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Sano K, Kuge A, Kondo R, Yamaki T, Homma H, Saito S, Sonoda Y. Postpartum reversible cerebral vasoconstriction with cortical subarachnoid hemorrhage and posterior reversible encephalopathy syndrome concomitant with vertebral artery dissection diagnosed by
MRI MSDE
method: A case report and review of literature. Clin Case Rep 2022; 10:e6257. [PMID: 36110331 PMCID: PMC9465692 DOI: 10.1002/ccr3.6257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 05/11/2022] [Accepted: 08/01/2022] [Indexed: 11/05/2022] Open
Abstract
Headache is one of the most common symptoms encountered during the postpartum period. The cause may be unknown, or the following illnesses are possible: cervical artery dissection (CAD), reversible posterior cerebral encephalopathy syndrome (PRES), and reversible cerebral vasoconstrictor syndrome (RCVS). It is suggested that they are interrelated and share a similar mechanism such as small vessel endothelial dysfunction, deficiencies in self‐regulation, and decreased sympathetic innervation of the posterior circulation. However, there are few reports of neuroradiological findings. We experienced a rare case of multiple postpartum vascular disease occurring at the same time. A 38‐year‐old woman suddenly developed thunderclap headache after giving birth. She was clear and had no neuropathy. Computed tomography revealed subarachnoid hemorrhage, including the cortical surface of the frontal lobe. Magnetic resonance image fluid‐attenuated inversion recovery revealed high‐intensity area in the bilateral basal ganglia and right occipital cortex. Angiography showed “string sausage” and extracranial left vertebral artery stenosis, but no aneurysm. Based on the clinical course and neuroradiological findings, we diagnosed her as postpartum vascular disease including CAD, PRES, RCVS, and cortical subarachnoid hemorrhage (SAH). Three‐dimensional black blood T1‐weighted images using a motion‐sensitized driven equilibrium three‐dimensional turbo spin echo (MSDE) sequencing method revealed an intramural hematoma consistent with the extracranial vertebral artery. After 3 months, MSDE lost its abnormal signal. Our case was rare in that multiple phenomena of postpartum vascular disease occurred at the same time. In particular, we could reveal that this speculation was reversible in the MRI MSDE sequencing.
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Affiliation(s)
- Kenshi Sano
- Department of Neurosurgery Yamagata City Hospital Saiseikan Yamagata Japan
| | - Atsushi Kuge
- Department of Neurosurgery Yamagata City Hospital Saiseikan Yamagata Japan
- Department of Emergency Medicine Yamagata City Hospital Saiseikan Yamagata Japan
| | - Rei Kondo
- Department of Neurosurgery Yamagata City Hospital Saiseikan Yamagata Japan
| | - Tetsu Yamaki
- Department of Neurosurgery Yamagata City Hospital Saiseikan Yamagata Japan
| | - Hiroshi Homma
- Department of Neurosurgery Yamagata City Hospital Saiseikan Yamagata Japan
| | - Shinjiro Saito
- Department of Neurosurgery Yamagata City Hospital Saiseikan Yamagata Japan
| | - Yukihiko Sonoda
- Department of Neurosurgery Yamagata University, School of Medicine Yamagata Japan
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Abstract
PURPOSE To provide updated evidence-based recommendations for the evaluation and treatment of primary and secondary headaches in pregnancy and postpartum. TARGET POPULATION Pregnant and postpartum patients with a history of or experiencing primary or new secondary headaches. METHODS This guideline was developed using an a priori protocol in conjunction with a writing team consisting of two specialists in obstetrics and gynecology appointed by the ACOG Committee on Clinical Practice Guidelines-Obstetrics and one external subject matter expert. ACOG medical librarians completed a comprehensive literature search for primary literature within Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements. RECOMMENDATIONS This Clinical Practice Guideline includes recommendations on interventions to prevent primary headache in individuals who are pregnant or attempting to become pregnant, postpartum, or breastfeeding; evaluation for symptomatic patients presenting with primary and secondary headaches during pregnancy; and treatment options for primary and secondary headaches during pregnancy and lactation. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence.
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Kalashnikova LA, Danilova MS, Gubanova MV, Dobrynina LA. [Cervical artery dissection in women: relationships with pregnancy and postpartum period]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:7-12. [PMID: 34874648 DOI: 10.17116/jnevro20211211017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To study the frequency of CeAD that developed during pregnancy or in post partum period among all CeADs in women; to study the course of pregnancy in women with prior CeAD. MATERIAL AND METHODS 162 women (mean age 37.1±4.1 years) with CeAD we examined at the Research Center of Neurology (Moscow), 98% women were studied during last 15 years. 140 women were of childbearing age (≤45 years, mean age - 35±2.8 years). All patients were interviewed whether or not CeAD occurred during pregnancy or in post partum period (CeADPPP). Obstetric history before and after CeAD was studied in 57 women of childbearing age (average age - 35.9±7.3 years at CeAD development). RESULTS CeADPPP developed in 6 out of 162 all female patients (3.7%) or of 140 childbearing age patients (4.3%). It occurred 2-6 months (4 patients) and 10 days after delivery (1 patient), or on the 25th week of pregnancy (1 patient). CeADPPP patients were younger than patients with CeAD out of pregnancy or postpartum period (29.8±8 years vs 35.1±6.7 years, p>0.05). CeADPPP in comparison with CeAD outside these periods more often involved internal carotid artery (ICA) (50% vs 35%, p=0.666), more often occurred in 2-3 arteries (50% vs 31%, p=0.386) and more often was accompanied by dissecting aneurysm development (50% vs 8%, p=0.013). After CeAD, 18 out of 57 patients in whom obstetric history was studied, including 3 patients with postpartum dissection had 29 pregnancies. The pregnancy outcomes were as follows: childbirth (17 pregnancies, 59%), fetal loss (8 pregnancies, 27%) and medical abortion (4 pregnancies, 14%). Delivery occurred on average 4.5±2.061 years after CeAD in women aged 33.0±4.25 years (cesarean section - 15 patients). Fetal loss occurred at 7.4±3.5 weeks of pregnancy in women aged 37.6±3.13 years on average 2.7±1.4 years after CeAD. Fetal loss frequency after CeAD was higher than before it (27% vs 7%, p=0.016). There were no CeAD recurrences during pregnancy and postpartum period in women who had previously undergone CeAD. CONCLUSION CeADPPP frequency among all dissections in women is 3.7-4.3%. The risk of CeAD recurrence during pregnancy or the postpartum period after prior CeAD is very low. The risk of fetal loss during 2.7±1.4 years after CeAD is higher than before it (27% vs 7%). Hormonal and growth factors associated with pregnancy and the postpartum period is suggested to contribute to cervical artery wall damage. It is possible that the prolonged action of some of these factors may disrupt the placental vessels formation, predisposing to miscarriage.
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Ruan CY, Gao BL, Pang HL, Zhang K, Zhang YH, Wei LP, Li TX, Wang ZL. Postpartum cerebral arterial dissections: Clinical features and treatment. Medicine (Baltimore) 2021; 100:e27798. [PMID: 34964745 PMCID: PMC8615341 DOI: 10.1097/md.0000000000027798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 10/26/2021] [Indexed: 11/26/2022] Open
Abstract
Postpartum cerebral arterial dissections are rare, and the clinical features, diagnosis, and treatment approaches are not clear to many physicians. This study was to investigate the clinical features, diagnosis, and treatment of postpartum cerebral arterial dissections.One patient with postpartum cerebral arterial dissections enrolled in our hospital was analyzed. All patients with postpartum cerebral arterial dissections retrieved from the PubMed were also included in this study and analyzed.A total of 45 patients with postpartum cerebral arterial dissections were retrieved including our case, with an age range of 24 to 44 years (mean 34). Thirty-six (80%) patients were older than 30 years of age (mean 35). There were 17 cases of cesarean section, 14 cases of natural labor, and 14 cases whose delivery modes were not reported. The clinical symptoms included headache in 35 cases (78%) and neck pain in 14 (31%). The symptoms occurred at a mean time of 11 days (range 0-53 days) following delivery. Among 45 patients, arterial dissections involved unilateral carotid or vertebral artery in 29 cases (64%), bilateral carotid or vertebral arteries in 8 (18%), 3 arteries in 3 (7%), and all bilateral carotid and vertebral arteries in 5 (11%). Fourteen (31%) patients were treated with antiplatelet agents, 27 (60%) with anticoagulation, 7 (16%) with both antiplatelet and anticoagulation medications, and only 2 (4%) with stent angioplasty. The prognosis was complete recovery in 30 (86%) patients and mild focal neurological symptoms in 5 (14%).Postpartum cerebral arterial dissections are rare, and correct diagnosis relies on imaging examination. Prognosis is usually favorable in patients with early diagnosis and prompt treatment.
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Affiliation(s)
- Chun-Yun Ruan
- Luoyang Central Hospital, Zhengzhou University, China
| | - Bu-Lang Gao
- Henan Provincial People's Hospital, Zhengzhou University, China
| | - Hong-Li Pang
- Luoyang Central Hospital, Zhengzhou University, China
| | - Kun Zhang
- Henan Provincial People's Hospital, Zhengzhou University, China
| | - Yao-Hui Zhang
- Luoyang Central Hospital, Zhengzhou University, China
| | - Li-Ping Wei
- Luoyang Central Hospital, Zhengzhou University, China
| | - Tian-Xiao Li
- Henan Provincial People's Hospital, Zhengzhou University, China
| | - Zi-Liang Wang
- Henan Provincial People's Hospital, Zhengzhou University, China
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Manasewitsch NT, Hanfy AA, Beutler BD, Antwi-Amoabeng D, Taha M, Elnaggar M, Chahal GS. Postpartum vertebral artery dissection: case report and review of the literature. Thromb J 2020; 18:30. [PMID: 33292273 PMCID: PMC7597033 DOI: 10.1186/s12959-020-00243-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 10/22/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Hypertensive disorders of pregnancy are associated with vascular complications, including ischemic stroke and cervical artery dissection. Vertebral artery dissection (VAD), however, is rare. We describe a 31-year-old female who presented with vertigo, nausea, and vomiting and was found to have a VAD. In addition, we discuss the presentation, differential diagnosis, and pathogenesis of this uncommon but clinically significant vascular event and summarize other cases of vertebral artery dissection described in the medical literature. CASE PRESENTATION A 31-year-old Hispanic woman presented 10 days postpartum with a one-day history of vertigo, nausea, vomiting, and frontal headache. The patient's pregnancy course had been complicated by preeclampsia, chorioamnionitis, and iron-deficiency anemia, and her delivery was complicated by acute hemorrhage. Physical examination was significant for left leg ataxia. Laboratory studies showed marked thrombocytosis. Emergent computed tomography (CT) scan of the head was obtained and revealed a left cerebellar ischemic large vessel stroke. Subsequent CT angiography of the head and neck showed a left VAD. Based on correlation of the clinical history and laboratory and imaging findings, a diagnosis of vertebral artery dissection secondary to reactive (secondary) thrombocytosis from overlapping iron-deficiency anemia and acute hemorrhage was established. The patient was started on a heparin infusion and experienced significant improvement after a four-day hospitalization. CONCLUSION VAD is a rare but important cause of neurologic symptoms in the postpartum period and should be considered in the differential diagnosis for women who present with headache and/or vertigo. Women aged 30 years or older and those with a history of a hypertensive disorder of pregnancy are at particularly high risk. Prompt diagnosis and management of VAD is essential to ensure favorable outcomes.
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Affiliation(s)
- Nicholas T Manasewitsch
- Department of Internal Medicine, University of Nevada, Reno School of Medicine, 1155 Mill Street, W-11, Reno, NV, 89052, USA
| | - Ahmed A Hanfy
- Department of Internal Medicine, University of Nevada, Reno School of Medicine, 1155 Mill Street, W-11, Reno, NV, 89052, USA
| | - Bryce D Beutler
- Department of Internal Medicine, University of Nevada, Reno School of Medicine, 1155 Mill Street, W-11, Reno, NV, 89052, USA.
| | - Daniel Antwi-Amoabeng
- Department of Internal Medicine, University of Nevada, Reno School of Medicine, 1155 Mill Street, W-11, Reno, NV, 89052, USA
| | - Moutaz Taha
- Department of Internal Medicine, University of Nevada, Reno School of Medicine, 1155 Mill Street, W-11, Reno, NV, 89052, USA
| | - Mohamed Elnaggar
- Department of Internal Medicine, University of Nevada, Reno School of Medicine, 1155 Mill Street, W-11, Reno, NV, 89052, USA
| | - Gurpreet S Chahal
- Department of Internal Medicine, University of Nevada, Reno School of Medicine, 1155 Mill Street, W-11, Reno, NV, 89052, USA
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Katsevman GA, Turner RC, Cheyuo C, Rosen CL, Smith MS. Post-partum posterior reversible encephalopathy syndrome requiring decompressive craniectomy: case report and review of the literature. Acta Neurochir (Wien) 2019; 161:217-224. [PMID: 30659351 DOI: 10.1007/s00701-019-03798-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 01/04/2019] [Indexed: 10/27/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is an uncommon but potentially devastating syndrome if not recognized and treated appropriately. As the name implies, recognition of the condition and proper management may reverse the clinical and radiological findings. However, diagnosis is not always straightforward. We present the case of a 24-year-old female who was 4 days post-partum and presented with headache, neck pain, and new-onset seizures. She had undergone epidural anesthesia during labor, and initial imaging was suggestive of intracranial hypotension versus pachymeningitis. Despite initial conservative therapy including anti-epileptic drugs, magnesium therapy, empiric antibiotics, and Trendelenburg positioning, the patient continued to deteriorate. Follow-up imaging was suggestive of PRES with signs of intracranial hypertension. The patient underwent a decompressive suboccipital craniectomy for refractory and severe PRES and later fully recovered. This case highlights the sometimes difficult diagnosis of PRES, possible association with pregnancy, eclampsia/preeclampsia and/or cerebrospinal fluid drainage, and the rare but life-saving need for decompression in severe cases.
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Harsha K, Parameswaran K. Is cervicocephalic dissection a part “postpartum vasculopathy” spectrum? A case of postpartum posterior reversible encephalopathy syndrome, bilateral petrous carotid artery dissections, and stroke. Neurol India 2016; 64:1305-1307. [DOI: 10.4103/0028-3886.193794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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