Sagittal sinus thrombosis in puerperium.

Dear Editor,

Postpartum headache is a very common complaint and it is not uncommon for an obstetrician to prescribe analgesic in such cases. This case highlights that rare etiology like cortical venous sinus thrombosis (CVST) should be kept in mind while dealing with persistent postpartum headache so as to prevent catastrophic complications.

Herein, we present a case of 23 years, para3 live 3 (P3L3) admitted on postpartum day 15 with complaints of fever, headache, and vomiting for last 4 days. She had a history of home vaginal delivery followed by postpartum hemorrhage 15 days back. She presented with throbbing headache in the frontal, parietal, and temporal regions. There was no history of seizures, loss of consciousness, bowel or bladder symptoms, neck pain, visual blurring, head injury, ear discharge, cough, breathlessness, chest pain, and foul smelling vaginal discharge.

On examination, she was drowsy and severely anemic. systemic, vaginal, and fundus examination was normal.

Her hemoglobin was 5 g%. Prothrombin time, activated partial thromboplastin time, and homocysteine level was normal. She was given two units of blood transfusion. Ultrasound of pelvis was normal. Computed tomography (CT) of brain showed venous infarct in bilateral frontal lobe with foci of hemorrhages suspicious of superior sagittal sinus thrombosis. Magnetic resonance imaging (MRI) of the brain with magnetic resonance venography (MRV) confirmed superior sagittal sinus thrombosis. Anticoagulant therapy in the form of low molecular weight heparin and warfarin was started and she is currently on follow-up [Figures 1 and 2].

Figure 1

Magnetic resonance (MR) venography showing superior sagittal sinus thrombosis

Figure 2

Hemorrhagic venous infarct in frontal lobe

The frequency of peripartum and postpartum cerebral venous sinus thrombosis is about 12 cases per 100,000 deliveries.[1] Most common venous sinus to develop thrombosis (or probably detected commonly) is the superior sagittal sinus.[23] Headache is the most frequent symptom, often mimics migraine but is persistently unilateral or diffuse and is not relieved after sleep, increases gradually over a couple of days, but can also start in a split second, mimicking intracerebral or subarachnoid hemorrhage.[4] Presence of focal neurological signs often misleads the diagnosis as intracranial space occupying lesion.

MRV is the diagnostic modality of choice.[5] Treatment of choice is anticoagulation. In the presented case, an urgent CT and MRI of the brain clinched the diagnosis. This case illustrates that clinical suspicion, supporting investigations, and a high index of suspicion are important in clinching the diagnosis.