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A Diagnostic Heuristic in Headache With Eclampsia and Seizure FREE TO VIEW

Karishma Kitchloo, MD; Pang Lam, MD; Abhinav Saxena, MBBS; Taek Yoon, MD; Chanaka Seneviratne, MD; Yizhak Kupfer, MD
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Maimonides Medical Center, Brooklyn, NY

Chest. 2015;148(4_MeetingAbstracts):269A. doi:10.1378/chest.2281701
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SESSION TITLE: Critical Care Student/Resident Case Report Posters II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Intracranial hypotension (IH) is a known complication of cerebrospinal fluid (CSF) leakage after an epidural procedure. It is thought to be secondary to damage of the dura during epidural anesthesia. In postpartum females, it can present as persistent headaches and, rarely, seizures.

CASE PRESENTATION: A 20-year-old female, six days after a normal vaginal delivery with epidural anesthesia, presented with headache and an episode of seizure. Headaches were described as worse on sitting up and improved upon lying down. Patient did not have any other neurological changes. On physical exam patient was found to be mildly hypertensive (115/72 mmHg) compared to her baseline. Lab studies show normal liver profile and urinalysis did not show any protein. The patient’s blood pressure was aggressively controlled due to presumed diagnosis of eclampsia. An MRI showed non-specific cerebral edema that maybe consistent with posterior reversible encephalopathy syndrome (PRES) versus IH. The patient’s symptoms did not improve with blood pressure control. Retrospective review and subsequent brain MRI showed finding consistent with IH. Patient’s symptoms resolved with time.

DISCUSSION: IH is an infrequent and under-diagnosed complication of an epidural CSF leak1. Case reports describe an association of IH with cortical and cerebral venous thrombosis and maybe associated with severe complications including tonsillar herniation2. Clinicians must maintain an index of suspicion for IH in the appropriate setting as headache and seizures3 can lead to the misdiagnosis of eclampsia. Our case illustrates the importance of obtaining an accurate history in differentiating between the two diagnoses. It maybe suggested that post-partum eclampsia may mask intracranial hypotension as a result of diagnostic heuristic.

CONCLUSIONS: Intracranial hypotension can often be overlooked or misdiagnosed as eclampsia in a postpartum female presenting with seizures and headche.

Reference #1: Schievink WI. Spontaneous Spinal Cerebrospinal Fluid Leaks and Intracranial Hypotension. JAMA. 2006;295(19):2286-2296. doi:10.1001/jama.295.19.2286.

Reference #2: Basoglu, Fulya, Ayhan Koksal, Batuhan Kaha, Neslihan Hatice, Sutpideler Koksal, and Sevim Baybas. "Two Cases of Cerebral Venous Sinus Thrombosis Due to Intracranial Hypotension after Epidural Anesthesia as a Diagnostic Challenge." Neurological Sciences 35.6 (2014): 941-43. Print.

Reference #3: Kraayvanger, L, Berlit, P. “Postpartum Secondary Cerebral Venous Sinus Thrombosis with Axial Transtentorial and Tonsillar Herniation as a Complication of Intracranial Hypotension Syndrome after Spinal Anesthesia.” Fortschr Neurol Psyhiatr 82.12 (2014): 698-700. Epub.

DISCLOSURE: The following authors have nothing to disclose: Karishma Kitchloo, Pang Lam, Abhinav Saxena, Taek Yoon, Chanaka Seneviratne, Yizhak Kupfer

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