2026 FSA Podium and Poster Abstracts

Introduction: Inadvertent dural puncture is a well-known complication of neuraxial procedures. Cerebral venous sinus thrombosis (CVST) is a rare and potentially life-threatening complication during the postpartum period. The signs and symptoms of CVST during the early stages may mimic those of a PDPH, thus making diagnosis and management for these conditions complex. This case report aims to discuss the nuances between the symptoms of PDPH and CVST, and to increase awareness on the association between unintentional dural puncture and the development of CVST. This case presents a patient whose course was complicated by unintentional dural puncture during epidural catheter placement, acute onset of PDPH managed with an epidural blood patch, and a subacute presentation of extensive CVST with multifocal venous infarcts.

Case Description: A 35-year-old woman with a BMI greater than 40 presented in active labor at 39 weeks of gestation. Labor analgesia with a combined spinal-epidural was complicated by unintentional dural puncture. On postpartum day (PPD) 1, the patient developed a positional headache characteristic of PDPH. An epidural blood patch procedure was performed with no complication and subsequent resolution of the headache. 

The patient returned to the hospital on PPD 9 with the sole symptom of a recurring headache with a vague description of changes in intensity based on positioning. She was discharged with Fioricet for conservative management as requested by the patient. On PPD 11, she presented to the obstetric ED with worsening headache, somnolence, photophobia, and altered mental status. A CT venogram showed extensive CVST in the superior sagittal sinus, bilateral transverse sinuses, right sigmoid sinus, and the right jugular foramen with involvement of cerebral veins. MRI confirmed thrombosis with venous infarcts.

The patient required therapeutic anticoagulation with supportive care in the neuro ICU. Neurologic deficits of left hemiparesis and gaze preference improved gradually. The patient was discharged on PPD 25 (hospital day 14 from readmission) to inpatient rehabilitation on apixaban with near-baseline function.

Discussion: This case aims to highlight the slight differences in symptoms and time of onset between PDPH and CVST during the postpartum period. The patient's initial positional headache was likely a PDPH from the unintentional dural puncture. The patient's recurrent headache was likely from an evolving CVST, as suggested by the recurrence of headache after a successful blood patch, loss of postural character for the headache, and further onset of neurological symptoms. Some proposed mechanisms of CVST after accidental dural puncture are due to alterations in CSF fluid dynamics, resulting in cerebral venous dilatation and stasis of flow. Heightened vigilance is warranted in obstetric patients with unintentional dural puncture. Early neuroimaging can be a crucial diagnostic tool for atypical/refractory postpartum headache after neuraxial anesthesia. Therapeutic anticoagulation is first line treatment for CVST, with prompt diagnosis yielding favorable outcomes.