Severe Postpartum Headache and Hypertension Caused by Reversible Cerebral Vasoconstriction Syndrome

Abstract

Reversible cerebrovascular vasoconstriction syndrome is an uncommon condition that presents as severe headache and hypertension. Recent literature suggests a 1% incidence in postpartum headache cases. It can cause subarachnoid hemorrhages, cerebral ischemia, and seizures. It is often misdiagnosed as postdural puncture headache or preeclampsia. In this case, a postpartum woman, who had received epidural anesthesia for labor, presented 5 days postpartum with severe headache that did not resolve with an epidural blood patch. She then became more hypertensive and suffered a grand mal seizure. When treatment for eclampsia failed to resolve her symptoms, magnetic resonance angiography was performed. It demonstrated the pathognomic signs of reversible cerebrovascular vasoconstriction syndrome. Her symptoms resolved with nimodipine.

Reversible Cerebral Vasoconstriction Syndrome in a Background of Eclampsia Responding to Milrinone Infusion

“…Eclampsia as defined by the American College of Obstetricians and Gynecologists (ACOG) is the occurrence of new-onset seizures or coma, both of which can occur in RCVS, in a patient who has been diagnosed with pre-eclampsia. Reversible cerebral vasoconstriction syndrome (RVCS) is characterized by multifocal vasoconstriction that gives the cerebral arteries the appearance of a “string of beads” [ 5 ]. The patho-physiology is poorly understood; it includes dysregulation of cerebral vascular tone, endothelial dysfunction, and oxidative stress leading to blood-brain barrier injury [ 6 ].…”

“…RCVS usually peaks within 2 weeks postpartum and resolves spontaneously after 3 months. However, RVCS needs to be treated, as most patients have brain pathology such as infarction, convexity SAH, lobar intracranial hemorrhage, or brain edema [ 5 ]. In our patient there were clinical and radiological findings supporting the diagnosis of RCVS, including the correlation with pregnancy and the concurrent eclampsia, new-onset headache, and seizures with radiological vasoconstriction confirmed by transcranial Doppler (TCD) and CT angiogram.…”

“…It may include trail of triple-H as in SAH-related vasospasm, nimodipine (60 mg every 4 h for 21 days), corticosteroids, immunoglobulins, and in refractory cases endovascular therapy either intra-arterial verapamil, nicardipine, or angioplasty. In the literature, there are only 3 patients successfully treated with milrinone (phosphodiesterase inhibitor-3); 2 of them were post- partum women and 1 was a post-transplant patient on tacrolimus [ 5 ]. Our patient was started on nimodipine; however, there was no improvement in TCD readings after 48 h; therefore, a decision was made to start i.v.…”

Hypertensive States during Labor and Puerperium

“…antihypertensive drug because the wrong drug can lead to the patient to develop eclampsia. According the study of Mcllroy et al [6] the reversible cerebrovascular vasoconstriction syndrome is an uncommon condition that presents as severe headache and hypertension. In spite off the rate of headache during puerperium is low, it can produce or allow to suspect serious neurological damage.…”

Reversible cerebral vasoconstriction syndrome: literature review

“…As the wrong or delayed diagnosis of RCVS usually results in unnecessary diagnostic tests, deleterious treatments, and increases the risk of neurological sequelae [ 3 , 5 , 21 ], to reduce mortality, early diagnosis and treatment are essential [ 13 , 22 , 23 ]. Thus, a greater understanding of the disease is necessary, in which we present an extensive literature review on this topic.…”