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Postpartum Cerebral Venous Thrombosis — FRCA Final MCQ

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HardObstetric AnaesthesiaPostpartum Cerebral Venous ThrombosisFRCA Final

A 28-year-old woman is reviewed 5 days after an elective caesarean section performed under uncomplicated spinal anaesthesia. She has had a progressively worsening, non-postural headache and vomiting for 48 hours. She now develops a focal motor seizure followed by persistent right-sided hemiparesis. She is afebrile, her blood pressure is 128/76 mmHg, and there is no meningism. Non-contrast CT demonstrates a left parasagittal haemorrhagic infarct that does not conform to an arterial territory. What is the most likely diagnosis?

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Correct answer: E — Intracranial venous sinus thrombosis

The diagnosis is intracranial venous sinus thrombosis, more commonly termed cerebral venous sinus thrombosis. The puerperium is prothrombotic, and CVST typically produces a progressive headache followed by seizures, focal deficits or impaired consciousness. A parasagittal haemorrhagic infarct outside an arterial territory is particularly suggestive of superior sagittal sinus or cortical venous thrombosis. CT venography or MR venography confirms the diagnosis; prompt therapeutic heparin anticoagulation is usual once confirmed. Post-dural puncture headache is typically orthostatic and does not explain the venous-territory infarct. Eclampsia remains possible despite normal blood pressure but does not best explain this imaging pattern. Subarachnoid haemorrhage usually presents with thunderclap headache and subarachnoid blood, while meningitis would more usually cause fever and meningism.

Reference: Ulivi L, Squitieri M, Cohen H, Cowley P, Werring DJ. Cerebral venous thrombosis: a practical guide. Practical Neurology. 2020;20:356–367. https://www.bmj.com/content/bmj/389/bmj-2024-083247.full.pdf