Reversible cerebral vasoconstriction syndrome with limb myoclonus following intravenous administration of methylergometrine

Atypical presentation of subdural block resulting in Horner's syndrome and loss of consciousness

Horner's syndrome is a rare side effect for patients receiving epidural anaesthesia. Studies described Horner's syndrome due to cephalic spread of injected anaesthetics, a high spinal anaesthesia, or a sign of an inadvertent subdural block. A 31-year-old woman (Gravida 1 Para 0) at 40 weeks and 2 days had a caesarean section secondary to second stage arrest. Fourteen minutes after she received the lidocaine bolus, she became unresponsive with nystagmus, unequal pupils and no pupillary reflex. Head CT and MRI showed no intracranial haemorrhage and 2 hours later, she had spontaneous resolution of neurological symptoms with no further sequelae. Although Horner's syndrome is a benign, transient process, clinicians should be mindful regarding epidural catheter placement causing subdural blocks resulting in spontaneous, reversible neurological deficits.

Traumatic brain injury in pregnancy

Trauma is the leading cause of nonobstetric maternal mortality and affects up to 8% of all pregnancies. Pregnant patients with traumatic brain injury (TBI) are an especially vulnerable population, and their management is complex, with multiple special considerations that must be taken into account. These include but are not limited to alterations in maternal physiology that occur with pregnancy, potential teratogenicity of pharmacologic therapies and diagnostic studies using ionizing radiation, need for fetal monitoring, Rh immunization status, placental abruption, and preterm labor. Despite these challenges, evidence regarding management of the pregnant patient with a TBI is lacking, limited to only case reports/series and retrospective analyses. Despite this uncertainty, expert opinion on management of these patients seems to be that, overall, the standard therapies for management of TBI are safe and effective in pregnancy, with a few notable exceptions described in this chapter. Significant work is needed to continue to develop best-practice and evidence-based guidelines for the management of TBI pregnancy.

Headache and pregnancy: a systematic review

This systematic review summarizes the existing data on headache and pregnancy with a scope on clinical headache phenotypes, treatment of headaches in pregnancy and effects of headache medications on the child during pregnancy and breastfeeding, headache related complications, and diagnostics of headache in pregnancy. Headache during pregnancy can be both primary and secondary, and in the last case can be a symptom of a life-threatening condition. The most common secondary headaches are stroke, cerebral venous thrombosis, subarachnoid hemorrhage, pituitary tumor, choriocarcinoma, eclampsia, preeclampsia, idiopathic intracranial hypertension, and reversible cerebral vasoconstriction syndrome. Migraine is a risk factor for pregnancy complications, particularly vascular events. Data regarding other primary headache conditions are still scarce. Early diagnostics of the disease manifested by headache is important for mother and fetus life. It is especially important to identify “red flag symptoms” suggesting that headache is a symptom of a serious disease. In order to exclude a secondary headache additional studies can be necessary: electroencephalography, ultrasound of the vessels of the head and neck, brain MRI and MR angiography with contrast ophthalmoscopy and lumbar puncture. During pregnancy and breastfeeding the preferred therapeutic strategy for the treatment of primary headaches should always be a non-pharmacological one. Treatment should not be postponed as an undermanaged headache can lead to stress, sleep deprivation, depression and poor nutritional intake that in turn can have negative consequences for both mother and baby. Therefore, if non-pharmacological interventions seem inadequate, a well-considered choice should be made concerning the use of medication, taking into account all the benefits and possible risks.

Simultaneous cesarean delivery and craniotomy in a term pregnant patient with traumatic brain injury

The management of pregnant patients with traumatic brain injury is challenging. A multidisciplinary team approach is mandatory, and management should be individualized according to the type and extent of injury, maternal status, gestational age, and fetal status. We report a 27-year-old term primigravida presenting after head injury with Glasgow coma scale score 11 and anisocoria. Depressed temporal bone fracture and acute epidural hematoma were diagnosed, necessitating an urgent neurosurgery. Her fetus was viable with no signs of distress and no detected placental abnormalities. Cesarean delivery was performed followed by craniotomy in the same setting under general anesthesia with good outcome of the patient and her baby.

Dramatic intracerebral hemorrhagic presentations of reversible cerebral vasoconstriction syndrome: three cases and a literature review

Reversible cerebral vasoconstriction syndrome (RCVS) refers to a number of disorders characterized by severe and sudden-onset (“thunderclap”) headaches and angiographic features of reversible, segmental, multifocal vasoconstriction of cerebral arteries. Although RCVS generally resolves without significant sequelae, a rare and possibly underrecognized hemorrhagic presentation has a worse potential course. We report three cases of hemorrhagic RCVS and review the literature. Three females (42, 54, and 33 years old, resp.) presented with severe headache, neurological deficits, and dramatic intracerebral hemorrhage (ICH). Patient 1 presented comatose with a 9 × 4 × 6.6 cm left deep intraparenchymal hemorrhage (IPH) and 1 cm midline shift. She underwent emergent surgical intervention. Patient 2 had a 3.3 × 1.5 cm left superior frontal IPH that enlarged to 4 × 2.5 cm within 12 hours with worsening headache and neurological deficits. She was successfully managed nonoperatively. Patient 3, after uncomplicated pregnancy and delivery, presented with a 1.5 cm left superior parietal IPH on postpartum day 7. Two days later, she acutely developed right hemiplegia. Repeat CT demonstrated a new 3.3 × 1.7 cm left frontal IPH. She was also successfully managed nonoperatively. Many diverse conditions are grouped within the category of RCVS. Dramatic ICH remains a rare and possibly underrecognized presenting feature. Prompt diagnosis and management are essential for obtaining the best outcome.