Postpartum Intracranial Thrombus and Hemorrhages: Case Report and Literature Review

Purpose: To report a rare case of postpartum intracranial thrombus and hemorrhages. Methods: Case Report. Introduction: Pregnancy is a state of physiologic hypercoagulability due to multiple factors, including increased estrogen and progesterone resulting in increased fibrinogen, von Willebrand factor, factors VII, VIII, and X, and a decrease in protein S and resistance to protein C. While this hypercoagulability aids the mother by reducing the risk of intrapartum blood loss, it puts the patient at increased risk for venous thromboembolism. Approximately 1 to 2 per 1,000 pregnant women are affected by venous thromboembolic complications. Case Report: A 20-year-old G3P2012 female presented twenty-four days postpartum from a vaginal delivery with a severe headache. Her past medical history was significant for pulmonary embolism (PTE) and deep vein thrombosis (DVT). Hematology had previously noted that she had low protein S (20%) and factor VIII (1%) levels at that time. The headache was on the left side of her head and radiated down her neck for three to four days. It was associated with sudden onset photophobia, left eye vision loss, and altered mental status. She described this headache as the worst headache of her life. Previously, at her three-week postpartum visit, she reported compliance with her enoxaparin 80 mg BID and had no complaints; however, she would report to the emergency department (ED) only ten days later. At the ED, a Computed Tomography (CT) scan of her head without contrast and Computed Tomography Angiography (CTA) scan of her head with contrast were obtained which revealed a left parieto-occipital intraparenchymal hemorrhage, left subarachnoid hemorrhage, small subdural hemorrhage overlying the left tentorium, and complete occlusion of the left transverse sinus concerning for thrombus. She was transferred to a higher level of care. Upon arrival at the Neuro intensive care unit (ICU), the patient remained afebrile with a white blood cell count of 13/mm3. A head Magnetic Resonance Imaging (MRI) without contrast, head Magnetic Resonance Venography (MRV) without contrast, and head CT without contrast were obtained. She was confirmed to have an occlusive proximal left transverse sinus thrombosis without discernable flow within the left sigmoid sinus or internal jugular vein, so a decision was made for a stat venous thrombectomy and cerebral angiogram. She underwent a successful mechanical thrombectomy and angioplasty of the left transverse sinus, sigmoid sinus, and left jugular vein with a nonocclusive clot still present at the conclusion of the procedure. Following the procedure, she was started on a heparin drip and a hypercoagulable workup was initiated which came back with a protein S activity of 9 IU/dL (lower limit of normal 63 IU/dL). Upon further discussions with the patient’s mother, it was also discovered that the patient was not as compliant as previously stated with her enoxaparin postpartum. Throughout her medical stay, she was monitored for acute neurological changes and her anticoagulation medications were switched from heparin drip to apixaban 5 mg BID. When medically stable, the patient was discharged on hospital day six. She presented back to the ED the following day with concerns for confusion, severe headache, and double vision, resulting in a stroke code. CT head without contrast and CTA head with contrast were unchanged since her previous hospitalization. Neurology was concerned about increased intracranial pressure secondary to her left transverse sinus thrombus, so ophthalmology was consulted. Neurology also performed a lumbar puncture, which was notable for an opening pressure of over 55 cm H2O. She was started on acetazolamide 250 mg BID and later increased to 500 mg BID. Ophthalmology did not appreciate any papilledema on physical exam and recommended she follow up outpatient. Hematology was also consulted during this hospitalization and recommended she switch from apixaban 5 mg BID to enoxaparin 1 mg/kg q12h with plans for outpatient transition to direct oral anticoagulant after four to six weeks of enoxaparin. After six days of medical management following her second admission, she was discharged. At thirty-two days following that discharge, she had outpatient follow-up with hematology and was transitioned to apixaban 10 mg BID for seven days then apixaban 5 mg BID indefinitely. She has since been doing well. Conclusions: The hypercoagulable state of pregnancy and puerperium increases the risk for venous thromboembolism five-fold compared to non-pregnant women during pregnancy and thirty to sixty-fold postpartum. In the case of our patient, she had additional risk factors, including protein S deficiency and lack of consistent anticoagulation compliance. This case highlights the importance of evaluating patients for previous personal or family history of blood clots or clotting disorders in order for them to be appropriately managed both throughout pregnancy and puerperium. This case also highlights the importance of close follow-up in the postpartum period, given that approximately half of all pregnancy-associated venous thromboemboli occur postpartum and this risk can remain elevated for up to twelve weeks following delivery.