A 36-year-old woman presented post-partum day 10 with progressive-onset headache and chest pain. She had delivered at 39 weeks following an uncomplicated L2-L3 epidural anesthesia and elective C-section. Blood pressure was 166/94 and NIHSS score was 0. Cerebral CT-scan demonstrated posterior high convexity subarachnoid hemorrhage (SHA). CT-angiography revealed dissections of the right extracranial vertebral artery (VA) and left intracranial and extracranial VA. The left intracranial VA was therapeutically embolized.
Three days later, CT-angiography showed de novo generalized homogeneous moderate cerebral arterial vasospasm, treated with nimodipine. There were no clinical nor laboratory signs of vasculitis.
The next day, she developed lower limbs paresthesias. She had required urinary catheterisation since admission. Spinal cord (SC) MRI revealed a T3 spinal SHA. Spinal angiography identified two fusiform aneurysms on left T3/T7 radicular branches. There was no clinical evidence of connective tissue disease. Conservative approach was elected. At three months, CT-angiography demonstrated resolution of the vasospasm and control spinal angiography was normal.
Post-partum neurovascular complications fall under the umbrella term of post-partum angiopathy, which sometimes co-exists with pre-eclampsia but can occur in normotensive women. However, SA during pregnancy have only been reported once, post-mortem.
Pathological descriptions suggest that arterial dissection might lead to the formation of SA, as supported in this case by the co-occurrence of cervical artery dissection and reversibility of SA. The high convexity SHA might be attributable to redistribution of spinal SHA, with SA rupture responsible for the initial chest pain. Alternatively, high convexity SHA could be secondary to intracranial VA dissection or reversible cerebral vasoconstriction.