Ultrasonic optic nerve sheath diameter can be used as a diagnostic measure after accidental dural puncture during cesarean section: a case report

Abstract

Background: Parturients are prone to postdural puncture headache (PDPH) after epidural puncture. Cerebral venous sinus thrombosis (CVST) is a fatal complication of PDPH. The main symptom of both is headache, however, the mechanism is not similar. For persistent PDPH, early differential diagnosis from CVST is essential. Optic nerve sheath diameter (ONSD) measurements can be used to identify changes in intracranial pressure as an auxiliary tool to distinguish the cause of headache.

Case presentation: The dura of a 32-year-old woman undergoing cesarean section was accidentally penetrated while administering epidural anesthesia, and the patient developed PDPH the subsequent day. The patient refused epidural blood patch (EBP) treatment and was discharged after conservative treatment. Fourteen days post-discharge, she was readmitted for a seizure. Magnetic resonance imaging (MRI) and Magnetic resonance angiography (MRA) indicated low cranial pressure syndrome and superior sagittal sinus thrombosis with acute infarction. The next morning, the EBP was performed with 15 ml autologous blood. Subsequently, the headache symptoms decreased during the day and worsened at night. ONSD measurement suggested dilation of the optic nerve sheath, and subsequently, the patient showed intracranial hypertension with papilledema. After dehydration and anticoagulant treatment, the patient's symptoms were relieved and she was discharged from the hospital 49 days later.

Conclusions: Headache is the main symptom of PDPH and cerebral venous thrombosis, which are difficult to distinguish. ONSD measurement may help to estimate the intracranial pressure, and early measurement may be helpful for women with PDPH to avoid serious complications, such as CVST.

Keywords: Cerebral venous thrombosis; Cesarean section; Optic nerve sheath diameter; Postdural puncture headache.

Fig. 1

Craniocerebral MRI scan showed narrowing or disappearance of the sulci, thickening and enhancement of the dura (a). The brain MRV showed that the swollen left parietal cortex, venous thrombosis (part of the superior sagittal sinus and local draining vein), possible venous infarction of the left parietal lobe, and the indistinct superior sagittal sinus (b). MRI: Magnetic Resonance Imaging; MRV: Magnetic Resonance Venography

Fig. 2

Compared with Figure a, the unclear portion of the superior sagittal sinus had no significant change, but the left parietal cortex swelling was decreased. a: the 1st day after admission (before EBP); b: the 3rd day after admission (after EBP). EBP: epidural blood patch

Fig. 3

The ONSD (yellow line) was measured 3 mm behind the eyeball and perpendicular to the linear axis of the optic nerve. The ONSD was 6.0 mm on the left and 6.2 mm on the right side. ONSD: optic nerve sheath diameter

Fig. 4

Fundus examination showed papilledema and fundus hemorrhage