Postpartum workup of postdural puncture headache leads to diagnosis and surgical treatment of thoracic pseudomeningocele: a case report

Postdural puncture headache is a well-known complication of neuraxial anesthesia in childbirth. There are, however, many other causes of postpartum headache, some of which may present like postdural puncture headache and confuse the diagnosis. We report a case of postpartum headache due to pseudomeningocele.

A 31-yr-old primigravida presented at 35 weeks gestation for induction of labour. A pre-pregnancy history of migraines was suspicious for low cerebrospinal fluid headache, but this had been ruled out by normal brain magnetic resonance imaging (MRI), and the headaches had resolved with pregnancy. A labour epidural was easily placed at L3/4. On postpartum day one the patient complained of mild headache, and the severe pre-pregnancy headache returned within weeks. The pounding occipital/hemispheric headache was associated with nausea and vomiting; it worsened over the day, and improved when the patient was supine. A repeat brain MRI showed evidence of intracranial hypotension, and an epidural blood patch was performed at L3/L4 with no improvement. A second blood patch was performed ten days later, still with no improvement. A subsequent brain MRI showed unchanged intracranial hypotension, and a spine MRI revealed a pseudomeningocele at T7. A computed tomography myelogram confirmed a T7/8 pseudomeningocele. The patient underwent direct microsurgical exploration and repair four months later, which was followed by re-operation ten months later. The patient’s condition has since remained significantly improved.

This case highlights the importance of maintaining a wide differential in the workup of postpartum headache after regional anesthesia, particularly in cases refractory to blood patch. This case also reveals a T7 pseudomeningocele causing spontaneous intracranial hypotension that otherwise may not have been detected and corrected.