Clinical Reasoning: A 33-year-old woman with severe postpartum occipital headaches

Abstract

A 33-year-old woman with history of occasional "migraines" complained of severe occipital headache, following an uncomplicated full-term vaginal delivery under epidural anesthesia. This headache was qualitatively and quantitatively different from her usual headaches. The diagnosis of low intracranial pressure headache related to inadvertent dural puncture was considered and 2 epidural autologous blood patches were performed with no relief. One week postpartum she presented to an outside hospital with complaints of poor concentration, difficulty in finding words, getting dressed, and feeding herself, and left arm numbness. Examination showed a blood pressure of 179/119 mm Hg, poor attention span, apraxia, and decreased sensation in the left hand. General physical examination was unrevealing.Head MRI (day 0) showed fluid-attenuated inversion recovery (FLAIR) hyperintensities (figure 1, A and B) and diffusion restriction with positive apparent diffusion coefficient (ADC) map (figure 1, C and D) in the right parietal lobe and in the splenium of the corpus callosum. The diagnosis of posterior reversible encephalopathy syndrome Upper panel MRI, performed on admission, showed FLAIR hyperintensities and diffusion restriction in the right parietal lobe and in the splenium of the corpus callosum (arrows). Lower panel, done on hospital day 3 when the patient deteriorated, showed worsening lesions involving the cortex and subcortical white matter of the parietal, posterior frontal, and occipital lobes, bilaterally (arrows).

Reversible Cerebral Vasoconstriction Syndrome Without Typical Thunderclap Headache

“…RCVS Without Thunderclap Headache in Case-Series or Case-Reports With RCVS.-Details about RCVS without TCH have been mainly described in smaller case-series [18][19][20][21][22][23][24][25] or in single case-reports with RCVS. [28][29][30][31][32][33][34][35] Two groups of patients can be distinguished, those with nonthunderclap headaches, and those without any headache. Given the increasing number of published cases with RCVS and the different appellations of RCVS previously used, our review is not exhaustive.…”

“…18,21,22 Patients with a history of migraine described that symptoms were unlike their usual migraine attacks. 18 Precipitant factors reported in RCVS with nonthunderclap headache were postpartum in 11 patients, 18,19,21,23,31,34,35 or vasoactive substances use in 14 patients, including cannabis, 18,24,30,32 antidepressants, 18,24,28,33 triptans, 18,21,33 amphetamine, 18,22 nasal decongestants, 21,22 bromocriptine, 29 energy drink, 18 dihydroergotamine, 18 or khat use. 28 The most frequent associated neurological symptoms were one-sided motor deficits, [18][19][20][21][22][23]25,[29][30][31]35 hemianopia, 25 or aphasia.…”

“…19,31 Although the functional outcome was usually good, death occurred in 5 women in the postpartum period. 19,31 The majority of these patients with RCVS and nonthunderclap headache had cerebral complications such as IS, 20,24,25,[29][30][31]35 ICH, 25,31 cSAH, 18,22,28,33 PRES, 19 SDH, 18 associated ICH and IS, 18,31 associated PRES and ICH, 19 associated PRES and IS, 19 associ-ated SDH and ICH, 18 associated ICH and cSAH, 21 associated IS, ICH, and cSAH, 19 or associated IS, ICH, and PRES. 34 We found 3 isolated case-reports with RCVS without headache.…”

“…Our literature search identified 87 patients with RCVS without TCH (Tables and ). These cases included 30 patients extracted from 2 large series of RCVS, 24 patients from 8 case‐series of RCVS, 21 patients extracted from 1 study dedicated to IS in the young, 4 patients extracted from 2 studies dedicated to cSAH and 8 single case‐reports . Overall, 69 patients had nonthunderclap headache, 15 patients did not have headache, and 3 patients had an unknown headache pattern because RCVS presented with coma, confusion, or aphasia …”

“…-Continued Details about characteristics of headache and outcome (mRS at 3 months) of patients in the series of IS 17 are Wolff personal data.These cases included 30 patients extracted from 2 large series of RCVS, 7,15 24 patients from 8 caseseries of RCVS, 18-25 21 patients extracted from 1 study dedicated to IS in the young,17 4 patients extracted from 2 studies dedicated to cSAH26,27 and 8 single case-reports [28][29][30][31][32][33][34][35]. Overall, 69 patients had nonthunderclap headache,7,15,[17][18][19]21,[25][26][27][28][29][31][32][33][34][35] 15 patients did not have headache,7,17,23,27,30 and 3 patients had an unknown headache pattern because RCVS presented with coma, confusion, or aphasia 17,19. Detailed clinical and radiological features were available for 57 of the 87 patients (Table 2).…”