Reversible cerebral vasoconstriction syndrome during caesarean section

Abstract

We describe the case of a 25-year-old parturient who presented sudden onset and short-lived severe headache caused by reversible cerebral vasoconstriction syndrome (RCVS) during an emergency caesarean section. The syndrome was triggered by phenylephrine administered intravenously to correct arterial hypotension following spinal anaesthesia. RCVS is a clinical and radiological syndrome attributed to transient disturbance in the control of cerebral arterial tone resulting in vasospasms. The syndrome can be precipitated by several triggers, including vasoactive drugs, often used during spinal anaesthesia, illicit drugs, pregnancy and postpartum state. Diagnosis and management can be challenging during pregnancy, peripartum or post partum, since many medications commonly used during these periods must be avoided to prevent triggering RCVS. The aim of this report is to raise the awareness, particularly for anaesthesiologists and obstetricians, of this rare and potentially serious syndrome. We discuss diagnosis, triggers, pathogenesis, clinical course and complications, as well as coordinated multidisciplinary management plans.

Reversible cerebral vasoconstriction syndrome: literature review

“…The puerperium is responsible for 10-50% of cases [7,[9][10][11]45]. In one-third of cases, it is associated with another known factor, such as vasoconstrictors used in epidural anesthesia and postpartum hemorrhage [10,55]. The history of migraine also proves to be a relevant risk factor, with a prevalence reported in the literature of 9.8-42% [10,20,56], an important finding, since the history of migraine increases the risk of bleeding complications in RCVS [9].…”

Krampfanfall mit intrakraniellen Blutungen nach Sectio caesarea in Spinalanästhesie

“…Es existieren Fallberichte zu koinzidentem Auftreten von RCVS und Eklampsie [14]. AuchbestimmteVorerkrankungen (Phäochromozytom, Porphyrie) oder neurochirurgische Operationen könnenprädisponieren [4], ebenso vasoaktive Substanzen wie Amphetamine, Cannabis, Kokain, Triptane und Antidepressiva [1,3,9,10]. Zusammenhänge mit einer vorbestehenden Migräne werden in bis zu 42 % beschrieben [13].…”

“…Zusammenhänge mit einer vorbestehenden Migräne werden in bis zu 42 % beschrieben [13]. Gerade das zeitgleiche Auftreten zusammen mit der Gabe kreislaufwirksamer Triggersubstanzen wie Phenylephrin oder Atropin, welche häufig im Rahmen geburtshilflicher Eingriffe gegeben werden, kann mit zur gesteigerten Prävalenz in diesem Patientenkollektiv beitragen und sollte zu entsprechender Aufmerksamkeit gemahnen [10].…”

“…Die Langzeitprognose hängt von möglicherweise bleibenden Einschränkungen in den Alltagsaktivitäten ab. Glücklicherweise erleiden weniger als 10 % der Betroffenen ein permanentes neurologisches Defizit [10].…”

Reader Response: Blood-Brain Barrier Permeability in Patients With Reversible Cerebral Vasoconstriction Syndrome Assessed With Dynamic Contrast-Enhanced MRI

“…3,4 For further evolution of RCVS, the postpartum period must be divided into caesarean-section and vaginal delivery subtypes. Caesarean-section is rarely complicated with RCVS, 5 whereas vaginal delivery is the most intense, prolonged, and repetitive VM known to humans.…”