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Rupture of Cerebral Aneurysm Immediately After Cesarean Delivery
Abstract Number: F5D-6
Abstract Type: Case Report/Case Series
Introduction: Neurological pathology is a rare but complex problem in the obstetric population. Previous case reports have shown postpartum cerebrovascular dissections, including five patients who presented within six weeks postpartum. There have been no published case reports of peripartum aneurysm or dissection immediately after cesarean delivery.
Case Presentation: The patient is a 33 y/o G1P0 with no PMH who underwent a scheduled cesarean delivery for breech presentation under spinal anesthesia. During skin closure, the patient developed hypotension that was refractory to pressor boluses followed by a sudden onset severe headache and hypertension with BP of 212/94. Immediately afterwards, she became unresponsive with an upward gaze and clonic movements. She was emergently intubated. A "stroke code" was called, and head CT scan showed subarachnoid hemorrhage. She was taken to interventional radiology, where an angiogram showed a large R ruptured posterior communicating artery aneurysm, which was coiled. Other non-ruptured aneurysms were noted including R para-ophthalmic and R carotid cave aneurysms, as well as B/L vertebral artery dissections. Upon further interview of the patient’s family, she had an aunt with a history of cerebral aneurysm and hemorrhage at a young age. She was extubated one day later in the ICU, and initially had short term memory deficits and uneven pupils. Other cranial nerves were intact and strength was 5/5 in all muscle groups. She was in the ICU for two weeks with an external ventricular drain, but eventually had a full neurological recovery. She was evaluated by maternal-fetal medicine who advised against future pregnancies given the likelihood of vascular aneurysm rupture.
Discussion: Case reports of patients with cerebral aneurysm rupture and dissection in the postpartum period are thought to be related to Valsalva during labor. There are also reports of dissection or subarachnoid hemorrhage days after cesarean delivery, without a definite implicating source. Our patient did not perform Valsalva maneuvers, and the rupture occurred immediately postpartum. In this case, the ruptured aneurysm and vascular dissections were likely caused by the dramatic increases in cardiac output and arterial compliance that are known to occur immediately after delivery. This patient had a family history, but no known PMH or preoperative neurological symptoms. Clinicians may want to consider vascular imaging in patients with strong family histories of aneurysm or dissection prior to pregnancy, as the hemodynamic changes in the peripartum period may increase morbidity and mortality in both vaginal and cesarean deliveries.
References: 1) Kelly, Jeannie C.,et al. "Postpartum internal carotid and vertebral arterial dissections." Obstetrics & Gynecology 123.4 (2014): 848-56. 2) Hall, Michael E., Eric M. George, and Joey P. Granger. "The heart during pregnancy." Revista Española de Cardiología (English Edition) 64.11 (2011): 1045-50.