Decompressive Craniectomy in Postpartum Cortical venous Thrombosis Masquerading as Postspinal Headache: What the Obstetrician should know – A Case Report

Abstract

Introduction: Cerebral venous sinus thrombosis is commonly seen during pregnancy or in the postpartum period due to multiple physiological changes resulting in an altered state of homeostasis and a hypercoagulable state. Cortical vein thrombosis is a subgroup of cerebral venous thrombosis where there is an involvement of the superficial cerebral veins and may occur with or without coexisting sinus venous thrombosis. Early identification of the diagnosis is of utmost importance to reduce morbidity and mortality. Differentiation from postspinal headache may be difficult until the occurrence of neurological features and a high level of suspicion for this condition is required. Contrast magnetic resonance imaging venography or computed tomography venography can confirm the diagnosis. Methods: We report a case of postpartum cortical venous thrombosis with malignant cerebral sinus venous thrombosis (CSVT). Results: The patient was managed with a lifesaving decompressive craniectomy (DC) procedure and anticoagulants with a favorable response. Conclusion: Obstetricians should be aware of this medical complication of pregnancy and of its management. Medical treatment with anticoagulants is the mainstay of therapy. Patients with malignant CSVT presenting with rapid and severe neurological decline carry a high mortality, and early DC in this subgroup can be lifesaving. Contraceptive agents containing estrogens should not be administered in patients with a previous history of CSVT, and prophylactic low-molecular-weight heparin should be administered throughout a subsequent pregnancy and continued into the puerperium.