Postpartum cerebral ischaemia after accidental dural puncture and epidural blood patch

Abstract

Puerperal women are reported to have a rate of cerebral infarction 13 times greater than non-pregnant females. We report a case of cerebral ischaemia in a 30-yr-old healthy parturient after epidural analgesia for labour, complicated by dural puncture treated with two epidural blood patches. Investigations showed the development of cerebral ischaemia on postpartum day 14. A transcranial Doppler ultrasonography showed vasospasm of the left middle cerebral artery still present at 3-month follow-up. At 1-yr follow-up, the patient had homonymous hemianopsia. We discuss the possible causative mechanism of the cerebral ischaemia in relation to the dural puncture and epidural blood patch.

Posterior Reversible Encephalopathy Syndrome with Vasospasm in a Postpartum Woman After Postdural Puncture Headache Following Spinal Anesthesia

“…Persistent leakage of CSF through the dural opening left by the lumbar puncture needle can result in sagging of the brain and traction on nerves and meningeal vessels (8,12,13). Presumably, the diminished volume of CSF in the cerebral ventricle may collapse the ventricle (14). This traction might cause mechanical stimulation on the arterial wall and, in theory, could induce vasospasm (14,15).…”

“…Presumably, the diminished volume of CSF in the cerebral ventricle may collapse the ventricle (14). This traction might cause mechanical stimulation on the arterial wall and, in theory, could induce vasospasm (14,15). Clearly, more clinical data are needed to prove this putative mechanism of collapsed ventricleinduced vasospasm.…”

Postpartum Seizure and Ischaemic Stroke following Dural Puncture and Epidural Blood Patch

“…Could the large volume of blood used in our patient have magnified the physiological effects of the epidural blood patch, including potentially the degree of cerebral vasoconstriction? While plausible, there is no proven link between epidural blood patch and stroke, a very rare occurrence, and it is known that cerebral infarction is already up to 13 times more frequent in puerperal women compared with nonpregnant women 24,26 .…”

“…Could the epidural blood patch have contributed to cerebral ischaemia? Mercieri et al 24 speculated that cerebral vasospasm may follow dural puncture or follow an epidural blood patch. Subdural and extradural haematomas are known to be powerful stimuli of cerebral vasoconstriction 25 but theirs is the only case report attributing epidural blood patch as the cause of ischaemia.…”