Postpartum dissecting aneurysm of the basilar artery

Pregnancy as a Subgroup in the Pathophysiologic Classification of Spinal Aneurysms

BACKGROUND

Aneurysms of spinal arteries not associated with any known predisposing condition are referred to as isolated spinal aneurysms (SAs). In our series, an SA was found in 2 patients during the postpartum period. The goal of this study is to determine whether an occurrence of an SA may be related to puerperium.

METHODS

In a retrospective analysis of our consecutive series of 10 cases of SAs from 2008 to 2020, we identified 2 cases of SAs during puerperium. Patients' charts and imaging were reviewed, for potential predisposing factors.

RESULTS

In both cases, angiography showed fusiform aneurysms of the anterior SA with concomitant bilateral vertebral artery (VA) dissections. Serum vasculitis and inflammatory panel and genetic testing for collagen disorders were negative in both cases. Review of the literature showed that pregnancy is associated with an increased risk of arterial dissections in various locations and supports the hypothesis that hemodynamic and hormonal changes may play a role in the formation of SAs.

CONCLUSIONS

Pregnancy and peripartum state may be a distinct cause of the formation of SAs, possibly as a result of increased hemodynamic stress and hormonal changes that may alter the arterial wall. It would be appropriate to add pregnancy as a subgroup in the classification of SAs. In our series, both cases were associated with bilateral VA dissections; it is possible that the bilateral VA stenosis may have contributed to the formation of the SAs. It is important to recognize this possibility when considering the occlusion of a dissected VA.

Dissecting intracranial aneurysm in pregnancy: A rare association

We report a case of dissecting aneurysm of the right posterior cerebral artery presenting with sudden onset headache and altered behavior during labor. A 26-year-old P1001 with uncomplicated antenatal period, except history of headache off and on since 32 weeks of pregnancy, developed sudden onset headache and altered behavior during 3^rd stage of labor. She had vaginal delivery and a live born male baby was delivered with good Apgar score. The CT was suggestive of subarachnoid hemorrhage and DSA was suggestive of dissecting aneurysm of the right P2 segment with hypoplasia of right P1 segment and A1 segment of posterior and anterior cerebral artery, respectively. The patient was managed conservatively. At 4-month follow-up, the patient was doing well. We discuss about the rare association of a dissecting aneurysm and pregnancy, especially dissection of the posterior cerebral artery.

Postpartum vertebral artery dissection with posterior reversible encephalopathy syndrome

We diagnosed postpartum eclampsia with posterior reversible encephalopathy syndrome (PRES) in a 35-year-old woman who began experiencing headaches after delivery. Cervical MR angiography (MRA) suggested concomitant vertebral artery (VA) dissection. Antiplatelet therapy was not indicated. Each episode resolved spontaneously. The patient subsequently developed sudden onset of thunderclap headache. She experienced a tonicoclonic seizure in the outpatient clinic. On the basis of clinical course and MRI, we diagnosed postpartum eclampsia with PRES. Antiplatelet therapy was not indicated, as there were no signs of stroke. Antiepileptic and antihypertensive medicines were used for a short term to control seizure and blood pressure. Subsequent MRI 17 days after discharge showed resolution of the abnormal signals, but the intramural heme signals became apparent on the dissecting segment of VA. Subsequent MRI after 3 months indicated resolution of arterial dissection. To the best of our knowledge, this represents the third report of postpartum cervicocephalic artery dissection with PRES in the literature.

Motor Vehicle Accidents: the Most Common Cause of Traumatic Vertebrobasilar Ischemia

Background:

Recent media exposure of strokes from chiropractic manipulation have focused attention on traumatic vertebrobasilar ischemia. However, chiropractic manipulation, while the easiest cause to recognize, is probably not the most common cause of this condition.

Methods:

We reviewed all consecutive cases of traumatic vertebrobasilar ischemia referred to a single neurovascular practice over 20 years, from the office files and hospital records.

Results:

There were 80 patients whose vertebrobasilar ischemia was attributed to neck trauma. Five were diagnosed as due to chiropractic manipulation, but the commonest attributed cause was motor vehicle accidents (MVAs), which accounted for 70 cases; one was a sports injury, and five were industrial accidents. In some cases neck pain from an MVA led to chiropractic manipulation, so the cause may have been compounded. In most vehicular cases the diagnosis had been missed, even denied, by the neurologists and neurosurgeons initially involved. The longest delay between the injury and the onset of delayed symptoms was five years.

Conclusions:

Traumatic vertebrobasilar ischemia is most often due to MVAs; the diagnosis is often missed, in part because of the delay between injury and onset of symptoms and, in part, we hypothesize, because of reluctance of doctors to be involved in medicolegal cases.

Acute vertebrobasilar occlusion: current treatment strategies

Acute vertebrobasilar occlusion (VBO) remains a disease with a high mortality. Local intraarterial fibrinolysis (LIF) can reduce the mortality rate from about 90 to 60%. The combined therapy of i.v. Abciximab and i.a. rt-PA with additional PTA/stenting may improve neurological outcome and significantly reduce mortality, despite an increase of overall bleeding complications. Additional PTA/stenting is an important treatment factor in cases of atherothrombotic occlusion. In embolic occlusions, mechanical catheter devices, such as basket or snare devices or rheolytic systems, are promising therapies for the near future. This article describes diagnostic criteria and treatment factors in acute VBO. Different treatment strategies, such as i.v. and i.a. fibrinolysis, adjunctive application of GP IIb/IIIa inhibitors, PTA/stenting and mechanical embolectomy are addressed in detail.

Atypical postpartum stroke presenting as opalski syndrome: case report and review of the literature

Background and Purpose

We present the first case of combined arterial (vertebral artery dissection) and venous [central sinus vein thrombosis (CSVT)] diseases presenting as Opalski syndrome in a female patient following induced delivery.

Case Description

A 32-year-old woman was admitted to our institute two weeks after induced delivery with intriguing neurological findings that were finally diagnosed as a combined venous-arterial disease. Although she was referred diagnosed with CSVT, her neurological findings indicated Wallenberg ‘plus’ syndrome with ipsilateral hemiparesis (Opalski syndrome), further confirmed by neuroimaging revealing arterial disease (vertebral artery dissection) combined with incidental acute CSVT. Coagulation, gynecological and cardiac problems were ruled out. Treatment consisted of continuous heparin with rigorous control of her blood pressure. Nine days later, the patient was discharged with prominent improvements. Most of the symptoms resolved following 3 months of rehabilitation.

Conclusions

Atypical strokes (such as Opalski syndrome) might present in postpartum patients. This rare diagnosis should be suspected in patients with Wallenberg ‘plus’ syndrome, and neuroimaging studies for determining the presence of arterial disease and brain stem lesions should be performed. Concomitant CSVT is rare and might mislead. Fine diagnosis followed by immediate conservative treatment can be of great benefit.

Intracranial vertebrobasilar artery dissection associated with postpartum angiopathy

Background. Cervicocephalic arterial dissection (CCAD) is rare in the postpartum period. To our knowledge this is the first reported case of postpartum angiopathy (PPA) presenting with ischemic stroke due to intracranial arterial dissection. Case. A 41-year-old woman presented with blurred vision, headache, and generalized seizures 5 days after delivering twins. She was treated with magnesium for eclampsia. MRI identified multiple posterior circulation infarcts. Angiography identified a complex dissection extending from both intradural vertebral arteries, through the basilar artery, and into both posterior cerebral arteries. Multiple segments of arterial dilatation and narrowing consistent with PPA were present. Xenon enhanced CT (Xe-CT) showed reduced regional cerebral blood flow that is improved with elevation in blood pressure. Conclusion. Intracranial vertebrobasilar dissection causing stroke is a rare complication of pregnancy. Eclampsia and PPA may play a role in its pathogenesis. Blood pressure management may be tailored using quantitative blood flow studies, such as Xe-CT.

Dissecting aneurysms limited to the basilar artery: report of two cases and review of the literature

Spontaneous dissecting aneurysms limited to the basilar artery are rare. We describe two patients who presented to our institution with different clinical problems, one with brain stem infarction and the other with subarachnoid hemorrhage. We describe the clinical and imaging features in these patients, their treatment, and outcome. We also reviewed the literature concerning this entity, and we have identified 32 patients (including our two patients) with angiographically confirmed dissecting aneurysms limited to the basilar artery. Of these, 40.6% presented with brain stem infarction, 50.0% presented with subarachnoid hemorrhage, and 9.4% presented with both infarction and subarachnoid hemorrhage. Patients who presented with basilar artery dissecting aneurysms and brain stem infarction tended to be younger (mean age, 38 +/- 7 years) than those who presented with subarachnoid hemorrhage (48 +/- 12 years) and were more likely to be male. We discuss the natural history of this entity and suggest an approach to clinical management for these patients.

Postpartum dissecting aneurysm of the posterior cerebral artery

Intracranial dissecting aneurysm may cause subarachnoid hemorrhage (SAH) or infarction, and postpartum dissecting aneurysm is rare. A 30-year-old 6 days postpartum woman presented with posterior cerebral artery (PCA) dissection evolving dramatically over a short period. She had been well until 6 days after delivery when she suffered sudden onset of headache, vomiting, and unconsciousness. CT scan demonstrated SAH and digital subtraction angiography (DSA) revealed a fusiform dilatation of the left PCA (P3/P4 segment). The initial diagnosis was ruptured dissecting aneurysm, and conservative management was recommended in the acute period. DSA showed smoothening of the vascular wall 6 days after onset, and obliteration of the left P3/P4 segment was observed 13 days after onset. She was discharged without neurological deficits 26 days after onset. Postpartum SAH due to dissecting aneurysm of the PCA is rare, but should be considered in the differential diagnosis of postpartum headache.

Basilar artery dissection

Object. Little is understood about the clinical manifestations of basilar artery (BA) dissections, which can present with subarachnoid hemorrhage (SAH), brainstem compression, or ischemia. In any instance, the prognosis seems poorer than that for vertebral artery (VA) dissection. The authors analyzed clinical presentations and radiological features of BA dissection with and without rupture.

Methods. Between 1998 and 2003, the authors treated 10 patients (eight men and two women, ranging in age from 32–78 years; mean age 54 years) with BA dissection. Diagnosis was based on clinical and radiological findings, including those from magnetic resonance imaging and cerebral angiography studies.

Of the 10 patients, five had impaired consciousness at disease onset. Among four patients presenting with SAH, two were treated conservatively and had fair outcomes without recurrent hemorrhage. The other two patients with SAH were treated using unilateral endovascular VA occlusion, but one of them subsequently suffered fatal rebleeding. A fifth patient presented with progressive signs of a mass involving the brainstem, whereas the remaining five patients showed brainstem ischemia; all were treated conservatively. Four patients could not return to their previous daily activities.

Conclusions. Basilar artery dissections are rare lesions associated with significant morbidity and death. The natural course of and the treatment options for BA dissection differ considerably from those for VA dissections. Management of these lesions is controversial and difficult, and requires particular care.

Emergency department presentation of bilateral carotid artery dissections in a postpartum patient

Spontaneous unilateral postpartum carotid arterial dissection is a rarely reported event. This is the first reported case of bilateral carotid artery dissection. A 35-year-old gravida 4, para 3 woman presented to our emergency department with complaint of headache for 3 days. Medical history included delivery of a full-term infant by cesarean section 9 days before presentation because of arrest of descent after 3 hours of pushing. Symptoms were later attributed to a parietal lobe cerebral vascular accident and bilateral internal carotid artery dissection. Physicians should consider the possibility of arterial dissection in any postpartum patient with unremitting headache when evaluation of typical causes fails to lead to a diagnosis. Appropriate diagnostic evaluation and treatment should be actively pursued in this population.

[Basilar artery dissection: case report]

We report a case of basilar artery dissection. MRI and angiographic study could ascertain the diagnosis.

Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation

STUDY DESIGN

Potential precipitating events and risk factors for vertebrobasilar artery dissection were reviewed in an analysis of the English language literature published before 1993.

OBJECTIVES

To assess the literature pertaining to precipitating neck movements and risk factors for vertebrobasilar artery dissection in an attempt to determine whether the incidence of these complications can be minimized.

SUMMARY OF BACKGROUND DATA

Vertebrobasilar artery dissection and occlusion leading to brain stem and cerebellar ischemia and infarction are rare but often devastating complications of cervical, manipulation and neck trauma. Although various investigators have suggested potential risk factors and precipitating events, the basis for these suggestions remains unclear.

METHODS

A detailed search of the literature using three computerized bibliographic databases was performed to identify English language articles from 1966 to 1993. Literature before 1966 was identified through a hand search of Index Medicus. References of articles obtained by database search were reviewed to identify additional relevant articles. Data presented in all articles meeting the inclusion criteria were summarized.

RESULTS

The 367 case reports included in this study describe 160 cases of spontaneous onset, 115 cases of onset after spinal manipulation, 58 cases associated with trivial trauma, and 37 cases caused by major trauma (3 cases were classified in two categories). The nature of the precipitating trauma, neck movement, or type of manipulation that was performed was poorly defined in the literature, and it was not possible to identify a specific neck movement or trauma that would be considered the offending activity in the majority of cases. There were 208 (57%) men and 158 (43%) women (gender data not reported in one case) with an average age of 39.3 +/- 12.9 years. There was an overall prevalence of 13.4% hypertension, 6.5% migraines, 18% use of oral contraception (percent of female patients), and 4.9% smoking. In only isolated cases was specific vascular disease such as fibromuscular hyperplasia noted.

CONCLUSIONS

The literature does not assist in the identification of the offending mechanical trauma, neck movement, or type of manipulation precipitating vertebrobasilar artery dissection or the identification of the patient at risk. Thus, given the current status of the literature, it is impossible to advise patients or physicians about how to avoid vertebrobasilar artery dissection when considering cervical manipulation or about specific sports or exercises that result in neck movement or trauma.

Dissecting aneurysms of the basilar artery

Ten patients (six men and four women; mean age, 40 yr) with spontaneous dissection of the basilar artery are reported. Clinically, six were admitted with subarachnoid hemorrhage (SAH) and four were admitted with brain stem ischemia. Angiography demonstrated string sign in four patients, pearl reaction in four, double lumen in one, and arterial ectasia with mural retention of contrast medium in one. Magnetic resonance imaging was performed in two patients. Follow-up angiograms or magnetic resonance angiography in six patients showed spontaneous healing in two patients, improvement in two, progression in one, and no change in one. Nine patients were treated medically, and one underwent selective intravascular occlusion of the dissecting aneurysm. One patient died after further SAH, two remain severely disabled, three have residual neurological deficit, and four are in good clinical condition. The most interesting observations in this series include a relatively good course in a substantial number of patients and low further bleeding potential after SAH, the late "globular" evolution, which may be favorable for reconstructive treatment, and the diagnostic value of associated computed tomographic/angiographic findings. Surgical options in basilar dissection are very poor; in some reported cases, wrapping has been tried with disappointing results. In light of the possibility of spontaneous healing or improvement, wrapping should be reserved for only those patients with recurrent SAH or angiographic progression of the dissection.