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Development of carotid and vertebral artery dissections in a postpartum woman with HELLP syndrome: a case report
Abstract Number: S-74
Abstract Type: Case Report/Case Series
Headaches develop in the first postpartum week in 12-39% of patients.1 We present a patient with HELLP syndrome and inadvertent dural puncture during epidural catheter placement, who was found to have a right internal carotid artery (ICA) and bilateral cervical vertebral artery dissections after complaining of a postpartum headache.
39 yo nulliparous patient presented with 48 h history of elevated blood pressure, 8 lb. weight gain, and headache. Laboratory tests on admission revealed platelet count of 144,000, transaminitis, elevated creatinine, and a urine protein/creatinine ratio of 0.9. Suspecting HELLP syndrome, OB team decided to proceed with cesarean delivery. While awaiting NPO requirement, an epidural catheter was placed due to potential for decreasing platelet count. First attempt at placement resulted in inadvertent dural puncture with 17 Ga Tuohy needle. Second attempt was done a level higher, and an epidural catheter was placed without issue. The rest of the operation and postoperative course proceeded uneventfully, until postoperative day (POD) 4 when she began complaining of right neck stiffness, which was treated with oral analgesics. On POD 5 she also developed a 10/10 positional headache, without any focal neurologic signs. She received an epidural blood patch later that day, which resulted in improvement in her symptoms. That night, her neck stiffness returned, and her headache returned the following morning. She underwent a second blood patch on POD 6, and again had relief of her symptoms. However, on POD 7, her headache and neck stiffness recurred, but were more severe in nature, and her headache was non-positional; all other neurologic findings were negative. A MRI/MRA was ordered, which showed a right cervical ICA dissection with pseudoaneurysm. She was admitted to the ICU and underwent CT angiogram, which confirmed the MRA findings, and also showed bilateral cervical vertebral artery dissections at the V2 segment. The rest of her workup was normal. She was started on a heparin infusion and transitioned to warfarin. Her symptoms resolved, and she was discharged home on warfarin with no permanent neurologic sequellae. Follow-up imaging 3 months later showed resolution of the dissections, but persistent right ICA pseudoaneurysm.
The differential for postpartum headache is broad, encompassing both benign and life threatening conditions. This patient’s symptoms were initially consistent with postdural puncture headache, but changes in the severity of the neck stiffness and positional nature of the headache prompted further evaluation. Although most carotid and vertebral dissections occur spontaneously or after trauma, there are reports of carotid or vertebral dissection in a preeclamptic patients. 2-4 No known association exists between intracranial hypotension and development of arterial dissection.
1. N Engl J of Med, Vol 344, No. 12, 898-906
2. Intl J of Ob Anes (2004) 13, 44-46
3. J Stroke Cerebrovasc Dis. 2010:16