Abstract
Purpose
We report a case of sagittal sinus thrombosis occurring after spinal analgesia for labour to highlight the difficulty of such diagnosis in the presence of postpartum atypical headache following regional anesthesia/analgesia.
Clinical features
A previously healthy 21 -yr-old, primiparous, preeclamptic parturient was admitted to the hospital at 37 weeks gestation for uterine contractions. Before pregnancy she was taking no medication other than oral contraceptives and was a non-smoker. Spinal analgesia was established on the first attempt at 8 cm of cervical dilation, in the setting of rapid progression of labour. Following an uneventful delivery, on the third day postpartum, the patient experienced gradual onset of an atypical headache with unclear postural character, followed by focal neurological signs five days later. Emergency neuroimaging revealed direct evidence of thrombosis in the posterior sagittal venous sinus. Anticoagulation was initiated with iv heparin (500 UI·kg-1·day-1). The patient’s headache decreased progressively and full motor recovery was noted by day 14 postpartum. After 24 days, the patient was discharged without any neurological disability. Common inherited thrombophilic dispositions were absent, with the exception of a decrease in protein S level.
Conclusion
Central venous thrombosis, while rare, is a recognized cause of puerperium stroke. The present case highlights the importance of considering the diagnosis in the presence of postpartum atypical headache following spinal anesthesia/analgesia. Early intervention with systemic heparinization is critical when the diagnosis is confirmed.
Résumé
Objectif
Présenter un cas de thrombose du sinus longitudinal, survenue après une rachianalgésie de fin de travail obstétrical, pour illustrer la difficulté d’établir ce diagnostic en présence de céphalées atypiques du postpartum.
Éléments cliniques
Une parturiente primipare de 21 ans, prééclamptique, antérieurement en bonne santé, est admise à l’hôpital à 37 semaines de grossesse pour contractions utérines. Avant la grossesse, elle prenait des contraceptifs oraux et ne fumait pas. La rachianalgésie est réalisée sans difficulté au premier essai, au moment où la dilatation cervicale est de 8 cm et le travail en progression rapide. Après un accouchement sans incident, au troisième jour du postpartum, la patiente présente des céphalées atypiques d’apparition graduelle à caractère postural mal défini, suivies de signes neurologiques focaux cinq jours plus tard. Un scanner cérébral et une résonance magnétique en urgence révèlent une thrombose du sinus veineux longitudinal postérieur. L’anticoagulation par héparine iv (500 UI·kg-1·jour-1) est instaurée. Les céphalées diminuent progressivement et la récupération motrice complète est établie au 14e jour du postpartum. La patiente quitte l’hôpital après 24 jours sans séquelles neurologiques. Le bilan de thrombophilie héréditaire s’est avéré négatif, à l’exception d’une baisse du niveau de protéine S.
Conclusion
La thrombose veineuse centrale, bien que rare, est une cause connue d’accident vasculaire puerpéral. Il est important de tenir compte du diagnostic en présence de céphalées atypiques du postpartum après une anesthésie/analgésie rachidi-enne. L’intervention précoce par une héparinisation complète est cruciale pour la confirmation du diagnostic.
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Kapessidou, Y., Vokaer, M., Laureys, M. et al. Case report: Cerebral vein thrombosis after subarachnoid analgesia for labour. Can J Anesth 53, 1015–1019 (2006). https://doi.org/10.1007/BF03022531
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DOI: https://doi.org/10.1007/BF03022531