Critical cases: Post-partum headache!
Tue, 08/20/2019 - 12:17am
- 22 yo F 3 weeks postpartum after uncomplicated SVD presents with severe headache and neck pain worsening over 24 hours
- Headache localized posterior and retro-orbital
- One episode vomiting
- No vision changes, fever, or neurologic complaints
- Vitals: afebrile, HR 97, BP 146/72
- General appearance: Pt appears uncomfortable, supine on stretcher
- Neuro: awake, alert and oriented. CN 2-12 intact, no oculomotor palsies or visual field deficits, no facial droop or slurred speech. No focal weakness. Gross sensation intact. No dysmetria. Normal tandem gait
- Primary headache, Cerebral venous thrombosis (CVT), Preeclampsia, Post-dural puncture headache (patient had epidural during labor), Idiopathic intracranial hypertension (pseudotumor cerebri), Meningitis, Intracranial mass lesion (tumor vs abscess), Intracranial hemorrhage
- Lab findings: normal D-dimer, no leukocytosis, mild anemia
- Urgent imaging: non-contrast CT head, which showed focal hypodensity concerning for edema vs venous infarct
- Contrast enhanced MR venography: abnormally low signal/absence of flow in the left transverse sinus, suggesting thrombosis
- Early anticoagulation! Patient was started on subcutaneous LMWH, admitted and bridged to Warfarin
Take home points:
- Cerebral venous thrombosis is rare, but should always be considered in patients with prothrombotic conditions
- Clinical presentation is highly variable - onset can be acute, subacute, or chronic.
- Headache is the most frequent symptom.
- Head CT scan is normal in up to 30 percent of CVT cases, and most of the findings with CVT are nonspecific.
- CTV or MRV is the best imaging modality for confirming diagnosis
- Tx = Anticoagulation with LMWH or unfractionated heparin