Clinical Reasoning: A 33-year-old woman with severe postpartum occipital headaches

Abstract

A 33-year-old woman with history of occasional “migraines” complained of severe occipital headache, following an uncomplicated full-term vaginal delivery under epidural anesthesia. This headache was qualitatively and quantitatively different from her usual headaches. The diagnosis of low intracranial pressure headache related to inadvertent dural puncture was considered and 2 epidural autologous blood patches were performed with no relief. One week postpartum she presented to an outside hospital with complaints of poor concentration, difficulty in finding words, getting dressed, and feeding herself, and left arm numbness. Examination showed a blood pressure of 179/119 mm Hg, poor attention span, apraxia, and decreased sensation in the left hand. General physical examination was unrevealing. Head MRI (day 0) showed fluid-attenuated inversion recovery (FLAIR) hyperintensities (figure 1, A and B) and diffusion restriction with positive apparent diffusion coefficient (ADC) map (figure 1, C and D) in the right parietal lobe and in the splenium of the corpus callosum. The diagnosis of posterior reversible encephalopathy syndrome (PRES) was entertained and the patient was treated for that condition with the antihypertensive agents nifedipine and lisinopril. The patient's condition deteriorated. On the third hospital day, she became cortically blind and mute, and had motor perseverations and left-sided weakness. Repeat head MRI showed marked worsening with lesions involving the cortex and subcortical white matter of the parietal, posterior frontal, and occipital lobes, bilaterally (figure 1, bottom panel). Figure 1 Head MRI axial cuts: Fluid-attenuated inversion recovery (FLAIR) (A, B, E, F) and apparent diffusion coefficient map (C, D, G, H) sequences Upper panel MRI, performed on admission, showed FLAIR hyperintensities and diffusion restriction in the right parietal lobe and in the splenium of the corpus callosum (arrows). Lower panel, done on hospital day 3 when the patient deteriorated, showed worsening lesions involving the cortex and subcortical white matter of the parietal, posterior frontal, and occipital lobes, bilaterally (arrows). ### Question for consideration: 1. What is the differential diagnosis? The differential diagnosis of multifocal infarcts in …