Recurrent intracranial hemorrhage due to postpartum cerebral angiopathy: implications for management

Subarachnoid hemorrhage: management considerations for COVID-19

Subarachnoid hemorrhage (SAH) has deleterious outcomes for patients, and during the hospital stay, patients are susceptible to vasospasm and delayed cerebral ischemia. Coronavirus disease 2019 (COVID-19) has been shown to worsen hypertension through angiotensin-converting enzyme 2 (ACE2) activity, therefore, predisposing to aneurysm rupture. The classic renin-angiotensin pathway activation also predisposes to vasospasm and subsequent delayed cerebral ischemia. Matrix metalloproteinase 9 upregulation can lead to an inflammatory surge, which worsens outcomes for patients. SAH patients with COVID-19 are more susceptible to ventilator-associated pneumonia, reversible cerebral vasoconstriction syndrome, and respiratory distress. Emerging treatments are warranted to target key components of the anti-inflammatory cascade. The aim of this review is to explore how the COVID-19 virus and the intensive care unit (ICU) treatment of severe COVID can contribute to SAH.

Subarachnoid hemorrhage and COVID-19: Association or coincidence?

ABSTRACT

Some evidences suggest the involvement of the central nervous system in patients infected with SARS-CoV-2. We aim to analyze possible associations between coronavirus disease 2019 (COVID-19) pandemic and spontaneous subarachnoid hemorrhage (SAH), in a comprehensive neurological center.We conducted a retrospective case series of 4 patients infected by COVID-19, who developed spontaneous SAH. Clinical data were extracted from electronic medical records.Between March 24, 2020, and May 22, 2020, 4 cases (3 females; 1 male) of SAH were identified in patients infected with SARS-CoV-2, in a comprehensive neurological center in Brazil. The median age was 55.25 years (range 36 -71). COVID-19-related pneumonia was severe in 3 out of 4 cases, and all patients required critical care support during hospitalization. The patients developed Fisher grade III and IV SAH. Digital subtraction angiography (DSA) was performed in 3 of the 4 patients. However, in only 1 case, an aneurysm was identified. Inflammatory blood tests were elevated in all cases, with an average D-dimer of 2336 μg/L and mean C-reactive protein (CRP) of 3835 mg/dl The outcome was poor in the majority of the patients, with 1 death (25%); 2 (50%) remained severely neurologically affected (mRS:4); and 1 (25%) had slight disability (mRS:2).This study shows a series of 4 rare cases of SHA associated with COVID-19. The possible mechanisms underlying the involvement of SARSCoV-2 and SHA is yet to be fully understood. Therefore, SHA should be included in severe neurological manifestations in patients infected by this virus.

Reversible Cerebral Vasoconstriction Syndrome: A Severe Neurological Complication in Postpartum Period

A 38-year-old woman 12 days after delivery of her second pregnancy was admitted to emergency room for a severe occipital headache started 3 days before, associated with confusion, nausea, vomiting and walking impairment. Neurological examination showed left hemiparesis, hypoesthesia in left arm and leg. Brain computer tomography images showed a large intraparenchymal hematoma in the right frontoparietal lobes with mass effect on adjacent subarachnoid spaces and on lateral ventricle. The third day during hospitalization, the patient experienced a sudden worsening of the neurological symptoms and a severe headache peaking within 1 minute (min); a new brain computed tomography and brain magnetic revealed another small intraparenchymal hematoma in the left parietal lobe with increase of the amount of subarachnoid hemorrhage. Digital subtraction angiography discloses multifocal narrowing of the middle and small arteries in both anterior and posterior circulation with a relative spare of large vessels. Postpartum reversible cerebral vasoconstriction syndrome with intracranial hemorrhage is a rare clinical condition that can be misdiagnosed with other dramatic neurological diseases such as eclamptic encephalopathy, cortical venous thrombosis, primary angiitis of the central nervous system or posterior reversible encephalopathy syndrome with whom may share predisposing factors and neurological presentation but clinical course, treatment and prognosis is quite different and emergency physicians and neurologists should consider this diagnosis in postpartum patients with hemorrhage.

Narrative Review: Headaches After Reversible Cerebral Vasoconstriction Syndrome

PURPOSE OF REVIEW

Reversible cerebral vasoconstriction syndrome (RCVS) is a disorder with distinct features: recurrent thunderclap headaches with reversible vasoconstriction of intracranial arteries. Substantial studies regarding outcomes after RCVS were conducted, showing favorable functional outcomes in most patients despite the potentially life-threatening complications of RCVS, including ischemic stroke, intracranial hemorrhage, or convexity subarachnoid hemorrhage. However, patients may report headaches after the resolution of RCVS while relative studies were scarce.

RECENT FINDINGS

Two prospective studies from different cohorts consistently revealed that RCVS recurred in at least 5% of patients. Patients with prior migraine history and patients whose thunderclap headaches are elicited by sexual activity or exertion are at higher risk for RCVS recurrence. On the other hand, several retrospective studies and case reports reported that chronic headaches are common in RCVS patients after the resolution of acute bouts. The chronic headaches after RCVS are sometimes disabling in certain patients. Headaches after RCVS are not uncommon but usually overseen. Medical attention and examinations are warranted in patient with RCVS who reported recurrence of thunderclap headaches or chronic headaches after RCVS.

Posterior Reversible Encephalopathy Syndrome and Reversible Cerebral Vasoconstriction Syndrome: Clinical and Radiological Considerations

Posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS) are relatively uncommon neurological disorders, but their detection has been increasing mainly due to clinical awareness and spreading of magnetic resonance imaging (MRI). Because these syndromes share some common clinical and radiologic features and occasionally occur in the same patient, misdiagnosis may occur. PRES is characterized by varied neurological symptoms including headache, impaired visual acuity or visual field deficit, confusion, disorders of consciousness, seizures, and motor deficits often associated to peculiar neuroradiological pattern even if uncommon localization and ischemic or hemorrhagic lesions were described. RCVS is a group of diseases typically associated with severe headaches and reversible segmental vasoconstriction of cerebral arteries, often complicated by ischemic or hemorrhagic stroke. Pathophysiological basis of PRES and RCVS are still debated but, because they share some risk factors and clinical features, a possible common origin has been supposed. Clinical course is usually self-limiting, but prognosis may fluctuate from complete recovery to death due to complications of ischemic stroke or intracranial hemorrhage. Neuroradiological techniques such as digital angiography and MRI are helpful in the diagnostic pathway and a possible prognostic role of MRI has been suggested. This review will serve to summarize clinical, neuroradiological features and controversies underlying both syndromes that may mislead the diagnostic pathway and their possible relationship with pathophysiology, clinical course, and prognosis.

Maternal Stroke: an Update

PURPOSE OF THE REVIEW

Maternal morbidity and mortality is rising in the USA, and maternal stroke is a major contributor. Here, we review the epidemiology, risk factors, and current recommendations for diagnosis and acute treatment of ischemic and hemorrhagic stroke during pregnancy and postpartum, focusing on recent evidence.

RECENT FINDINGS

The incidence of maternal stroke has risen in recent years, possibly due to increasing rates of hypertensive disorders of pregnancy. The risk of maternal stroke is highest in the peripartum and early postpartum period. Preeclampsia is highly associated with reversible cerebral vasoconstriction syndrome and posterior reversible encephalopathy syndrome and is also associated with long-term increased risk of stroke and vascular dementia. Hypertensive disorders of pregnancy, migraine, and infections are risk factors for maternal stroke. Limited data suggest that thrombolytics and endovascular reperfusion therapy are safe and effective in pregnant women with ischemic stroke, but few data are available regarding safety of thrombolytics in the postpartum period. New consensus guidelines are now available to assist with management of ischemic and hemorrhagic stroke in pregnancy. Many gaps remain in our understanding of maternal stroke. While risk factors have been identified, there are no prediction tools to help identify which women might be at highest risk for postpartum stroke and require closer monitoring. The risk of recurrent maternal stroke has not been adequately quantified, limiting clinicians' ability to counsel patients. The complex pathophysiology of preeclampsia and its effects on the cerebral vasculature require further targeted study. An increased focus on the prevention, recognition, and optimal treatment of maternal stroke will be critical to reducing maternal morbidity and mortality.

The Impact of Pregnancy on Hemorrhagic Stroke in Young Women

BACKGROUND

Pregnancy is a sex-specific risk factor for causing hemorrhagic stroke (HS) in young adults. Unique physiological characteristics during pregnancy may alter the relative risk for HS in pregnant/postpartum (PP) women compared to HS in other young women. We compared patient characteristics and HS subtypes between young non-pregnant and PP women.

METHODS

We reviewed the medical records of all women 18-45 years old admitted to our center with HS from October 15, 2008 through March 31, 2015, and compared patient characteristics and stroke mechanisms using logistic regression.

RESULTS

Of the 130 young women with HS during the study period, 111 were non-PP women, and 19 PP women. PP women had lower proportions of vascular risk factors such as hypertension, prior stroke, and smoking, and a higher proportion of migraine (36.8 vs. 14.4%, p = 0.01). After adjusting for hypertension, smoking, migraine, prior stroke and prior myocardial infarction, PP women had lower odds of having an underlying vascular lesion (OR 0.14, 95% CI 0.04-0.44, p = 0.0009) and a higher proportion of the reversible cerebral vasoconstriction syndrome (RCVS) as cause of their HS.

CONCLUSIONS

Women with pregnancy-associated HS had fewer cerebrovascular risk factors, lower odds of having -underlying vascular lesions, and higher proportion of -migraine and RCVS compared with similar-aged non--pregnant women. Pregnancy-associated HS appears to represent a unique pathophysiological process, requiring targeted study.

Postpartum reversible cerebral vasoconstriction syndrome: Review and analysis of the current data

Postpartum reversible cerebral vasoconstriction syndrome (PPRCVS) is a rare but serious cause of headache that occurs in the early postpartum period. The rarity of this disorder has limited the current literature to single case reports and small, observational case series. The lack of familiarity with PPRCVS may contribute to mismanagement of these unique patients and lead to poor outcomes. To address current gaps in the understanding of PPRCVS, this review and data analysis characterizes the demographics, presentation, clinical course, management and prognosis of PPRCVS and provides a general review of the epidemiology, pathophysiology and diagnosis to assist clinicians who may care for patients with this rare disorder.

Cerebrovascular emergencies in pregnancy

Caring for pregnant and postpartum patients with neurological disease carries specific challenges. In performing a diagnosis, it is often difficult to differentiate between true pathology and neurological symptoms resulting from normal pregnancy physiology. Treating the pregnant patient can be problematic as well. Providers need to be aware of the possible untoward effects of maternal treatments on the developing fetus, but not withhold therapies that reduce disease-related morbidity and mortality. Given the complexities of conducting trials during pregnancy, few treatments are based on high-quality data; observational data and clinical expert opinion often guide treatments. With the exception of preeclampsia/eclampsia, neurological diseases typically do not warrant early delivery in the absence of fetal distress. Multidisciplinary care, utilizing the expertise of anesthesiology, critical care medicine, emergency medicine, maternal-fetal medicine, neurology, and radiology, is essential in ensuring prompt diagnosis and treatment.

Reversible Cerebral Vasoconstriction Syndrome, Part 1: Epidemiology, Pathogenesis, and Clinical Course

Reversible cerebral vasoconstriction syndrome is a clinical and radiologic syndrome that represents a common presentation of a diverse group of disorders. The syndrome is characterized by thunderclap headache and reversible vasoconstriction of cerebral arteries, which can either be spontaneous or related to an exogenous trigger. The pathophysiology of reversible cerebral vasoconstriction syndrome is unknown, though alterations in cerebral vascular tone are thought to be a key underlying mechanism. The syndrome typically follows a benign course; however, reversible cerebral vasoconstriction syndrome may result in permanent disability or death in a small minority of patients secondary to complications such as ischemic stroke or intracranial hemorrhage.

Reversible cerebral vasoconstriction syndromes: what the cardiologist should know

OPINION STATEMENT

Over the past decade, the reversible cerebral vasoconstriction syndromes (RCVS) have emerged as a group of conditions with easily recognizable clinical-angiographic features and a usually benign prognosis. The RCVS affect young individuals, mostly women, and the majority present with recurrent, severe, 'thunderclap' headaches. Vascular imaging studies show dynamic and reversible narrowing and dilatation of multiple intracerebral arteries. Brain imaging usually shows no parenchymal lesions, however, approximately one-third of patients develop ischemic or hemorrhagic strokes or reversible brain edema. The etiopathogenesis of this syndrome remains unclear. It has been associated with diverse conditions such as pregnancy, vasoconstrictive drug use, and neurovascular procedures. Recent studies characterizing RCVS have made it relatively easy to exclude mimics such as aneurysmal subarachnoid hemorrhage and primary angiitis of the central nervous system. There is no proven treatment, although calcium channel blockers may help to reduce the intensity of headaches. Empiric glucocorticoid treatment should be avoided. Since most patients do well with simple observation alone, invasive strategies such as pharmacologically-induced hypertension, balloon angioplasty, and direct intra-arterial vasodilator infusion should be reserved for patients showing clear clinical progression.

Subarachnoid and intra-cerebral hemorrhage in young adults: rare and underdiagnosed

OBJECTIVES

Convexity subarachnoid and intra-cerebral hemorrhages, in patients aged<50 years, are always a diagnostic challenge. This condition is characterized by acute headaches with or without neurological symptoms and/or seizures, and by the radiological demonstration of subarachnoid and/or intra-cerebral hemorrhages and, more rarely, by the association of ischemic events.

PATIENTS AND METHODS

In a prospective series of 30 consecutive patients (median age 31 years; 22 women) with a subarachnoid and intra-cerebral hemorrhages, 19 were diagnosed with reversible cerebral vasoconstriction syndrome (RCVS), 7 with cerebral venous sinus thrombosis (CVST), and 4 with a bleeding mycotic aneurysm (MA).

RESULTS

RCVS appeared spontaneously in 16 patients and was related to the postpartum period in three cases. Subarachnoid hemorrhage (SAH) was demonstrated in 24 patients as follows: 18 cases were in cortical areas, 4 were in the polygon of Willis, one was inter-hemispheric, and one was inter-hemispheric/intra-cerebral. A convexity pure intra-cerebral hemorrhage (ICH) was recorded in 6 cases. Among the 7 patients suffering from CVST, the superior sagittal sinus was involved in 4 cases, the transverse sinuses (TS) in 2, and the TS plus sigmoid sinus (SS) in one.

CONCLUSION

The three most common causes in this series were RCVS, followed by CVST and bleeding from MA. Because of atypical clinical or radiological presentations, this large spectrum of etiologies can cause diagnostic difficulties. Therefore, careful analysis is needed to ensure correct and prompt diagnosis and to avoid any dangerous delays in management.

Reversible cerebral vasoconstriction syndrome

Reversible cerebral vasoconstriction syndrome is characterized by severe headaches with or without focal neurologic deficits and/or seizures, and segmental constriction of cerebral arteries that resolves within 3 months. This increasingly recognized syndrome is supposedly due to a transient disturbance in the control of cerebral vascular tone with sympathetic overactivity. It can cause stroke in the young. It affects mainly middle-aged women. More than half the cases occur after exposure to vasoactive substances or during postpartum. The manifestations have a monophasic course, without new clinical symptom after 4 weeks, and range from pure cephalalgic forms with recurrent thunderclap headaches over 1-2 weeks to rare catastrophic forms with multiple hemorrhagic and ischemic strokes, brain edema and death. Diagnosis may be hampered by the dynamic nature of clinicoradiological features. Convexity subarachnoid hemorrhage or stroke may occur a few days after initial normal imaging, and cerebral vasoconstriction is maximal on angiography 2-3 weeks after clinical onset. Symptomatic treatment includes rest and removal of vasoactive substances. Nimodipine has been proposed to reduce thunderclap headaches within 48 hours, but has no proven effect on the hemorrhagic and ischemic complications.

Reversible cerebral vasoconstriction syndrome

Recurrent thunderclap headaches, seizures, strokes, and non-aneurysmal subarachnoid haemorrhage can all reveal reversible cerebral vasoconstriction syndrome. This increasingly recognised syndrome is characterised by severe headaches, with or without other symptoms, and segmental constriction of cerebral arteries that resolves within 3 months. Reversible cerebral vasoconstriction syndrome is supposedly due to a transient disturbance in the control of cerebrovascular tone. More than half the cases occur post partum or after exposure to adrenergic or serotonergic drugs. Manifestations have a uniphasic course, and vary from pure cephalalgic forms to rare catastrophic forms associated with several haemorrhagic and ischaemic strokes, brain oedema, and death. Diagnosis can be hampered by the dynamic nature of clinicoradiological features. Stroke can occur a few days after initial normal imaging, and cerebral vasoconstriction is at a maximum on angiograms 2-3 weeks after clinical onset. The calcium channel blocker nimodipine seems to reduce thunderclap headaches within 48 h of administration, but has no proven effect on haemorrhagic and ischaemic complications.

Postpartum RCVS and PRES with normal initial imaging findings

Postpartum angiopathy as clinical presentation of reversible cerebral vasoconstriction syndrome remains an intriguing phenomenon. The diagnosis needs to be considered in women presenting with thunderclap headache with or without associated neurological deficits. Here, we present a patient with thunderclap headache with initial normal laboratory and cerebral imaging findings, including intracranial angiography. Her condition worsened over several days and magnetic resonance imaging revealed changes initially compatible with posterior reversible encephalopathy syndrome, sequentially ischemic stroke and narrowing of the intracranial arteries. Although the patient was in coma for several days, she completely recovered and the focal vasoconstriction fully resolved. This case underscores the complex and variable presentation of postpartum angiopathy and illustrates the diagnosis to be (re)considered even if cerebral vasoconstriction is not documented at the onset of symptoms.

Headache in pregnancy: a nuisance or a new sense?

Headache is a very commonly encountered symptom in pregnancy and is usually due to primary headache disorders which are benign in nature. It can however be quite debilitating for some women who may need therapeutic treatment of which there are several options safe to use in pregnancy. It is equally important though to recognise that headache may be a sign of serious underlying pathology. This paper aims to provide a clinically useful guidance for differentiation between primary and secondary headaches in pregnancy. The primary headache disorders and their management in pregnancy are explored in depth with brief overviews of the causes for secondary headaches and their further investigation and management.

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

Neurological deficits associated with methylergometrine have been reported primarily as a result of reversible cerebral vasoconstriction syndromes (RCVS). RCVS are characterized by reversible multifocal vasoconstrictions of the cerebral arteries heralded by acute severe headache with or without neurological deficits. Here, we present the first case of suspected RCVS with transient limb myoclonus following the intravenous administration of methylergometrine during cesarean section. A 31-year-old woman who received slowly infused intravenous methylergometrine during a cesarean section suddenly reported severe occipital headache after 40 min, followed by apnea and unconsciousness for 8 min. A second administration of methylergometrine to treat the weakness of her uterine contractions resulted in a repeated loss of consciousness within minutes and the development of limb myoclonus. No abnormalities were detected by brain computerized tomography, magnetic resonance imaging, and electroencephalogram. She fully recovered spontaneously within 12 h. We consider that the transient limb myoclonus in our patient appeared as a result of RCVS caused by the intravenous administration of methylergometrine.

Cortical subarachnoid hemorrhage associated with reversible cerebral vasoconstriction syndrome after elective triplet cesarean delivery

Reversible cerebral vasoconstriction syndromes (RCVS) comprise a group of disorders characterized by prolonged, but reversible vasoconstriction of the cerebral arteries, usually associated with acute-onset, severe, recurrent headaches, with or without additional neurological signs and symptoms. Various complications of this condition have been observed, such as cortical subarachnoid hemorrhages (cSAH), intracerebral hemorrhages, reversible posterior leukoencephalopathy, ischaemic strokes and transient ischaemic attacks. It is important to include RCVS in thunderclap headache differential diagnosis and among non-aneurismatic subarachnoid hemorrhage causes. In the past years, thanks to the major diffusion of new diagnostic tools such as magnetic resonance, computed tomography and digital subtraction angiography, RCVS have been demonstrated to be more frequent than previously thought. We report an illustrative case of a woman affected by a small cSAH, associated to RCVS, after elective triplet cesarean delivery. To our knowledge, this is the first case of cSAH associated to RCVS after a triplet pregnancy.

Post-partum transverse sinus thrombosis presenting as acute psychosis

Whilst cerebral vascular disease and mental illness in the post-partum period are well recognised, their co-existence and the concept of organic psychoses in pregnancy, parturition and the puerperium remains poorly appreciated (Brockington 2006; Brockington Arch Women's Ment Health 10: 177-178, 2007a; Brockington Arch Women's Ment Health 10: 305-306, b). We report a woman who was referred to the Medical team on-call with a mixed presentation of euphoria, mutism and aggressive behaviour but ultimately demonstrated to have a transverse sinus thrombosis and recovered well with anti-coagulation. This serves an important reminder of the implications of a missed medical diagnosis in this high-risk and vulnerable group of patients.

Benign cerebral angiopathy; postpartum cerebral angiopathy: characteristics and treatment

Benign cerebral angiopathy and postpartum cerebral angiopathy are reversible cerebral arterial vasoconstriction syndromes. Presentation includes recurrent severe headaches, altered consciousness, and focal neurologic deficits; ischemic and/or hemorrhagic strokes can occur. No standard management has been established, but most authors agree that 1) acute-phase treatment includes cessation of vasoconstrictors, treatment of associated conditions, vasospasm treatment (calcium channel antagonists), and corticosteroids; 2) other measures include headache relief, blood pressure control, and stroke, cerebral edema, and seizure treatment; 3) definitive diagnosis requires conventional angiography and exclusion of alternative diagnosis; 4) a second arterial examination after 4 to 6 weeks is mandatory to confirm reversibility of vasoconstriction; 5) brain biopsy is indicated to rule out cerebral vasculitis in severe cases with clinical deterioration under steroid treatment or atypical findings; 6) immunosuppression should be reserved for patients with brain-leptomeningeal biopsy-proven vasculitis or used while waiting for a brain biopsy result; and 7) long-term measures include secondary stroke prevention and treatment of complications.

[Reversible cerebral vasoconstriction syndrome]

Reversible cerebral vasoconstriction syndrome (RCVS) is more frequent than previously thought and is probably underdiagnosed. The mean age of onset is 42 years, and it affects slightly more women than men. RCVS is attributed to a transient, reversible dysregulation of cerebral vascular tone, which leads to multifocal arterial constriction and dilation. More than half the cases (60%) are secondary to exposure to vasoactive substances (e.g., cannabis, antidepressants, and nasal decongestants) or occur in the postpartum period. RCVS has a characteristic clinical and radiological course, developing in a single phase after a sudden onset, and there is generally no new event after 1 month. The main pattern of presentation begins with recurrent thunderclap headaches, often triggered by sexual activity or various Valsalva's maneuvers, over a period of 1 to 3 weeks. Seizures and focal neurological deficits are less frequent and generally start after the headaches. Cortical subarachnoid hemorrhage (22%), intracerebral hemorrhage (6%), seizures (3%), and reversible posterior leukoencephalopathy (9%) are early complications, occurring mainly within the first week. Ischemic events, including TIAs (16%) and cerebral infarction (4%), occur significantly later than hemorrhagic strokes, mainly during the second week. Diagnosis requires the demonstration of the characteristic "string and beads" on cerebral angiography and can be difficult, for 21% of patients have a normal initial magnetic resonance angiography (MRA) and 9% both a normal MRA and a normal transcranial Doppler. In these cases, the initial investigations must be repeated after a few days. The final diagnosis is made when a follow-up MRA shows resolution or at least marked improvement of the arterial abnormalities within 12 weeks. RCVS is sometimes associated with other large artery lesions of the head and neck, including dissections and unruptured aneurysms, especially during the postpartum period. Nimodipine is the treatment most often recommended. In our experience, it is not especially effective in severe RCVS. Relapses are possible but rare and have not yet been reported in prospective series. Although the exact pathophysiology remains speculative, strong recommendations against vasoactive substances appear prudent.

[Reversible cerebral vasoconstriction syndrome]

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by severe headaches, as well as vasoconstriction of cerebral arteries, which resolves spontaneously in one to three months. This condition has a moderate female preponderance. The mean age of onset is around 45 years. About 60% of the cases are secondary, mainly occurring during postpartum and/or after exposure to vasoactive substances. The main clinical presentation includes multiple recurrent thunderclap headaches over one to three weeks. The major complications of RCVS are localized cortical subarachnoid hemorrhages (cSAH) (20-25%) and parenchymal strokes (5-10%). Complications occur with different time courses: hemorrhages (cSAH and intracerebral hemorrhages), and posterior reversible encephalopathy syndrome are early events occurring during the first week, while ischemic events including TIAs and cerebral infarcts occur significantly later, during the second week. Diagnosis requires the demonstration of the "string and beads" aspect of cerebral arteries by a cerebral angiogram (MRA, CTA or conventional) and the demonstration of the complete or marked normalisation of arteries by a repeat angiogram performed within 12 weeks of onset. Treatment is based on nimodipine that seems to reduce thunderclap headaches within 48h. However, nimodipine has not proven any efficacy against the hemorrhagic and ischemic complications of RCVS. Relapses are possible but rare and have not been reported yet in prospective series. It seems appropriate to advise the patients to avoid sympathomimetic and serotoninergic substances.

Recurrent Thunderclap Headaches and Multilobar Intracerebral Haemorrhages: Two Cases of Reversible Cerebral Vasoconstriction Syndrome (RCVS)

We describe two patients with thunderclap headaches due to reversible cerebral vasoconstriction syndrome (RCVS). The first patient illustrates multilobar intracerebral haemorrhages as an under-appreciated feature of RCVS, and the second illustrates recurrent thunderclap headache (presumed recurrent RCVS) after a long interval of 4 years. These cases demonstrate the spectrum of presentation of RCVS, a clinically under-recognized condition.

Overlapping features of eclampsia and postpartum angiopathy

INTRODUCTION

Postpartum cerebral angiopathy (PPA) is considered one of a diverse group of rare conditions termed "reversible cerebral vasoconstriction syndromes". Existing literature suggest considerable overlap in the manifestations of eclampsia and PPA.

METHODS

Retrospective case series review of PPA and eclampsia from a single neurosciences intensive care unit patient log identified over a consecutive 18-month period. A MEDLINE search (using OVID) of the English literature from 1950 through October 2008 was also performed.

RESULTS

Four patients who meet the obstetrical criteria for eclampsia and four patients whose clinical and radiographic features were consistent with PPA were identified. Twenty-eight patients with PPA were identified from the literature and showed significant clinical and radiographic overlap without cohort.

CONCLUSION

Given the overlapping clinical, laboratory, and radiographical features of eclampsia and PPA, it is probable they share a similar underlying pathophysiological mechanism and represent different clinical expressions of the same pregnancy-related disorder. The obstetrical definition of eclampsia may be to strict when applied in the neurosciences intensive care unit.

Spontaneous isolated convexity subarachnoid hemorrhage: presentation, radiological findings, differential diagnosis, and clinical course

Object

The clinical characteristics and overall outcome in patients with spontaneous isolated convexity subarachnoid hemorrhage (SAH) are not well described in the literature. The purpose of this study was to examine the mode of presentation, common origins, radiographic findings, and clinical course in a large case series of such patients.

Methods

A retrospective single-center chart review of all patients in whom nontraumatic primary convexity SAH was diagnosed between 2002 and 2007 was performed. Twenty patients were identified and analyzed for presenting symptoms, radiological and laboratory findings, hospital course, and outcome.

Results

There were 15 women and 5 men in our series, and the mean age was 52 years (range 18–86 years). The most common presenting symptom was headache, with 15 patients experiencing it as a chief complaint. Other frequent manifestations included altered mental status (8 patients), focal neurological deficits (7), and seizure (4 patients). An underlying cause of the hemorrhage was identified in 13 cases, whereas the remainder went unresolved. Of the known causes, 5 were due to posterior reversible encephalopathy syndrome, 3 were caused by thrombocytopenia or anticoagulation, and the remainder were isolated cases of lupus vasculitis, drug-induced vasculopathy, postpartum cerebral angiopathy, hypertensive microangiopathy, and Call–Fleming syndrome. All patients with unknown disease origins had favorable outcomes, whereas 8 of 13 patients with an identifiable underlying disorder experienced favorable outcomes.

Conclusions

Spontaneous isolated convexity SAH is rarely caused by aneurysm rupture, has a distinct mode of presentation, and generally carries a more favorable prognosis than that of aneurysmal SAH.

Reversible cerebral vasoconstriction syndrome associated with subarachnoid hemorrhage

INTRODUCTION

Reversible cerebral vasoconstriction syndrome (RCVS) is a rare vasculopathy of unknown etiology. Ischemic stroke and intracerebral hemorrhage are well-documented sequelae, but subarachnoid hemorrhage is an uncommon complication of RCVS.

METHODS AND RESULTS

We report six cases of RCVS associated with subarachnoid hemorrhage. Two cases occurred in postpartum women, two in women with a history of migraines, one in a woman who recently stopped taking her anti-hypertensive medications, and one in a man after sexual intercourse. All six patients presented with the classic thunderclap headache. Two patients experienced generalized tonic-clonic seizures, and two patients had small ischemic infarcts. Segmental vasoconstriction was demonstrated on cerebral angiography in all six cases. Aneurysmal subarachnoid hemorrhage and other etiologies were excluded. Reversibility of the segmental vasoconstriction was confirmed by follow-up angiography in four patients and by transcranial Doppler sonography in two patients. All six patients had an excellent neurological outcome.

CONCLUSIONS

Reversible cerebral vasoconstriction syndrome may be associated with subarachnoid hemorrhage. RCVS should be included in the differential diagnosis of non-aneurysmal subarachnoid hemorrhage.

Postpartum Reversible Cerebral Vasoconstriction Syndrome

Postpartum reversible cerebral vasoconstriction syndrome, also known as postpartum cerebral angiopathy, is clinically characterized by headache and focal neurologic deficits, and angiographically by transient, fully reversible cerebral vasoconstriction. A 26-year-old woman was brought to the emergency room with a 3-day history of confusion, agitation, and headache. She was 2 weeks postpartum. She went on to develop right leg weakness two days after admission. A cerebral angiogram showed diffuse irregularities of all intracerebral vessels, and MRI showed multiple acute infarcts. Her clinical condition improved significantly over the next several days without any intervention, and she was discharged. MRA 3 months after initial presentation was normal. It is important to consider this syndrome in the differential diagnosis in patients presenting with headache and focal neurologic deficits in the postpartum period.

Postpartum headache: is your work-up complete?

OBJECTIVE

Headache is a common finding in the postpartum period, and there are limited data describing the cause and treatment of women with postpartum headache. Our objective was to describe our experience with women who were hospitalized for postpartum headache and to develop a management algorithm for these women.

STUDY DESIGN

Data for 95 women with headache >24 hours after delivery from 2000-2005 were reviewed retrospectively. Maternal assessment included an evaluation for benign and serious causes of headache that included preeclampsia, dural puncture, and neurologic lesions. Neurologic imaging were performed on the basis of initial neurologic findings and clinical course. Outcomes that were studied included cause, a need for cerebral imaging, neurologic findings, maternal complications, and long-term follow-up evaluations.

RESULTS

The mean onset of headache was 3.4 days (range, 2-32 days) after delivery. Tension-type/migraine headache was the most common cause (47%). Preeclampsia/eclampsia and spinal headache comprised 24% and 16% of cases, respectively. Anesthesia evaluation was required in 15 patients because of suspected spinal headache; blood patch was required in 12 of these patients. Cerebral imaging was performed in 22 patients because of focal neurologic deficits and/or failure to respond to initial therapy; 15 of these women (68%) had abnormal findings. Ten patients had serious cerebral pathologic findings, such as hemorrhage, thrombosis, or vasculopathy. There were no deaths; 2 women had minor residual neurologic damage on follow-up evaluation.

CONCLUSION

The evaluation of persistent headaches that develop >24 hours after delivery must be performed in a stepwise fashion and requires a multidisciplinary approach. Preeclampsia should be considered initially in women with hypertension and proteinuria. Normotensive women should be evaluated initially for tension-type/migraine headache or spinal headache. Patients with headache that is refractory to usual therapy and patients with neurologic deficit require cerebral imaging to detect the presence of life-threatening causes.

Imaging of Neurologic Disorders Associated with Pregnancy and the Postpartum Period

Diverse pathologic conditions affect the central nervous system (CNS) and pituitary gland during pregnancy and the puerperium. Some are specific to the physiologic process of reproduction (eg, eclampsia, postpartum cerebral angiopathy, Sheehan syndrome, lymphocytic adenohypophysitis). Others are nonspecific but occur more often in pregnant women (eg, cerebral infarction, dural venous thrombosis, pituitary apoplexy). Recognition of the characteristic imaging findings in eclampsia, for example, may allow exclusion of other disorders. Even when imaging changes are nonspecific, knowledge of those entities associated with pregnancy and awareness of the increased likelihood of certain diseases in pregnancy will allow a more informed differential diagnosis. Differentiation of primary nonaneurysmal subarachnoid hemorrhage (SAH) from aneurysmal SAH is an example. Moreover, earlier use of imaging will result in fewer delayed diagnoses. For example, magnetic resonance venography allows early diagnosis of cerebral venous thrombosis. Even when the imaging changes are less specific, knowledge of likely possibilities will lead to more appropriate earlier use of imaging. For example, the stimulatory effects of pregnancy on prolactinoma, meningioma, hemangioblastoma, vestibular schwannoma, and metastatic tumors such as breast cancer and choriocarcinoma suggest the early use of CNS imaging to avoid the consequences of a delayed diagnosis.