Postpartum Cerebral Venous Thrombosis and Spinal CSF Leak after Epidural Anesthesia

SUMMARY: Postpartum headache following obstetric epidural anesthesia may be secondary to post-dural puncture headache (PDPH) from spinal CSF leakage or cerebral venous thrombosis (CVT). Although these entities are generally considered distinct, intracranial hypotension from persistent spinal CSF leakage may contribute to the development of CVT. We present four postpartum patients with imaging-confirmed CVT and coexisting spinal CSF leaks after lumbar epidural anesthesia. All patients initially presented with headache and were diagnosed with CVT, prompting anticoagulation therapy. However, imaging findings of intracranial hypotension were initially overlooked in every case despite being present on the initial brain MRI. Subsequent spine MRI demonstrated epidural fluid consistent with CSF leakage in all patients. Epidural blood patching resulted in rapid clinical improvement, with interval resolution of intracranial hypotension findings, and the CVT resolved after anticoagulation therapy. These cases suggest that persistent spinal CSF leakage may coexist with and potentially contribute to CVT in susceptible postpartum patients. Recognition of this association is important because diagnosis of CVT may prematurely end the radiologic evaluation of postpartum headache, reducing recognition of coexisting intracranial hypotension and persistent spinal CSF leakage. Consideration of both entities may facilitate appropriate treatment with anticoagulation and, when indicated, epidural blood patching.