Resolution of Internal Carotid Dissection with Middle Cerebral Artery Occlusion in Pregnancy

Abstract

Introduction. Cervical artery dissection (CAD) is a common cause of stroke in younger patients. While the incidence of stroke in pregnancy is increasing, CAD remains a rare cause of ischemic stroke in the pregnant population, with only 30 cases described in the literature, most in the postpartum period. Methods. The case of a pregnant patient at 18 weeks of gestation presenting with CAD and ischemic stroke following intercourse is discussed. Discussion. CAD results from an intimal tear in the carotid artery, allowing accumulation of blood in the vessel wall. Stroke results from embolization of thrombogenic material in the wall. Etiology includes minor trauma, connective tissue disorders, or anatomic variations of the carotid artery. Most patients present with headache and/or neck pain, while ischemic symptoms are seen in at least 50% of patients. In the pregnant population, imaging with MRI or MRA of the head and neck aids in diagnosis. Once the diagnosis is made, patients are treated with either anticoagulation or antiplatelet medications. The optimal treatment in both pregnant and nonpregnant patients has not been well-studied. Conclusion. CAD is an important diagnosis to consider in a pregnant patient with persistent headache, especially if neurological symptoms are present. Imaging should be quickly obtained so treatment can be initiated.

Combined reperfusion therapy to treat cryptogenic acute ischemic stroke during the first trimester of pregnancy: case report and literature review

“…Most etiologies described in literature pertain to a young population with stroke: cardiac valve diseases (especially rheumatologic valve disease), coagulopathy, and patent foramen ovale. 2 , 13 , 23 , 24 The most frequent etiology of cerebral infarction in this population is cervical artery dissection. The risk of cervical artery dissection is accrued during pregnancy and postpartum by modifications of media due to hormonal changes.…”

“…The risk of cervical artery dissection is accrued during pregnancy and postpartum by modifications of media due to hormonal changes. 23 , 25 Pregnant women presenting with stroke should thus undergo the same etiological investigation as the general young population with stroke, paying particular attention to exploration of cervical and intracranial arteries, transoesophageal echocardiography, and detection of biological prothrombotic agents (platelet count, lupus anticoagulant and anticardiolipin antibody). Most cerebrovascular events occurring during pregnancy are related to eclampsia and cerebral venous thrombosis, both of which cause cerebral infarction and hematomas.…”

“… 29 However, these abnormalities are more likely to cause venous thromboembolism, and have been described during advanced stages of pregnancy or during the postpartum. 23 , 29 …”

Ischemic stroke and floating thrombosis in dissection of the common carotid artery in patient at third week of pregnancy: Surgical technical success and maintenance of pregnancy

“…2 Although medical treatment has been described in similar cases, a medical and surgical strategy with heparin and a surgical operation were adopted in our case based on our experience with floating thrombus and the evidence reported in the literature. 8–11 The endovascular approach, in our opinion, represents an additional risk of embolization and is a potentially perilous alternative to open surgery. Finally, a very important role in the successful treatment of the patient was played by the multidisciplinary process, inasmuch as the special characteristics of this case demanded the input of multiple skills.…”

Vertebrobasilar and internal carotid arteries dissection in 188 patients

“…Iatrogenic injuries of the cervical and intracranial arteries are possible as well, including local anesthetic injection, and neck, oral, transnasal and skull base surgery [49,55,84]. Certain types of medication can occasionally produce dissections [50,54,85], then arterial elongation [60], fibromuscular dysplasia and connective tissue diseases [8,12,42,[86][87][88], polycystic kidney disease, pregnancy and postpartum [89][90][91], as well as certain gene mutations [9,86,[92][93][94]. Some of these causes were also observed in our patients.…”