Postpartum postural headache due to superior sagittal sinus thrombosis mistaken for spontaneous intracranial hypotension

PURPOSE: To describe a case of superior sagittal sinus thrombosis in the puerperal period and the difficulties encountered in the diagnosis and management. CLINICAL FEATURES: A 29-yr-old multiparous woman presented with a postural headache four weeks after a normal pregnancy and vigorous delivery. Initial presentation suggested spontaneous intracranial hypotension (SIH) since there was no history of epidural or spinal anesthesia, or trauma or surgery to her back or neck. Conservative therapy was initially offered and then a lumbar epidural blood patch (LEBP) was performed, although it failed to relieve the postural headache. A dural leak could not be demonstrated but an MRV (magnetic resonance venography) revealed a superior sagittal sinus thrombosis (SSST). Although anticoagulant therapy was immediately initiated, the neurologist remained convinced that the postural headache was secondary to SIH, and, consequently, a second epidural blood patch was requested. Anesthesia was reluctant to perform an LEBP at this point and suggested continuing anticoagulation until a subsequent MRV demonstrated recannalization of the SSST. This advice was followed and the postural headache resolved spontaneously with intravenous anticoagulation. CONCLUSION: The present case illustrates the importance of a multidisciplinary approach to the management of this rare complication of pregnancy. This case also highlights the importance of reviewing the differential diagnosis when considering treatment of a postural headache in the puerperium.