The Journal of Emergency Medicine, Vol. 29, No. 3, pp. 289 –293, 2005
Copyright © 2005 Elsevier Inc.
Printed in the USA. All rights reserved
0736-4679/05 $–see front matter

doi:10.1016/j.jemermed.2005.02.010

Clinical
Communications: OB/GYN

HEADACHE AND SEIZURE IN A YOUNG WOMAN POSTPARTUM
Mini R. DeLashaw, MD, PhD, Thomas L. Vizioli Jr., MD, and Francis L. Counselman, MD
Department of Emergency Medicine, Eastern Virginia Medical School and Emergency Physicians of Tidewater, Norfolk, Virginia
Reprint Address: Francis L. Counselman, MD, Department of Emergency Medicine, Raleigh Building, Room 304, 600 Gresham Dr.,
Norfolk, VA 23507

e Abstract—A 19-year-old woman, 8 days postpartum,
presented to the Emergency Department (ED) with a chief
complaint of headache, decreased vision, and agitation.
Past medical history was unremarkable. Physical examination was remarkable only for dry mucous membranes,
decreased visual acuity, and trace pedal edema bilaterally.
While in the ED, the patient experienced a generalized
tonic-clonic seizure. Computed tomography (CT) scan of
the head was suspicious for venous infarction. Magnetic
resonance imaging (MRI) and MR venography revealed
sagittal sinus and left transverse sinus thrombosis. The risk
factors, clinical presentation, diagnostic evaluation, and
management of cerebral venous thrombosis are reviewed.
© 2005 Elsevier Inc.

raphy is considered the best noninvasive method of diagnosing CVT. We present a patient with a classic
presentation of CVT.

CASE REPORT
A 19 year-old woman, gravida 1, para 1, presented to the
Emergency Department (ED) with the chief complaint of
headache and decreased vision. On the night before
presentation, the patient gradually developed a generalized headache and took one of her boyfriend’s acetaminophen/hydrocodone tablets. Upon awakening on the
morning of presentation, she described her headache as
greater in intensity. The family became concerned with
her symptoms, including her increasing agitation, and
called emergency medical services (EMS) for transport
to the ED.
The patient described her headache as generalized,
dull, constant, and increasing in intensity. She denied any
exacerbating or relieving factors. She had no previous
history of migraines or other headaches. The only associated symptom was decreased vision. She had some
light perception, with only darker and lighter shadows
visible.
The patient denied head injury or trauma. She denied
tinnitus, sore throat, or upper respiratory tract infection
symptoms. She denied chest pain, shortness of breath,
nausea or vomiting. Other than the headache and visual

e Keywords—seizure; cerebral venous thrombosis; sagittal
sinus thrombosis; headache; transverse sinus thrombosis

INTRODUCTION
Cerebral venous thrombosis (CVT) is a relatively rare
condition. The majority of patients are women, with a
median age of 37 years. Common risk factors among
women include use of oral contraceptives, pregnancy,
and the postpartum period. Typical signs and symptoms
include headache, seizure, paresis, and mental status
changes. Although computed tomography (CT) scan of
the head is frequently used as a screening study, magnetic resonance imaging with magnetic resonance venog-

Clinical Communications: Obstetrics and Gynecology is coordinated by Colleen Campbell, MD, of the University of
California San Diego Medical Center, San Diego, California

RECEIVED: 23 April 2004; FINAL SUBMISSION RECEIVED: 15 November 2004;
ACCEPTED: 23 February 2005
289

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M. R. DeLashaw et al.

Figure 1. A nonenhanced CT scan of the brain demonstrates loss of cortical sulci in the right frontal, parietal and temporal lobes.

symptoms, there were no other neurologic complaints.
She denied any motor weakness or paresthesias.
The past medical history was significant only for a
spontaneous vaginal delivery 8 days prior, with decreasing lochia and no vaginal bleeding. The pregnancy and
delivery were without complications.
The patient denied alcohol, tobacco, or illicit drug
use.
Physical examination revealed an awake and alert
woman. Vital signs were: temperature 38.8°C (101.9°F)
rectally; pulse 107 beats/min; respiratory rate 20 beats/
min; blood pressure 171/113 mm Hg; and an oxygen
saturation of 98% on room air. The head and neck
examination was remarkable only for dry mucous membranes. A funduscopic exam was not performed. The
neck was supple with full range of motion and without
lymphadenopathy. Cardiovascular examination revealed
a regular rhythm, without murmurs, rub or gallop. The
lungs were clear to auscultation. Examination of the
abdomen was normal. The patient had trace pedal edema
bilaterally. The neurologic examination revealed an awake
and alert patient. Visual acuity was to light perception only.
All other cranial nerves were intact. Upper and lower

extremity motor strength was 5/5 and reflexes were 2⫹
and symmetrical.
Shortly after completion of the physical examination,
the patient experienced a generalized tonic-clonic seizure, which terminated immediately after the administration of lorazepam (Ativan) 2 mg i.v. The patient was also
given magnesium sulfate 4 g i.v. for suspected postpartum eclampsia.
The serum white blood cell (WBC) count was 9.0 ⫻
103/uL, with a normal differential. She was slightly anemic, with a hemoglobin of 9.4g/dL and a hematocrit of
28.9%; the platelet count was normal. Electrolytes, glucose, BUN and creatinine were all within normal limits.
Urinalysis demonstrated 15 ketones, 1 to 5 red blood
cells, 1 to 5 white blood cells, no protein and few
bacteria. A urine drug screen was positive for opiates
only. Coagulation studies were normal. A portable chest
X-ray study was normal. A computed tomography (CT)
scan of the head without contrast demonstrated loss of
the cortical sulci in the right frontal, parietal and temporal lobes (Figure 1). Magnetic resonance imaging (MRI)
of the brain and MR venography were recommended due
to suspicion for venous infarction. The MRI demon-

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291

Figure 2. A MR venogram of the brain reveals a relative lack of signal in the superior aspect of the sagittal sinus, consistent with
a sagittal sinus thrombosis.

strated increased signal intensity on T2 in the gyri of the
frontal lobes bilaterally and in the gray white junction of
the occipital lobes bilaterally, suggestive of saggital sinus and left transverse sinus thrombosis. The MR
venogram showed relative lack of signal in the superior
sagittal sinus, consistent with thrombus (Figure 2).
After returning from the Radiology department, the
patient experienced a second generalized tonic-clonic
seizure; this resolved spontaneously. The patient was
given phenytoin (Dilantin) 18 mg/kg loading dose i.v.
and the Obstetrics and Gynecology and Neurology services were consulted. Hypercoagulation studies were
ordered, including Protein S, Protein C, antiphospholipid antibodies, Factor V Leiden and antithrombin III
levels.
The patient was postictal on examination by Neurology, but arousable. No focal deficits were identified. In
view of the MR venogram findings, the patient received
an intravenous heparin bolus and was started on a drip.
The patient was admitted to the intensive care unit (ICU).
The patient was continued on Dilantin. In the ICU, an
electroencephalogram (EEG) demonstrated only moderate generalized slowing; no epileptiform discharges were
noted. On day two, the patient was started on warfarin
(Coumadin). Once the International Normalized Ratio
reached therapeutic levels, the heparin was discontinued.
The hypercoagulation studies were all within normal limits.
In view of the patient’s persistent high blood pressure, she
was started on valsartan (Diovan) 80 mg p.o. daily with

good results. The patient continued to improve and remained without seizure activity in the hospital. The patient
was discharged on day five on Diovan, Dilantin and Coumadin, with Neurology follow-up.

DISCUSSION
Cerebral venous thrombosis (CVT) is a relatively rare
condition, but the diagnosis was made in our patient after
an unexplained seizure and a suspicious head CT scan
prompted further evaluation using MRI. Although useful
in this case, CT scans are read as normal or nondiagnostic in up to 30% of patients with CVT (1). The diagnosis
is based on presenting symptoms, past medical history,
and the presence of risk factors. Patients with risk factors
and classic symptoms of CVT should receive further
evaluation regardless of initial CT scan results to avoid
missing this potentially fatal condition.
The International Study on Cerebral Vein and Dural
Sinus Thrombosis (ISCVT), a recent multinational, multicenter prospective study that followed 624 patients with
CVT, identified common characteristics, risk factors, and
prognosis (2). According to the ISCVT trial, 79% of
patients diagnosed with CVT are white and 75% are
women, and the median age is 37 years. Thrombophilic
disorders (protein C and Protein S deficiency, antithrombin III deficiency, activated protein C resistance, factor V
Leiden mutation, antiphospholipid antibody, nephrotic

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syndrome, and hyperhomocysteinemia) account for 34%
of patients with CVT. Patients with active infections
(i.e., rhinosinusitis, meningitis, otitis) account for 12%.
Among female patients, 54% are on oral contraceptives,
14% are postpartum, and 6% are pregnant. Other less
common predisposing conditions include trauma, malignancies, hematologic disorders, vasculitis and systemic
inflammatory disorders. Thirteen percent of patients with
CVT have no identifiable risk factor, whereas 44% have
more than one risk factor (2). Among peripartum women,
pregnancy-related hypertension, older age, infections, and
cesarean delivery are common risk factors associated with
CVT (3–5). Changes that contribute to a prothrombic
state in pregnancy and puerperium include a decrease in
inhibitors of protein S and increased levels of fibrinogen,
factor VII, factor VIII, factor X, and protein C inhibitors
(6). Factor V Leiden and Factor II gene mutations have
also been shown to play a role in CVT development in
patients taking oral contraceptives (7).
The most frequent signs and symptoms of CVT include headache (88%), seizure (39%), paresis (37%),
papilledema (28%), mental status changes (22%), visual
changes, cranial nerve deficits, and focal weakness (2,8).
In retrospect, our patient presented in a classical fashion
for CVT. The course is often indolent, with patients
presenting days to weeks after the onset of symptoms.
Presentations vary according to the location and size of
the thrombosis, the rate of development, and the amount
of collateral venous drainage (2,9). Women with CVT
associated with pregnancy and puerperium present with
similar symptoms, neurological findings, and neuroimaging results when compared to patients with CVT secondary to other causes. However, obstetric patients tend
to be younger and present with a more acute onset of
symptoms, similar to our patient (10). The diagnosis of
CVT should be considered in women with any neurologic symptoms during pregnancy or puerperium (8).
The ED evaluation of a patient suspected of having a
CVT begins with a thorough history and physical examination. Other diagnoses that should be considered include simple headache, intracranial hemorrhage, meningitis, aneurysm, and pseudotumor cerebri. In postpartum
patients who have received epidural anesthesia, intracranial hypotension from a cerebrospinal fluid (CSF) leak
should be considered. Likewise, although postpartum
patients who present with seizures are more likely to
have eclampsia, seizures secondary to CVT also should
be considered. Physical examination findings of CVT
most often include papilledema. Neurologic findings
range from subtle deficits to profound coma. A classic
triad of headache, papilledema, and high opening pressures on lumbar puncture has been described, but is also
present in patients with pseudotumor cerebri (9).
Lumbar puncture will usually yield high opening

M. R. DeLashaw et al.

pressures. Cerebrospinal fluid analysis is useful for ruling out an infectious etiology of a headache and is
usually normal in patients with CVT.
Quantitative D-dimer measurement recently has been
proven to be useful for the evaluation of suspected venous thrombosis and pulmonary embolism. Lalive et al.
investigated the utility of quantitative D-dimer levels in
54 patients suspected of having a CVT (11). Twelve of
the 54 enrolled patients were found to have CVT, and 10
of the 12 had D-dimer levels greater than 500 ng/mL
(sensitivity of 83% and negative predictive value of
95%). The two patients with CVT and a D-dimer less
than 500 ng/mL had a history of headache lasting greater
than 30 days. In the 42 patients without CVT, only four
had D-dimer levels greater than 500 ng/mL (specificity
of 90% and positive predictive value of 71%). The authors concluded that patients with less than 1 month of
symptoms and a D-dimer value less than 500 ng/mL are
unlikely to have CVT. Alternatively, further workup is
warranted in all patients with symptoms consistent with
CVT and D-dimer level greater than 500 ng/mL (11).
This test is of limited value, however, in pregnant patients. D-dimer has been shown to increase gradually
during the course of pregnancy (12). Chabloz et al.
demonstrated that for the time period of the 35th week of
pregnancy through delivery, D-dimer values are consistently greater than 500 ng/mL (12).
Although laboratory values may contribute to the
clinical picture, neuroimaging is the most effective tool
for diagnosing CVT. Angiography is considered the gold
standard, but is not commonly used unless endovascular
thrombolytics are employed for clot dissolution. CT
scans of the head are typically obtained in the initial
workup, but are not sensitive or specific enough to safely
exclude the diagnosis. Findings suggestive of CVT on
CT scan include evidence of infarction, hemorrhage, or
edema that do not correspond to an arterial distribution.
These and other characteristic signs on CT scan may
suggest CVT, but are not diagnostic, and additional imaging is usually required. Magnetic resonance imaging
with magnetic resonance venography is both sensitive
and specific, and is considered the best noninvasive
method of diagnosing CVT. Using this imaging method,
the thrombus and subsequent changes in flow patterns
can be directly visualized (13).
All patients should receive a hypercoagulation workup
after being admitted. Even if an etiology for CVT is obvious, 44% of patients have more than one risk factor,
including undiagnosed coagulation abnormalities (2).
Neurology should admit these patients. The treatment
of choice for CVT is heparin, followed by long-term
anticoagulation with warfarin. The recommended length
of anticoagulation is 3 to 6 months, or longer if an
underlying prothrombotic condition is still present (1).

Headache and Seizure

Patients should be immediately considered for anticoagulation regardless of the duration of symptoms, severity
of neurologic deficit, or presence of intracranial hemorrhage due to the potential for full recovery. These patients, when compared to those with arterial strokes,
typically respond well to treatment (1). Symptomatic
treatment may be accomplished with analgesics, anticonvulsants, medications to decrease intracranial pressure
(i.e., mannitol, steroids, acetazolamide, and diuretics),
and treatment of the prothrombotic condition.
The use of systemic or local thrombolytics has not
been studied in a randomized controlled trial, but results
from many case reports suggest that thrombolytics are
useful, especially in patients whose condition is refractory to anticoagulation (14).
According to results from the ISCVT trial, the longterm prognosis for patients is better than previously
reported, with only 13% of patients dying or having a
poor neurologic outcome (2). Factors associated with
increased morbidity and mortality include coma, hemorrhage on the admission head CT scan, malignancy, male
gender, age greater than 37 years, mental status changes,
thrombosis of a deep cerebral vein, and a concurrent
central nervous system infection. Patients identified with
these risk factors may benefit from local thrombolysis or
procedures aimed to reduce intracranial pressures (2). In
a retrospective study by Cantu and Barinagarrementeria,
mortality of CVT in pregnancy and puerperium was
found to be significantly less than CVT in other patient
groups. Although the initial symptoms and severity of
illness were similar in both groups, the final outcome was
good in 80% of patients with obstetric etiologies compared with 58% of patients with other causes. The mortality rates were 9% and 33%, respectively (10).
Cerebral venous thrombosis is a rare, but potentially
fatal condition that may be easily dismissed as a simple

293

headache. The diagnosis should be considered in women
with any neurological symptoms during pregnancy or
puerperium. Awareness of risk factors and common presenting symptoms will help identify patients who require
neuroimaging and who may benefit from the prompt
administration of anticoagulation or thrombolysis.

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