Pneumocephalus-Induced Seizure Following Epidural Anesthesia in Labor: A Case Report

Background Pneumocephalus is a rare but serious complication of epidural anesthesia in which air enters the central nervous system and is associated with a spectrum of neurological presentations. We report a case of pneumocephalus-induced seizure following accidental dural puncture during labor epidural placement, resulting in acute maternal neurological compromise and concomitant fetal distress. Case Presentation A 29-year-old woman, G4P2012, with no history of seizures, epilepsy, or hypertensive disorders of pregnancy, presented at 40 weeks and 4 days in active labor. Epidural anesthesia was placed using the loss-of-resistance-to-air technique; dural puncture was noted at the time of placement. Eight hours later, she was found unresponsive with right gaze deviation, fecal incontinence, and inability to follow commands. Fetal decelerations were simultaneously identified. She was fully dilated. Non-contrast head computed tomography (CT) demonstrated periventricular pneumocephalus and extensive epidural air throughout the visualized spinal column. While in the imaging suite, her mental status began to improve. She was transferred to the delivery suite, where she achieved spontaneous vaginal delivery while still in a post-ictal state. Mental status returned to baseline approximately two hours after the initial event. Four hours after the acute neurological event, she developed a positional frontal headache radiating to the neck. Levetiracetam was initiated for seizure prophylaxis. Repeat head CT on postpartum day 1 demonstrated resolving pneumocephalus, and routine electroencephalogram (EEG) on postpartum day 2 was normal. At two-week follow-up, the patient denied any recurrent seizure activity, and neurological examination was normal. Conclusions Pneumocephalus should be considered in the differential diagnosis of peripartum seizure and acute neurological deficit, particularly following epidural placement complicated by dural puncture. Notably, the classic thunderclap headache was absent in this case. Prompt cranial imaging and high-flow oxygen therapy are warranted even without this hallmark symptom. As pneumocephalus is self-limited, long-term antiseizure medication is unlikely to be necessary.