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///2018 Abstract Details
2018 Abstract Details2019-08-02T15:57:01-05:00

“Thunderclap headache": a case of intracranial haemorrhage due to Reversible Cerebral Vasoconstriction Syndrome (RCVS) and preeclampsia

Abstract Number: S5D-2
Abstract Type: Case Report/Case Series

Dominika M Dabrowska MD1 ; Catherine Sheehan FRCA2; Chiara Maria Pieretti MD3; Sonal Patel MD4; Micheal McEwan MBBS5; Joanna Girling MA MRCP FRCOG6

Introduction: Postpartum headache can affect nearly 40% of women in the first week after delivery and may cause a diagnostic conundrum for treating physicians. We describe a case of a life-threatening intracranial haemorrhage as a result of Reversible Cerebral Vasoconstriction Syndrome (RCVS) and underlying preeclampsia. To our knowledge, this is the first report of such a complication in an obstetric patient.

Case report: A 40 y.o. woman underwent an elective caesarean section in our unit. Her past obstetric history consisted of gestational diabetes and mild preeclampsia. She had an uneventful surgery under regional anaesthesia and was discharged home with normal blood pressure. Two weeks after, she re-presented with a sudden-onset severe headache and blood pressure values of 207/109 mmHg. There was no focal neurology and her pupils were equal and reactive. Her initial management was Nifedipine, Hydralazine and Magnesium Sulphate. Rapid senior multidisciplinary review was arranged and urgent CT head was requested immediately. It revealed a 25mm haematoma in the left basal ganglia with extensive haemorrhage into the ventricular system and hydrocephalus. The working diagnosis was an intracranial haemorrhage due to hypertensive aetiology. She was intubated and transferred to the local neurosurgical centre where she had an external ventricular drain inserted. Her diagnosis at discharge was Reversible Cerebral Vasoconstriction Syndrome (RCVS). The patient underwent neurological rehabilitation with excellent progress. Within 6 months she was living independently at home with some residual short-term memory deficit.

Discussion: Reversible Cerebral Vasoconstriction Syndrome (RCVS) is a rare but serious cause of postpartum headache. The exact incidence of RCVS is unknown, but current literature suggests that it may be under-diagnosed due to lack of appropriate imaging. It is more common in women and 10% of all cases present post-partum. It has an explosive onset, is frequently described as “worst-ever” headache and can be associated with other abnormal neurology. Characteristic imaging reveals multifocal vasoconstriction and vasodilatation of the intracranial arteries, which can be prolonged but is reversible and resolves spontaneously within a few months.1 Intracerebral haemorrhage may complicate both RCVS and preeclampsia, so it is difficult to ascertain the exact pathology of our patient's presentation.2 We recommend thorough history and examination to lead choices of appropriate investigation for sudden onset post-partum headaches. The possibility of RCVS should always be considered, as treatment and prognosis can be significantly different.

References:1.Skeik N et al. Postpartum reversible cerebral vasoconstriction syndrome: review and analysis of the current data. Vasc Med.2015 Jun;20(3):256-65.2. Werring DJ. Reversible Cerebral Vasoconstriction Syndrome and Intracranial Hemorrhage Some Answers, Many Questions. Stroke. 2010;41:2455-2456.

SOAP 2018