Zupan Zeljko, Sotosek Tokmadzić Vlatka, Matanić-Manestar Marinka, Sustić Alan, Antoncić Igor, Dunatov Sinisa, Pavlović Ivan, Antulov Ronald
Department of Anaesthesiology, Reanimatology and Intensive care, Medical Faculty Rijeka, University of Rijeka, Tome Strizica 3, 51 000 Rijeka, Croatia.
Croat Med J. 2012 Aug;53(4):379-85. doi: 10.3325/cmj.2012.53.379.
The aim of this study is to report the first case of simultaneous appearance of cerebral venous thrombosis (CVT) and bilateral subdural hematomas (SDHs) following epidural analgesia for labor and delivery and to point out the difficulty of establishing such a diagnosis in the presence of postpartum headache. A 26-year old primigravida with a history of epilepsy received epidural analgesia for delivery. Three days after the uneventful spontaneous vaginal delivery she complained about the headache. Patient responded very well to the pain medication and oral hydration, and the headache was relieved. Ten days after the delivery, the headache reoccurred, and an epidural blood patch was performed that successfully relieved her symptom. Stronger progressive headache with nausea reappeared two days later and the parturient was readmitted to hospital. Urgent neuroimaging examinations detected CVT of right the transverse sinus, ipsilateral cortical veins, and partially occluded superior sagittal sinus, as well as bilateral subacute/chronic SDHs. The treatment of the patient with low molecular weight heparin and antiaggregation therapy was effective. In this case, the diagnosis was delayed because of atypical clinical presentation and potentially confounding events (epidural analgesia and assumption that it was a case of PDPH). It is important to carefully observe patients in such conditions and promptly conduct suitable diagnostic tests. Otherwise, unrecognized intracranial complications and delay of appropriate therapy could be life-threatening.
本研究的目的是报告首例分娩时硬膜外镇痛后同时出现脑静脉血栓形成（CVT）和双侧硬膜下血肿（SDH）的病例，并指出在产后头痛的情况下建立这种诊断的困难。一名有癫痫病史的26岁初产妇在分娩时接受了硬膜外镇痛。在顺利自然阴道分娩三天后，她抱怨头痛。患者对止痛药物和口服补液反应良好，头痛得到缓解。分娩十天后，头痛再次出现，进行了硬膜外血贴治疗，症状成功缓解。两天后，再次出现伴有恶心的更严重的进行性头痛，产妇再次入院。紧急神经影像学检查发现右侧横窦、同侧皮质静脉脑静脉血栓形成，上矢状窦部分闭塞，以及双侧亚急性/慢性硬膜下血肿。该患者采用低分子量肝素和抗聚集治疗有效。在这种情况下，由于临床表现不典型和潜在的混淆事件（硬膜外镇痛以及认为是产后头痛病例），诊断被延迟。在此类情况下仔细观察患者并及时进行适当的诊断检查非常重要。否则，未被识别的颅内并发症和适当治疗的延迟可能会危及生命。
