Post-caesarean Section Headache: A Case Report of Post-dural Puncture Headache and Cerebral Venous Thrombosis Following Epidural Anaesthesia

Abstract

Post-dural puncture headache (PDPH) is a common complication of epidural and spinal anaesthesia in obstetric medicine. In rare cases, PDPH can be associated with complications such as cerebral venous thrombosis (CVT) as well. We discuss a recent case of a young female who developed PDPH and CVT concurrently after undergoing epidural anaesthesia for initially uncomplicated labour and delivered via an emergency caesarean section. She developed an orthostatic headache a few hours post administration of the epidural anaesthetic, which was initially treated as a suspected PDPH by giving simple analgesia and caffeine. Her symptoms did not improve and she underwent further neuroimaging, which revealed the development of a CVT. Despite the prompt administration of enoxaparin, the headache persisted and did not respond to increased doses of analgesia. After deliberation and inter-departmental discussion, an epidural blood patch was performed, leading to the prompt resolution of the headache. This report highlights a rare concurrence of PDPH and CVT, causing a diagnostic dilemma that resulted in treatment delays for the patient. Treating both conditions raises difficult practical questions, especially regarding the use of an epidural blood patch as opposed to anticoagulation. Given the risk of fatal complications such as venous cerebral infarction, seizures, and subdural hematoma, prompt treatment of both PDPH and CVT is strongly recommended. The multifactorial mechanism by which CVT develops with intracranial hypotension and PDPH also makes it essential for clinicians to keep an open mind when managing post-caesarean headaches, requiring inter-departmental cooperation to ensure optimal patient outcomes.

Keywords: autologous blood patch; cerebral venous thrombosis; dural venous sinus thrombosis; epidural anaesthesia; post dural puncture headache; post-partum headache.

Figure 1. Non-contrast CT brain showing blood clot in the superior sagittal venous sinus (purple arrow)

CT: computed tomography

Figure 2. CT cerebral venogram showing the filling defect in the superior sagittal venous sinus due to a thrombus (orange arrow)

CT: computed tomography

Figure 3. MRI venogram of the brain

The image showed features of intracranial hypotension and superior sagittal venous thrombus. The green arrow points to the filling defect in the superior sagittal venous sinus due to a thrombus. The blue arrow shows reduced mamillopontine distance and reduced pontomesencephalic angle. The yellow arrow points to mild tonsillar herniation due to caudal cerebral tonsil descent MRI: magnetic resonance imaging