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Postpartum cerebral venous sinus thrombosis following obstetric neuraxial blockade: a literature review with analysis of 58 case reports

Published:September 15, 2021DOI:https://doi.org/10.1016/j.ijoa.2021.103218

      Highlights

      • Review of 58 cases of cerebral venous sinus thrombosis (CVST) after neuraxial block.
      • Accidental dural puncture (ADP) in 40%; post-dural puncture headache (PDPH) in 79%.
      • A change in nature of headache is a key red-flag symptom of CVST.
      • The reported incidence of ADP and PDPH lend support to their association with CVST.
      • Therapeutic anticoagulation with multidisciplinary input is mainstay of management.

      Abstract

      Background

      Cerebral venous sinus thrombosis (CVST) is a rare complication of pregnancy. It usually presents with a headache and may mimic a post-dural puncture headache (PDPH) in women who receive a neuraxial block.

      Methods

      Medline, CINAHL and EMBASE databases were searched to identify postpartum cases of CVST following neuraxial block. The aim was to delineate the characteristics, presentation, investigations, and outcomes of postpartum women who presented with CVST.

      Results

      Forty-nine articles with 58 case reports were identified. Forty-two women (72.4%) had an epidural attempted whilst 16 women (27.6%) received a spinal anaesthetic. Accidental dural puncture (ADP) was reported in 17 women (40.5%). Headache was the presenting symptom in 57 women (98.3%); 26 women (44.8%) also experienced seizures. Post-dural puncture headache was reported in 46 (79.3%) and an epidural blood patch was performed in 26 women (44.8%). Superior sagittal sinus, transverse sinus, and cortical veins were the most common sites of thrombosis. The median time to diagnosis was 6.5 days from delivery. Magnetic resonance imaging was the most common diagnostic neuro-imaging modality. Full neurological recovery was reported in 48 (82.8%), whilst neurological deficits were reported in six (10.3%) women.

      Discussion

      The diagnosis of CVST may be overlooked in women who present with headache following neuraxial block. A change in character of headache with loss of postural element, and focal neurological signs are the key clinical features that could help anaesthetists differentiate headache of CVST from PDPH. The high reported rates of ADP and PDPH lend support to their possible association with CVST.

      Keywords

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