Surgical treatment of space occupying edema and hemorrhage due to cerebral venous thrombosis during pregnancy.

Background: During late pregnancy and the puerperium cerebral venous and sinus thrombosis (CVST) is a rare but important cause of stroke. Despite adequate anticoagulation some patients deteriorate, which may warrant the use of more aggressive treatment modalities.

Case Report: A 29-year-old pregnant woman (29th week of pregnancy) presented with diffuse headaches and a progressive left hemiparesis. MRI revealed a CVST involving the superior sagittal sinus, the left lateral sinus, and the rectal sinus. Furthermore, it showed a space occupying brain edema and a congestional bleeding within the frontal and parietal lobes on the right side. Despite immediate intravenous anticoagulation and treatment with mannitol the patient developed a progressive loss of consciousness and unilateral third nerve palsy as a result of a beginning transtentorial herniation. Due to the severe course of the CVST an urgent decompressive craniectomy and shortly thereafter a cesarean section were performed. The patient made an excellent recovery.

Conclusion: While previous reports have demonstrated the feasibility of decompressive hemicraniectomy in selected patients with CVST and beginning herniation due to space occupying brain edema, venous infarction and congestional bleeding with mass effect, our rare case supports the notion that this procedure can also be life-saving in pregnant women.