title: Puerperal Extracranial Vertebral Artery Dissection and Nonaneurysmal Subarachnoid Hemorrhage.
abstract: Previously reported only a few times before, we present a case of extracranial vertebral dissection and spontaneous frontoparietal subarachnoid hemorrhage (SAH) in the puerperium, discussing possible mechanisms and difficulties in management. A 35-year-old woman presented 10 days postcaesarean section with neck pain and vertigo with normal initial investigations. Following recurrent vertigo, headache, and ataxia, imaging revealed a frontoparietal SAH and vertebral artery dissection. The patient was consequently treated with aspirin, and then following a return of symptoms 3 weeks later, warfarin therapy was continued for 6 months. The possible underlying mechanisms for this case are discussed, including reversible cervical vasoconstriction syndrome and posterior reversible encephalopathy syndrome, although neither was identified. The small SAH alongside recurrent posterior circulation symptoms resulted in the initiation of antithrombotic therapy. This report supports studies demonstrating higher incidence of cervicocephalic arterial dissection in the puerperium. Moreover, the heterogeneous presentation and manifestations of such cases require individualized treatment, and warrant studies into underlying mechanisms behind extracranial dissection and nonaneurysmal SAH.
authors.affiliation: Department of Cardiovascular Sciences Department, University of Leicester, Leicester, United Kingdom. Electronic address: j1garr@outlook.com.
authors.forename: James W
authors.initials: JW
authors.lastname: Garrard
authors.affiliation: Department of Neurosurgery and Neurosonology, Hospital das Clínicas da Universidade de São Paulo, São Paulo, Brazil.
authors.forename: Renata F
authors.initials: RF
authors.lastname: Simm
authors.affiliation: Department of Neurosurgery and Neurosonology, Hospital das Clínicas da Universidade de São Paulo, São Paulo, Brazil.
authors.forename: Edson
authors.initials: E
authors.lastname: Bor-Seng-Shu
authors.affiliation: Department of Neurosurgery and Neurosonology, Hospital das Clínicas da Universidade de São Paulo, São Paulo, Brazil.
authors.forename: Ricardo C
authors.initials: RC
authors.lastname: Nogueira
mesh_terms: D000328:Adult; D000925:Anticoagulants / Q000627:therapeutic use; D001241:Aspirin / Q000627:therapeutic use; D005260:Female; D006801:Humans; D019547:Neck Pain / Q000188:drug therapy / Q000209:etiology; D011644:Puerperal Disorders / Q000175:diagnosis* / Q000188:drug therapy; D013345:Subarachnoid Hemorrhage / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy; D016896:Treatment Outcome; D020217:Vertebral Artery Dissection / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy; D014717:Vertigo / Q000188:drug therapy / Q000209:etiology; D014859:Warfarin / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D014859:Warfarin; D001241:Aspirin
keywords: Puerperium; cervicocephalic artery dissection; reversible cervical vasoconstriction syndrome; stroke; subarachnoid hemorrhage; vertebral artery dissection