Postpartum trifecta: simultaneous eclamptic intracerebral hemorrhage, PRES, and herniation due to intracranial hypotension.

BACKGROUND

In the postpartum patient, sudden depression of consciousness may be caused by a number of etiologies and can result in serious consequences. Rapid, accurate diagnosis allows for specific treatments that optimize outcome, but diagnosis can be challenging in this population. We present a case of postpartum herniation due to intracranial hypotension in a patient with eclampsia, posterior reversible encephalopathy syndrome (PRES), and intracerebral hemorrhage (ICH).

METHODS

Case report.

RESULTS

A 26-year-old woman developed headache on postpartum day (PD) 1 after cesarean section with epidural anesthesia. Over the next 3 days, she developed progressively worsening headache and hypertension. On PD 5, she had a generalized seizure, leading to endotracheal intubation, propofol infusion, and transfer to our institution. By PD 6, she opened her eyes to voice, followed commands, moved all extremities, and had briskly reactive 4 mm pupils. MRI showed L parasagittal ICH with minimal mass effect, edema consistent with PRES, and brain descent with obliteration of the basal cisterns and tonsillar herniation. Later on PD 6, after diuresis for pulmonary edema, she became unresponsive with a dilated and nonreactive left pupil. She was laid flat for transport to CT, with improvement in arousal and pupil reactivity within 5 min. Intravascular volume was repleted with normal saline and albumin, and she was placed in the Trendelenburg position. Over the subsequent 8 h, she developed a dilated and nonreactive left pupil whenever her head was raised to horizontal. Her head position was gradually successfully raised over 48 h without need for a lumbar epidural blood patch. She was discharged home on PD 13 with only mild left arm dysmetria.

CONCLUSIONS

Intracranial hypotension may coexist with other potential causes of cerebral herniation in the postpartum period. Establishing this diagnosis is crucial because its treatment is opposite that of other causes of herniation.