A case report and narrative review of literature of spontaneous intracranial hypotension during the postpartum period

Abstract

Introduction: Spontaneous intracranial hypotension (SIH) is defined as the occurrence of orthostatic headache resulting from spontaneous cerebrospinal fluid (CSF) leak. Orthostatic headaches are not always related to SIH. When symptoms declare in the postpartum period after neuraxial anesthesia, postdural puncture headache (PDPH) is more often suspected. We present here the first case of SIH occurring 3 months after vaginal delivery with epidural anesthesia.

Methods: For the writing of our case, we conducted a Pubmed search of SIH in association with the postpartum period. We then proceeded to make a narrative review of literature of SIH using the same search engine.

Results: SIH has an annual incidence of 5/100 000 and middle-aged women are the most affected. Clinical presentation consists of orthostatic headache in more than 90% of patients. Meningeal irritation and cochlear-vestibular symptoms are other frequently reported signs. Known risk factors are connective tissue disease and trivial trauma. There are no clear evidences regarding the appropriate imaging and treatment modalities in SIH. Common practice suggest the realization of brain MRI with diffuse pachymeningeal enhancement being the most pathognomonic sign. Treatment usually consists of bed rest for a limited period of time followed by one or more blind lumbar epidural blood patches (EBP) if necessary. Other treatment options include targeted EBP and surgery.

Discussion and conclusion: SIH is often underdiagnosed and misdiagnosed. Anesthetists in particular are not familiar with the pathology. Only two cases of postpartum SIH are reported in literature. This review highlights SIH as a possible cause of postpartum headache and the need for healthcare providers to recognize the syndrome.