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Rosalik KF, Havemann LM, Wasickanin ME, McCaulley JA, Edwards SM, Leonard KM. Vertebral artery dissection in relation to pregnancy: a case series and literature review. AJOG GLOBAL REPORTS 2023; 3:100281. [PMID: 38046533 PMCID: PMC10692729 DOI: 10.1016/j.xagr.2023.100281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Abstract
Cervical artery dissection is an uncommon condition for which pregnancy and postpartum states confer increased risk. Although the majority of patients with this condition fully recover, including resolution of the dissection on imaging, long-term sequelae include a variety of cardiovascular conditions that may be associated with high rates of morbidity and mortality. Here, we review 2 cases of vertebral artery dissection in relation to pregnancy. Our first case will review the management of a pregnant patient with a history of vertebral artery dissection; whereas our second case reviews a presentation of postpartum vertebral artery dissection. Providers should maintain a high suspicion of cervical artery dissection in pregnant and postpartum patients presenting with headache and neck pain.
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Affiliation(s)
- Kendal F. Rosalik
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Madigan Army Medical Center, Tacoma, WA (Drs Rosalik, Wasickanin, McCaulley, and Edwards)
| | - Logan M. Havemann
- Department of Obstetrics and Gynecology, Carl R. Darnall Army Medical Center, Fort Hood, TX (Dr Havemann)
| | - Morgan E. Wasickanin
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Madigan Army Medical Center, Tacoma, WA (Drs Rosalik, Wasickanin, McCaulley, and Edwards)
| | - Jill A. McCaulley
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Madigan Army Medical Center, Tacoma, WA (Drs Rosalik, Wasickanin, McCaulley, and Edwards)
| | - Sarah M. Edwards
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Madigan Army Medical Center, Tacoma, WA (Drs Rosalik, Wasickanin, McCaulley, and Edwards)
| | - Katherine M. Leonard
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Womack Army Medical Center, Fort Bragg, NC (Dr Leonard)
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Azad HA, Prasad N, Shlobin NA, Mitra A, Cloney MB, Hopkins BS, Jahromi BS, Potts MB, Dahdaleh NS. Clinical Characteristics, Course, and Outcomes of Vertebral Artery Dissections in the Postpartum Period. Neurosurgery 2021; 89:792-799. [PMID: 34383947 DOI: 10.1093/neuros/nyab296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 06/06/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Postpartum vertebral artery dissections (ppVADs) are rare but potentially morbid conditions that occur in otherwise healthy patients. OBJECTIVE To evaluate clinical characteristics of ppVADs. METHODS Demographic, clinical, treatment, and outcome data were collected on ppVADs and are presented in a case series of 12 patients and compared to the general cohort. RESULTS In total, 12 patients had ppVADs in our cohort of 310 patients with vertebral artery dissections (VADs). They occurred 11.27 days (95% CI, -0.85 to 23.39) postdelivery. Of these, there were 5 (42%) with a hypertensive disorder of pregnancy, and 4 (33%) who had migraines. A total of 3 (25%) had ischemic strokes and 1 (8%) had a subarachnoid hemorrhage. In total, 2 patients (17%) had unfavorable modified Rankin Scale (mRS, 2-6) at discharge from hospital. Patients with ppVADs more often had bilateral VADs (42% vs 17%, P = .03), had pseudoaneurysms (50% vs 18%, P = .0068), were younger (33.83 years vs 44.32 years, P = .018), and had lower Charlson Comorbidity Index (CCI = 0 vs 0.99, P = .0038). Anticoagulant treatment was used in a similar percentage of patients. Multivariate analysis revealed 3 factors were predictive of change in mRS: CCI (OR = 1.09, 95% CI, 1.02-1.15), stroke (OR = 0.78, 95% CI, 0.65-0.95), and mRS at hospital discharge (OR = 0.80, 95% CI, 0.74-0.87). CONCLUSION There are only 15 isolated ppVADs reported in the literature; this study adds 12 patients with 17 ppVADs. Postpartum VADs occur in younger, healthier patients than in the general cohort, raising questions about mechanism of injury. The majority of ppVADs have good neurological outcomes.
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Affiliation(s)
- Hooman A Azad
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Nikil Prasad
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Nathan A Shlobin
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Akash Mitra
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Michael B Cloney
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Benjamin S Hopkins
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Babak S Jahromi
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Matthew B Potts
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Nader S Dahdaleh
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Cerebrovascular events during pregnancy and puerperium. Rev Neurol (Paris) 2021; 177:203-214. [PMID: 33642057 DOI: 10.1016/j.neurol.2021.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 02/05/2021] [Indexed: 11/20/2022]
Abstract
Though cerebrovascular complications of pregnancy remain relatively rare, they represent a potentially devastating event that necessitates prompt identification and treatment. Eighteen percent of strokes occurring in young women are linked to pregnancy. They occur mostly in the third trimester or during the post-partum period. Their biggest risk factors are hypertension, preeclampsia/eclampsia and migraine. Cerebrovascular events occurring during this period may involve specific pathophysiological processes that include embolic phenomena or endothelial dysfunction, but can also have common etiologies that are simply favored by the context of pregnancy. Thus, posterior encephalopathy and vasoconstriction cerebral syndrome are relatively frequently involved in cerebrovascular complications of pregnancy. Other very specific causes like amniotic fluid embolism or postpartum cardiomyopathy can also be responsible for such events. The management of stroke during pregnancy must be multidisciplinary and include a neurovascular expertise. Some conditions can lead to a long-life follow-up and modify the management of a future pregnancy.
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Shanmugalingam R, Reza Pour N, Chuah SC, Vo TM, Beran R, Hennessy A, Makris A. Vertebral artery dissection in hypertensive disorders of pregnancy: a case series and literature review. BMC Pregnancy Childbirth 2016; 16:164. [PMID: 27422677 PMCID: PMC4947248 DOI: 10.1186/s12884-016-0953-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 07/09/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Arterial dissection is a rare complication of pregnancy and puerperium. There have been reports of aortic, coronary and cervical artery dissection in association with preeclampsia, however, vertebral artery dissection is rarely reported particularly in the antenatal setting in the presence of a Hypertensive Disorder of Pregnancy (HDP).The general annual incidence of symptomatic spontaneous cervicocephalic arterial dissection is 0.0026 % and a data registry reported that 2.4 % of these occurred in the post-partum period. The actual incidence of vertebral artery dissection in HDP is unknown as the current literature consists of case series and reports only with most documenting adverse outcomes. Given the presence of collateral circulation, unilateral vertebral artery dissections may go unrecognised and may be more common than suspected. CASE PRESENTATION We present a case series of four patients with vertebral artery dissection in association with HDP, two of which occurred in the antenatal setting and two in the post-partum setting. All our patients had favourable outcome with no maternal neurological deficit and live infants. Our discussion covers the proposed pathophysiology of vertebral artery dissection in HDP and the management of it. CONCLUSION Our case series highlights the need to consider VAD an important differential diagnosis when assessing pregnant women with headache and neck pain particularly in the context of HDP.
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Affiliation(s)
- Renuka Shanmugalingam
- Liverpool Hospital, Elizabeth Street, Liverpool, 2170 NSW Australia
- Western Sydney University, Penrith, Australia
- Vascular Immunology Research Group, Heart Research Institute, Newtown, Sydney Australia
| | - Nina Reza Pour
- Liverpool Hospital, Elizabeth Street, Liverpool, 2170 NSW Australia
| | - Siang Chye Chuah
- Liverpool Hospital, Elizabeth Street, Liverpool, 2170 NSW Australia
| | - Thi Mong Vo
- Liverpool Hospital, Elizabeth Street, Liverpool, 2170 NSW Australia
| | - Roy Beran
- Liverpool Hospital, Elizabeth Street, Liverpool, 2170 NSW Australia
| | - Annemarie Hennessy
- Campbelltown Hospital, Therry Road, Campbelltown, 2560 NSW Australia
- Western Sydney University, Penrith, Australia
- Vascular Immunology Research Group, Heart Research Institute, Newtown, Sydney Australia
| | - Angela Makris
- Liverpool Hospital, Elizabeth Street, Liverpool, 2170 NSW Australia
- Western Sydney University, Penrith, Australia
- University of New South Wales, Sydney, Australia
- Vascular Immunology Research Group, Heart Research Institute, Newtown, Sydney Australia
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Schoen JC, Campbell RL, Sadosty AT. Headache in pregnancy: an approach to emergency department evaluation and management. West J Emerg Med 2015; 16:291-301. [PMID: 25834672 PMCID: PMC4380381 DOI: 10.5811/westjem.2015.1.23688] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Revised: 12/11/2014] [Accepted: 01/09/2015] [Indexed: 12/24/2022] Open
Abstract
Headache is a common presenting complaint in the emergency department. The differential diagnosis is broad and includes benign primary causes as well as ominous secondary causes. The diagnosis and management of headache in the pregnant patient presents several challenges. There are important unique considerations regarding the differential diagnosis, imaging options, and medical management. Physiologic changes induced by pregnancy increase the risk of cerebral venous thrombosis, dissection, and pituitary apoplexy. Preeclampsia, a serious condition unique to pregnancy, must also be considered. A high index of suspicion for carbon monoxide toxicity should be maintained. Primary headaches should be a diagnosis of exclusion. When advanced imaging is indicated, magnetic resonance imaging (MRI) should be used, if available, to reduce radiation exposure. Contrast agents should be avoided unless absolutely necessary. Medical therapy should be selected with careful consideration of adverse fetal effects. Herein, we present a review of the literature and discuss an approach to the evaluation and management of headache in pregnancy
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Affiliation(s)
- Jessica C Schoen
- Alpert Medical School of Brown University, Department of Emergency Medicine, Providence, Rhode Island
| | - Ronna L Campbell
- Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota
| | - Annie T Sadosty
- Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota
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Abstract
Pregnancy creates alterations in maternal physiology which predispose to unique neurologic disorders. Pre-eclampsia, eclampsia, certain types of ischemic and hemorrhagic stroke, reversible cerebral vasoconstriction syndrome, posterior reversible encephalopathy syndrome, and thunderclap headache all appear to share a common origin from vascular endothelial dysfunction, with overlapping clinical presentations. Multiple sclerosis often improves during pregnancy. Compression mononeuropathies may occur in the extremities. Myasthenia gravis may affect second stage labor. Various inflammatory peripheral neuropathies, dystrophies, myopathies may occur during pregnancy. The safety of specific immune suppressants is reviewed. Epilepsy does not have a significant effect upon the course of pregnancy, albeit there is a modest increase in the need for cesarean section. Certain antiepileptic drugs may produce fetal malformations, most notably valproic acid. Brain tumors are rare during pregnancy, but may increase in size due to activation of hormonal receptors on tumor cells surfaces, water retention, and engorged blood vessels.
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Affiliation(s)
- H Steven Block
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
| | - José Biller
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA.
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L’accident vasculaire cérébral secondaire à une dissection artérielle vertébrale : complication rare de l’éclampsie. Presse Med 2012; 41:88-90. [DOI: 10.1016/j.lpm.2011.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Revised: 05/18/2011] [Accepted: 06/14/2011] [Indexed: 11/22/2022] Open
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