Post-Partum Seizure Management

Diagnostic Approach

The American Heart Association recommends distinguishing between post-ictal paralysis, seizure secondary to cerebral venous thrombosis (CVT), and eclampsia in postpartum women with seizures 1
CVT must be urgently excluded given the postpartum timing and high mortality risk, with a 5-20 times higher risk of CVT in postpartum women 1
The presence of ipsilateral dural thickening and enhancement on MRI may indicate isolated cortical vein thrombosis 1

MRI with venography (MRV) is mandatory to exclude CVT, as plain MRI can miss isolated cortical vein thrombosis 1
CT venography or MR venography should be performed immediately to exclude CVT 1
Digital subtraction angiography (DSA) is indicated if venographic studies are inconclusive but clinical suspicion remains high 1
Interictal EEGs are typically normal in syncope but abnormal in epilepsy, with a diagnostic yield of 51% for EEG obtained within 24 hours of the seizure 3

The American Heart Association/American Stroke Association guidelines recommend immediate anticoagulation with heparin even in the presence of hemorrhagic transformation if CVT is confirmed 2
Therapeutic anticoagulation should be initiated and continued despite intracranial hemorrhage, as the benefits outweigh risks in CVT 2
Antiepileptic therapy with levetiracetam should be started if CVT is confirmed, with a loading dose followed by maintenance 2, 1
If hypocalcemia is identified, calcium and vitamin D supplementation should be initiated immediately, as hypocalcemic seizures may resolve with supplementation alone 4

Antiplatelet agents are NOT indicated in this clinical scenario, as they are used for atherosclerotic cerebrovascular disease, not for seizure disorders 5
If CVT is confirmed, anticoagulation (not antiplatelet therapy) is required 2, 1

Do not dismiss this as simple post-ictal weakness without excluding CVT, as delayed diagnosis carries significant mortality 1
Plain MRI can miss isolated cortical vein thrombosis; venographic imaging is mandatory 1
The combination of postpartum status, seizure, and focal neurological deficit is CVT until proven otherwise 1
Dural enhancement on MRI may be misinterpreted as post-lumbar puncture syndrome when it actually indicates CVT 1
Do not withhold anticoagulation in CVT even if hemorrhage is present 2