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Postpartum headache, loss of consciousness, this reason is not simple!

 Last Update: 2023-02-01
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Intracranial venous sinus thrombosis is a special type of cerebrovascular disease, often onset in wasting diseases, brain trauma, puerperium, blood diseases, heart disease, eye, nose and facial infections, meningitis, sepsis, etc.
, the condition is more critical, and even can endanger life, postpartum women are very easy to induce
.
The author met a postpartum pregnant woman with venous thrombosis in the clinic, and summarized her consultation and treatment ideas for your reference
.

Patient, female, 20 years old

Complaints: postpartum headache for 4 days, exacerbation with impaired consciousness for 1 day

First, the idea of medical history questioning

1.
Regarding acute headache, you should first ask about the location and nature of the headache, the relationship with changes in position, other accompanying signs, and the development process
.
The most common cause is cranial hypertension, and its underlying causes include cerebrovascular accident (which includes not only hemorrhagic but also infarct nature), central nervous system infection, and mass lesions
.
If headache is sudden and blood pressure rises, intracranial hemorrhage
is warranted.
If fever begins with headache, nausea and vomiting a few days later, meningitis
should be suspected.
If you have a pulsatile headache with oculomotor palsy, you need to be alert for posterior communicating artery aneurysm
.
At the same time, it is also necessary to exclude headaches caused by other systems, such as patients who present with headaches but find red eyes, ask whether they are accompanied by eye pain, photophobia is obviously alert to glaucoma attacks, etc
.

2.
For patients with acute consciousness disorders, they cannot provide any medical history
in emergency work.
Family members should be questioned more on objective facts than subjective discomfort
.
For example, the time of fever, the relationship between fever and the decline in consciousness, general conditions such as drinking, sleep, stool, etc
.
A major past medical history is also helpful
.
However, once the patient's level of consciousness has recovered after diagnosis and treatment, it is important to ask the medical history again and replenish
it at any time.

3.
The patient in this case is a young mother
.
Pregnant and maternal women should be carefully informed about obstetric history
.
Because of the physiological particularities of pregnancy and motherhood, they are prone to some diseases, such as the headache symptoms of this patient after childbirth, and it should be thought that it was in the hypercoagulable period
at that time.
There is also the relationship between anemia, high blood pressure, etc.
and pregnancy
.
At the same time, extra caution is required during diagnosis and treatment to avoid unnecessary medication and radiation exposure
.

4.
Because the patient has been treated in an external hospital, ask about the examination, treatment and response
to the treatment given by the hospital.
This helps to determine the nature of the
disease.

▌Ask for results

Present medical history: 9 days before admission, a healthy baby boy was delivered spontaneously in a local hospital, and symptoms such as urinary frequency, urgency, and dysuria occurred after delivery, and he was not accompanied by fever at that time, and was treated with intravenous antibiotics in the local hospital
.
Headache 4 days before admission, pronounced pain in the left frontotemporal region, accompanied by nausea and vomiting
.
The headache persists without improvement
.
2 days ago, he was treated in a local hospital, measured blood pressure 160/90mmHg, body temperature 37.
3°C, hemoglobin 6.
5g/L
.
After antihypertensive and antibiotic therapy, the disease continued to progress, and drowsiness
occurred 1 day before admission.
The head CT found bleeding in the left temporal lobe and cerebellar hemisphere, and then transferred to our hospital
.

Anamnesis: Thrombocytopenia was discovered at the age of 13, and platelets rose to normal after the hormone was applied at the local hospital, and the specific dose of application is unknown
.
Anemia
is detected at prenatal testing.
History of spontaneous abortion 1 year ago
.
Personal and family history: nothing special
.

2.
Physical examination

▌1.
When analyzing
the physical examination before the physical examination, it should be noted that the manifestations of the nervous system may be part of the systemic disease, and the whole system should be examined first
.
Patients with anemia, in addition to the signs of anemia itself, pay attention to check for skin yellowing, ecchymosis, rash, etc.
, and whether there is hepatosplenomegaly
.
Neurological signs are key
to localizing the diagnosis.
Patients mainly present with headache with impaired consciousness, and attention should be paid to checking meningeal signs and the degree of impaired consciousness
.
When the patient cannot be qualified for examination due to consciousness disorder, it is difficult to obtain accurate signs such as muscle strength, and attention should be paid to whether the patient's limbs are autonomous, whether the facial wrinkles are symmetrical, etc.
, to help determine whether there is brain parenchymal involvement
.
In this case, the patient has elevated body temperature, so the possible sources of infection include infection of the central meridian system itself, urinary tract infection, puerperal infection, and lung infection, etc.
, and a detailed physical examination of the above systems is required to distinguish them
.

▌Physical examination:
body shape, anemia
.
Body temperature 38.
5 ° C, heart rate 100 beats / min, rhythm.

The breath sounds in both lungs are coarse, and small blister sounds
can be heard at the bottom.
Palpation of the abdomen reveals that the fundus is located in the subumbilical 2 fingers, and lochia is within normal range
.
Sleeping, echoing, questioning can occasionally be vaguely answered, physical examination is not cooperative
.
Bilateral pupil 3.
5 mm, photoreaction present
.
Bilateral eyes are centered
.
Bilateral frontal lines and nasolabial folds are symmetrical
.
Voluntary activity is visible in both limbs, less suspicious right side movement, slight weakness, symmetrical tendon reflexes in the extremities, and negative bilateral Babinski sign
.
Strong neck, positive meningeal sign
.
Fundus examination reveals no obvious abnormalities
.

▌2.
Post-physical examination analysis
can further verify the preliminary clinical judgment
through signs.
The more prominent neurologic sign in this patient is acute impaired consciousness with positive meningeal signs and suspicious right limb involvement
.
Consider possible involvement
of the cerebral cortex, brainstem reticular activation system, meninges, and left parenchyma.
Results from further ancillary testing need to be combined
.
Differentiate between cerebrovascular accident and central system infection
.
Constitutional examination reveals a significant appearance of anaemia but no signs
of hemolysis.
A higher than normal temperature and a murmur on auscultation of the lungs suggest a possible
lung infection.
Abdominal palpation of the uterus can restore the normal range of lochia, which can largely exclude infection during the puerperium
.
There is currently no evidence of systemic involvement of
other systems.

3.
Further auxiliary inspection

1.
Routine examination, including blood, urine, stool routine, blood biochemistry, coagulation, chest x-ray, abdominal ultrasound, electrocardiogram, etc
.

2.
Starting from the patient's anemia, further screening Coombs test, blood smear, triathlon, folic acid, vitamin B12
.

3.
The patient is a young woman, and there is thrombocytopenia in adolescence, hormone therapy is effective, and should be screened for erythrocyte sedimentation rate, complement, antinuclear antibodies, autoantibodies, etc
.
Patients with a history of spontaneous abortion should be alert to antiphospholipid antibody syndrome, screening for anticardiolipin antibodies, lupus anticoagulants, etc
.

4.
Cranial imaging examination, for the lesions of the central nervous system, imaging examination is the most intuitive non-invasive examination
.
Urgent head CT can immediately determine the presence of bleeding and mass lesions
.
Head MRI can be further clarified
.
Nature of
the lesion.

5.
Lumbar puncture examination, cerebrospinal fluid examination can help diagnose the nature of the disease, especially for infectious diseases are more meaningful
.
However, in patients with acute intracranial hypertension, lumbar puncture requires caution
.

6
.
Angiography angiography, this patient is a mother, need to be alert to venous system thrombosis.
If necessary, pan-cerebral angiography can be performed urgently to identify the lesion as early as possible and treat
it aggressively.

Localization: According to the above examination results, the lesions localized in the left temporal lobe and cerebellar hemispheres are consistent with the left transverse sinus and sigmoid sinus drainage area
.
Associated with pulmonary infection
.

Qualitative: thrombosis of venous sinuses, secondary infarct bleeding
.
Further investigations should be done to look for underlying causes
other than postpartum hypercoagulability.

▌Main inspection results:

1.
Blood routine, blood smear, triathlon, etc.
suggest microcytic hypochromic anemia
.

2.
ANA: nuclear point type, 1:320
.
ACL（++）
。 The OD value is 0.
401
.
LA（-）
。 Negative for retest
.
Coombs（-）
。

3.
Chest radiograph: the texture of both lungs is thick, and the double lower lungs are scattered in patchy shadows
.

4.
Cranial CT: hemorrhage in the left temporal lobe and cerebellar hemisphere, accompanied by edema (as shown in Figure 1).

5.
Cranial magnetic resonance: left cerebellar hemisphere, temporal lobe hemorrhage
.
Occlusion of the left transverse sinus and sigmoid sinus (as shown in Figure 2).

6.
Cranial angiography: the left transverse sinus and sigmoid sinus are not shown, and the left jugular vein is poorly developed (as shown in Figure 3).

7.
Lumbar puncture: lumbar puncture in the early stage of the disease, cerebrospinal fluid pressure greater than 350mmH2O
.
The number of white blood cells is normal and the protein is mildly elevated
.
There were no abnormalities
in etiology.
Due to the patient's family economic reasons and other reasons, the delivery of gene next-generation sequencing
was refused.

Fig.
1 CT of the head showed left temporal lobe and cerebellar hemorrhage with edema

Fig.
2 MRI of the head showed left temporal lobe and cerebellar hemisphere hemorrhage with edema

Fig.
3 DSA results showed that the left transverse sinus and sigmoid sinus were not shown, and the left jugular vein was poorly developed

4.
Preliminary diagnosis

▌Based on the above results, the diagnosis is: left transverse sinus, sigmoid sinus thrombosis
, left cerebellar hemisphere, temporal lobe hemorrhage
hypertension
Iron deficiency anemia
lung infection ▌ Diagnosis basis:
The patient is female, postpartum symptoms, intracranial hypertension, high suspicion of intracranial venous sinus thrombosis, imaging provides direct evidence, left transverse sinus and sigmoid sinus thrombosis is clear
.
We should be alert to the presence of antiphospholipid antibody syndrome for the underlying cause, but patients with low antiphospholipid antibody titers do not currently meet diagnostic criteria
.
Further follow-up observation is still required
.

5.
Treatment and follow-up

The treatment of venous sinus thrombosis mainly includes anticoagulation, symptomatic and supportive treatment
.
The patient was diagnosed on the same day and started low-molecular weight heparin anticoagulation, followed by a transition to oral warfarin
.
Combined with dehydration to reduce intracranial pressure, the condition quickly improved and stabilized
.
The intracranial hematoma has been absorbed
.
Other anemias, high blood pressure, lung infections, etc.
have also improved quickly after symptomatic treatment
.
During the recovery period, the pressure and protein of the cerebrospinal fluid of the lumbar puncture were within the normal range
.

During treatment, progressive thrombocytopenia was found and diagnostic bone puncture
was performed.
Consider thrombocytopenia, and the main causes considered thrombocytopenia at that time are idiopathic, heparin-related, and wasting
.
Combined with the patient's previous history of thrombocytopenia and other abnormal immune markers, idiopathic may be large
first.
In addition, from the relationship between the time of this low molecular weight heparin anticoagulation treatment and platelet changes, it is not consistent with HIT
.
At the same time, there is already no process of fresh thrombosis, there is no consumption
.
A final diagnosis of idiopathic thrombocytopenic purpura is likely
.

The clinical diagnosis process of this case was actually very fast, because the head CT showed bleeding at that time, and our judgment focused on whether the bleeding was primary or secondary, and after active auxiliary examination, the cause
was quickly identified.
Active diagnostic and therapeutic measures were taken to make the patient's clinical symptoms recover
quickly.
Although patients have elevated antiphospholipid antibodies, the current evidence is not sufficient as a diagnostic criterion for antiphospholipid antibody syndrome, and further observation and follow-up are required, and relevant indicators
are regularly reviewed.

References:[1] HE Pingge, GONG Xianghe, WU Hui.
A case report of intracranial venous sinus thrombosis during the puerperium.
Journal of Practical Cardio-Cerebrovascular Diseases.
2022.
09.

[2] ZHAO Cuicui, MA Jinqi.
Risk assessment and prevention analysis of venous thrombosis during pregnancy and puerperium.
Heilongjiang Medicine.
2022,46(18).
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