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Neurology India, Vol. 54, No. 4, October-December, 2006, pp. 447-448 Letter To Editor Multiple dural sinus thrombosis: A differential diagnosis of a postpuncture headache in a puerperal patient Monsalve GuillermoA, Ortega Roberto, Rueda-Acevedo Mauricio Department of Neurology and Neurosurgery, Hospital Militar Central, Universidad Militar Nueva Granada, Bogota Code Number: ni06158 Sir, Cerebral venous thrombosis (CVT) in a puerperal patient is an infrequent event. Several physiopathological mechanisms have been proposed but the certain cause has not been cleared yet. This 18-year-old woman had 20 days of global progressive postural headache. She had a vaginal childbirth 20 days before without complications; she received an L3-L4 epidural anesthesia in that setting, she had a deep venous thrombosis (DVT) of the lower limb during pregnancy without further treatment and study and it was interpreted as a DVT associated with the pregnancy itself. A diagnosis of postpuncture headache was suspected and she was conservatively treated. The patient came again to us complaining of a similar headache. Physical and neurological examinations were normal. During her hospital stay, behavioral changes and hallucinations were found. A contrast-enhanced brain CT scan suggested a superior longitudinal sinus thrombosis. A contrast-enhanced cerebral RM image showed a filling defect in the superior sagittal, right transverse and sigmoid dural sinuses with a void delta-sign [Figure - 1]. An angiography by MR (MRA) showed a filling defect in the described sinuses. Initially, a full anticoagulation with intravenous heparin and then with warfarin were started. She is neurologically asymptomatic on follow-up and her last brain image showed complete recanalization of the thrombosed sinuses. Differentiating clinically a postpuncture headache from a CVT is not difficult because postpuncture headache has a postural pattern that CVT headache does not. It is remarkable that the initial presentation of multiple dural sinus thromboses was a postpuncture headache after a spinal anesthesia. Lumbar tap is a risk factor for CVT in women with risk factors.[1] We found a few reports of CVT in puerperal patients with epidural or spinal tap.[2],[3] The change of intracranial pressure due to the spinal tap can itself lead to a CVT. After a dural puncture, both pressure and volume of the cerebrospinal fluid decrease. This decrease is responsible for a rostrocaudal sagging effect and this causes a stretching effect which could injure the fragile venous endothelium wall and decrease the CSF pressure leading to venous vasodilatation, stasis and thrombosis[Figure - 1]. The cascade of events in the CVT after a lumbar tap is: firstly, a decrease in the CSF pressure with the tap and the receptors of adenosine become active, this produces vasodilatation in the cerebral venous system leading to the headache and with sufficient venous endothelial damage and blood stasis lead the thrombosis of the cerebral veins and dural sinuses.[4] For this reason neurologists and related specialists have to take into account a CVT in a puerperal patient with postpuncture headache after a spinal anesthesia. References
Copyright 2006 - Neurology India The following images related to this document are available:Photo images[ni06158f1.jpg] |
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