RCVS, which has been described in the literature since the early 1970’s, is characterized by severe headache (especially called thunderclap headache), with or without other acute neurological symptoms, and diffuse segmental vasoconstriction of cerebral arteries, which is reversible within 3 months.5 It’s common in postpartum women and called postpartum cerebral angiopathy.3.6 Previous studies revealed that 5-12% of RCVS patients are postpartum women.7, 8 As neuroradiorogical findings of RCVS, in one third to a half of cases reveal cSAH, reversible cerebral edema called PRES, cervicocarotid dissection (CAD), intraparenchymal hemorrhage, subdural hemorrhage and ischemic stroke.3, 9-12 cSAH is the most frequent finding of RCVS and was reported to account for 30-38% of hemorrhagic complications.8, 9 cSAH associated with postpartum angiopathy could result from rupture or reperfusion injury affecting the small arteries of the leptomeninges.13 The diagnosis of RCVS should be considered in patients who present with recurrent thunderclap headache, with or without focal neurological signs and non-aneurysmal SAH.14 PRES is one of the hypertensive encephalopathies that can cause cerebral edema, seizures, and both ischemic and hemorrhagic strokes.15 It was reported that approximately 4% of 95 women with postpartum headache were diagnosed with PRES.1 Bartynski et al. reported that the parietal and occipital lobes were the most frequently abnormal regions in 134 patients of PRES, but lesions of basal ganglia, such as our case, were found in 14% of the series.16
It is suggested that RCVS and PRES are interrelated and share pathophysiologic mechanisms such as small vessel endothelial dysfunction, deficiencies in self-regulation, and decreased sympathetic innervation of the posterior circulation.3, 10, 14, 15 In one prospective study of 77 consecutive male and female patients with RCVS, 7 (9.1%) developed PRES.10
CAD is a major cause of cerebral ischemia and hemorrhage in young adult17, but it is a rare complication during the postpartum period. The presence of intramural hematoma (IMH) is the basis of the diagnosis of CAD.18 IMH, which can be identified on MSDE, characteristically has a crescentic shape adjacent to the vessel lumen and often spirals along the length of the artery.18, 19, 20 Previous reports suggested that the MSDE-3D-TSE sequence was useful for assessing vessel walls in the dissection and aneurysms.21-23 MSDE causes phase dispersion of blood spin using a magnetic field to suppress blood flow signal, producing 3D T1-weighted images.24 Digital subtraction angiography (DSA) is the gold standard for diagnosis and follow-up of CAD; however, it is invasive and cannot determine IMH.17 Other angiographic features are luminal flap, false lumen, long tapered stenosis, and dissecting aneurysms.17 We were able to confirm the presence of intramural hematoma and the process of its change, so we have diagnosed with CAD on MRI-MSDE method.
To the best of our knowledge, 26 women and 35 dissections have described postpartum patients with CAD, including our patient (Table 1).25-36 The mean age was 35 years (range, 26-44 years); the mean time from birth to onset was 10.5 days (range, 1 hour-53 days). For CAD-affected lesions, 15 (57%) women had a single lesion and the other women (43%) had multiple lesions. Among the 26 women with CAD, 6 (23%) had SAH, 6 (23%) had RCVS, and 9 (34%) had infarction. One case had PRES based on FLAIR high-intense area in the bilateral occipital area.34 Previous reports indicate that 8-12% of RCVS patients have CAD.13, 37 Wiebers et al. described the first case of a 44-year-old woman with postpartum CAD in 1985.25 She developed infarction in the left MCA territory and was treated with heparin. The first CAD-related RCVS case was diagnosed incidentally.38 Arnold et al. reported that 6% of 102 postpartum women with CAD.30 Interestingly, the prognosis was good with or without antithrombotic therapy.
According to our case and previous reports, we speculate that postpartum vascular lesions are a series of pathological conditions. Although not confirmed in our case, RCVS and CAD are associated with alteration of the vessel wall of the vasa vasorum, vasculopathy-related arterial tears and genetic predisposition.6, 10, 39, 40 RCVS and PRES share a vulnerability in the posterior circulation. 10, 39 These pathologies have been speculated to include small vessel endothelial dysfunction, defective autoregulation, and reduced sympathetic innervation of the posterior circulation.10, 39, 41
In some pathological reports, skin biopsy of CAD patients revealed ultrastructural derangements of type I and type III collagen fibrils. 42, 43 Another study including superficial arterial biopsy of CAD patients showed degradation with inflammatory and erythrocytic accumulation between the tunica media and adventitia. 44
In pregnancy and postpartum periods, endothelial damage associated with sudden changes in blood pressure led to the destruction of the blood-brain barrier. 5, 45 In addition, increased activity of the immune system can activate proteolytic enzymes such as matrix metalloproteinases and cause weakening of the arterial wall. 44 A series of conditions may indicate arterial wall instability and dysfunction. Our case began with stiff shoulders and then became aware of thunderclap headache. From this mode of onset, CAD first occurred, and we speculated that RCVS and PRES could be induced by being aware of stiff shoulders and pain.