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 pu erperal period and the difficulties encountered in the diagnosis and manage ment. 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 th ere was no history of epidural or spinal anesthesia, or trauma or surgery t o her back or neck. Conservative therapy was initially offered and then a l umbar epidural blood patch (LEBP) was performed, although it failed to reli eve the postural headache. A dural leak could not be demonstrated but an MR V (magnetic resonance venography) revealed a superior sagittal sinus thromb osis (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. Anesth esia was reluctant to perform an LEBP at this point and suggested continuin g anticoagulation until a subsequent MRV demonstrated recannalization of th e SSST. This advice was followed and the postural headache resolved spontan eously with intravenous anticoagulation, Conclusion: The present case illustrates the importance of a multidisciplin ary approach to the management of this rare complication of pregnancy. This case also highlights the importance of reviewing the differential diagnosi s when considering treatment of a postural headache in the puerperium.