cranial nerves. Secondly, according to the Monro-Kelli hypothesis, when there is a loss of one component inside the cranium there is a compensatory increase in other components to keep the intracranial pressure constant. When CSF is lost there will be compensatory venodilatation and cerebral venous congestion. These two mechanisms lead to the typical headache seen in PDPH [1, 4].

Accidental dural puncture occurs in 0.15%-1.5% of labour epidural analgesia, and 50%-80% of these cases develop PDPH [3]. PDPH is characteristic with frontal or occipital headache appearing 24–72 hours from dural puncture and associated with nausea, vomiting, diplopia, photophobia and tinnitus. The headache is essentially positional. The conservative management options include simple analgesia, adequate hydration and caffeine. When symptomatic therapy fails an epidural blood patch is indicated. Other options to manage PDPH include acupuncture, greater occipital nerve block, and sphenopalatine ganglion block, although these have not yet shown proven benefit [4].

Our patient had the typical clinical picture of PDPH which was conservatively managed initially. She strongly refused an epidural blood patch, and her persistently debilitating state forced us to consider other causes of postpartum headache.

Dural puncture is considered one of the risk factors for CVT, although the link between dural puncture and CVT is poorly understood [5]. Several mechanisms of pathogenesis have been postulated, with the completion of Virchow’s triad leading to CVT. According to Monro-Killie doctrine change in one intracranial component leads to compensatory decrease or increase of volume of another element within the rigid cranium. When CSF is lost after dural puncture, there will be compensatory cerebral vasodilatation which leads to slowing of blood flow. Reduced CSF absorption into venous sinuses would increase the blood viscosity. Lastly, the negative pressure gradient created by the CSF leak stretches the cerebral vessels, causing endothelial damage.

A retrospective study of 46 individuals from the general population has shown that dural puncture can trigger CVT when there is another predisposing factor for thromboembolism [6, 7]. Therefore, it is prudent to screen any patient with CVT following dural puncture for other risk factors, including thrombophilic conditions such as antiphospholipid syndrome, protein C and S deficiency, antithrombin III deficiency, lupus anticoagulant, anticardiolipin antibodies, factor V Leiden mutation, and malignancy.

Puerperium associated CVT has more acute onset and better prognosis compared to thrombosis due to other causes.

PDPH is common following inadvertent dural puncture in pregnant women. In case of persistent of disabling headache, it is important to exclude other serious causes of postpartum headache, with the involvement of a multidisciplinary team.

CVT – Cerebral venous sinus thrombosis

PDPH – Post-dural puncture headache

CSF – Cerebrospinal fluid

CT – Computed tomography

NCCT – Non-contrast computed tomography

CECT – Contrast enhanced computed tomography

INR – International Normalised Ratio

Ethics approval and consent to participate –

Ethics approval not applicable for case reports in the relevant IRB (Teaching Hospital Peradeniya, Sri Lanka)

Informed written consent was taken and the document is attached separately

Consent for publication –

Informed written consent was taken and the document is attached separately

Availability of data and material – not applicable
Competing interests – not applicable
Funding – not applicable
Authors' contributions –

BH, MS, AR, SN, AA and SS contributed in writing and revising the anaesthesiology related section of the case report. CG contributed in writing and revising the obstetrics related section of the case report. SW contributed in writing and revising the neurology related section of the case report. GS contributed in writing and revising the manuscript. All authors read and approved the final manuscript.

Acknowledgements – not applicable
Authors' information –

1. Bhagya Hewawasam – MD (Anaesthesiology), Senior Registrar in Anaesthesiology, Teaching Hospital Peradeniya, Kandy, Sri Lanka

2. Mihirinie Sumithraarachchi – MBBS, Registrar in Anaesthesiology, Teaching Hospital Peradeniya, Kandy, Sri Lanka

3. Ashani Rathnayake – MD (Anaesthesiology), Senior Lecturer, Department of Anaesthesiology and Critical Care, Faculty of Medicine, University of Peradeniya, Kandy, Sri Lanka

4. Saman Nanayakkara– MD (Anaesthesiology), Head, Department of Anaesthesiology and Critical Care, Faculty of Medicine, University of Peradeniya, Kandy, Sri Lanka

5. Senani Samarasinghe – MD (Anaesthesiology), Senior Lecturer, Department of Anaesthesiology and Critical Care, Faculty of Medicine, University of Peradeniya, Kandy, Sri Lanka

6. Anura Abeysundara – MD (Anaesthesiology), Senior Lecturer, Department of Anaesthesiology and Critical Care, Faculty of Medicine, University of Peradeniya, Kandy, Sri Lanka

7. Sajitha Weerasinghe – MD (Medicine), Consultant Neurologist, Teaching Hospital Peradeniya, Kandy, Sri Lanka

8. Champika Gihan – MD (Obstetrics and Gynaecology), Head, Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Peradeniya, Kandy, Sri Lanka

9. Githmini Sandaru – MBBS, Research Assistant, Department of Anaesthesiology and Critical Care, Faculty of Medicine, University of Peradeniya, Kandy, Sri Lanka

Cantú C, Barinagarrementeria F. Cerebral venous thrombosis associated with pregnancy and puerperium: Review of 67 cases. Stroke. 1993 Dec;24(12):1880-4. doi:10.1161/01.str.24.12.1880. PMID: 8248971.
Goldszmidt E, Kern R, Chaput A, Macarthur A. The incidence and etiology of postpartum headaches: a prospective cohort study. Can J Anaesth. 2005 Nov;52(9):971-7. doi:10.1007/BF03022061. PMID: 16251565.
Rodrigues AS, Montenegro L, Alves CVL, Mascarenhas N, Lucas MP, Pedro D. Cerebral venous thrombosis after unintentional dural puncture: Raising awareness for an uncommon cause of postpartum headache. Turk J Anaesthesiol Reanim. 2023 Apr;51(2):147-9. doi:10.5152/TJAR.2023.22124. PMID: 37140581; PMCID: PMC10210632.
Janvier AS, Russell R. Postpartum headache - diagnosis and treatment. BJA Educ. 2022 May;22(5):176-81. doi: 10.1016/j.bjae.2021.12.004. PMID: 35496646; PMCID: PMC9039472.
Edwards LS, Cuganesan R, Cappelen-Smith C. Cerebral venous thrombosis as a complication of intracranial hypotension after lumbar puncture. BMJ Neurol Open. 2020 Sep 30;2(2). doi:10.1136/bmjno-2020-000046. PMID: 33681792; PMCID: PMC7903169.
Guner D, Tiftikcioglu BI, Uludag IF, Oncel D, Zorlu Y. Dural puncture: an overlooked cause of cerebral venous thrombosis. Acta Neurol Belg. 2015 Mar;115(1):53-7. doi: 10.1007/s13760-014-0305-z. PMID: 24838384.
Rodrigues AS, Montenegro L, Alves CVL, Mascarenhas N, Lucas MP, Pedro D. Cerebral venous thrombosis after unintentional dural puncture: Raising awareness for an uncommon cause of postpartum headache. Turk J Anaesthesiol Reanim. 2023 Apr;51(2):147-9. doi:10.5152/TJAR.2023.22124. PMID: 37140581; PMCID: PMC10210632.

No competing interests reported.

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You are reading this latest preprint version

Post dural puncture headache and its potential to obscure sinister pathologies: A case report

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Abstract

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Background

Case presentation

Discussion

Conclusion

Abbreviations

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