Case Report

Postpartum stroke, a diagnostic challenge Abstract

Postpartum stroke is rare, and because complaints are similar to preeclampsia, diagnostic confusion may delay the diagnostic workup that should include prompt computerized tomography of the brain. We describe a patient with postpartum stroke who died because of extensive ischemic damage throughout the brain with 3 simultaneous Arterial occlusions. We stress the importance of raising this diagnosis in your workup because adequate measurements like angiography and intra-arterial thrombolysis could signifi- cantly improve the patient’s outcome.

A 33-year-old woman was admitted to the hospital after resuscitation for cardiac arrest, 19 days after delivery of her second child. Primarily, she presented with complaints of dizziness, nausea, and vomiting to her general practitioner (GP). Vital signs and consciousness were normal. Additional Neurological examination demonstrated a positional nystag- mus without other abnormalities. She was diagnosed with a benign positional vertigo and treated with intramuscular promethazine under surveillance of the GP. Few minutes later, the GP found the patient collapsed with apnea and cardiac arrest. Cardiopulmonary resuscitation was started successfully, and upon arrival at the emergency department, the patient was intubated and demonstrated a normal electrocardiogram. Both pupils were dilated and unrespon- sive to light, and the left pupil was transformed. Glasgow Coma Scale was 3 (E₁ M₁ V₁).

Emergency Computerized tomography of the cerebrum demonstrated extensive ischemic damage through- out the brain. Additional cerebral angiography showed a thrombus in the left Internal carotid artery as well as the right vertebral artery and a complete occlusion of the Basilar artery (Fig. 1).

An attempt to regain perfusion by intra-arterial thrombo- lysis was unsuccessful presumably because of the large thrombus formation. The next day, the patient deteriorated neurologically with absent brain-stem reflexes. Clinical brain death was confirmed by isoelectric electroencephalography. A heart-beating donor procedure was initiated, and the patient’s kidneys and liver were removed. During the

Fig. 1 Cerebral angiography with a thrombus in the left internal carotid artery.

workup for the donor procedure, a transesophageal ultra- sound demonstrated a thrombus in the left cardiac auricular. Cerebrovascular disorders including both infarction and hemorrhage are uncommon puerperal phenomena. In the United States, the overall risk of pregnancy-related stroke was estimated to be between 24.6 and 34.2 per 100000 deliveries [1,2]. The mortality rate is high, between 8% and 20%. Moreover, in survivors, residual Neurological sequelae are reported to be present in up to 40% of the cases [2,3]. Most patients with postpartum stroke present within 14 days after delivery. The clinical presentation can be diverse but usually includes headache (80%), composite Neurological deficits (60%), seizures (55%), and/or visual changes (50%). Because complaints are similar to preeclampsia, diagnostic confusion may delay the diagnostic workup that should include prompt CT of the brain. As for stroke, in general, the time to treatment is essential in preserving brain tissue and preventing permanent neurological damage. Therefore, addi- tional cerebral angiography may be useful to confirm the diagnosis, even with a strong clinical suspicion and a negative CT scan. Recently, Mendez et al [4] reported the first

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843.e4 Case Report

successful intra-arterial thrombolysis for ischemic stroke in the postpartum period.

The puerperium is notorious for thromboembolic com- plications due to a Hypercoagulable state. These thromboem- bolic complications are mainly venous occlusions like deep vein thrombosis and pulmonary embolism. However, in case of a postpartum stroke, Witlin et al [5] demonstrated an equal number of arterial (6/20) and venous intracranial occlusive lesions (7/20).

Because only small series have been reported, it is difficult to define risk factors for postpartum stroke. So far, a simultaneous occlusion of 3 cerebral arteries has not been reported.

Conclusion

In summary, postpartum stroke is a rare disease and a diagnostic challenge for the clinician. Criteria for prevention are enigmatic. A fast diagnostic workup including prompt neuroimaging by cerebral angiography might allow some patients to undergo successful thrombo- lytic treatment.

Philip L.J. DeKoninck MD Johanna M.A. Pijnenborg MD, PhD Department of Obstetrics and Gynaecology TweeSteden Hospital, PO Box 90107

5000 LA Tilburg, The Netherlands E-mail address: [email protected]

Stefan W. van Zuthphen MD

Department of Intensive Care

TweeSteden Hospital 5000 LA Tilburg, The Netherlands

Department of Surgery TweeSteden Hospital

5000 LA Tilburg, The Netherlands

Edo P.J. Arnoldous MD, PhD Department of Neurology TweeSteden Hospital

5000 LA Tilburg, The Netherlands

doi:10.1016/j.ajem.2008.01.045

References

1. James AH, Bushnell CD, Jamison MG, Myers ER. Incidence and risk factors for stroke in pregnancy and the puerperium. Obstetr Gynecol 2005;106(3):509-16.
2. Lanska DJ, Kryscio RJ. Risk factors for peripartum and postpartum stroke and intracranial venous thrombosis. Stroke 2000;31(6):1274-82.
3. Simolke GA, Cox SA, Cunningham FG. Cerebrovascular accidents complicating pregnancy and the puerperium. Obstet Gynecol 1991;78: 37-42.
4. Mendez JC, Masjuan J, Garcia N, de Lecinana M. Successful intra- arterial thrombolysis for acute ischemic stroke in the immediate postpartum period: case report. Cardiovasc Intervent Radiol 2006 [electronic publication ahead of print].
5. Witlin AG, Matter F, Sibai BM. Postpartum stroke: a twenty-year experience. AM j Obstet Gynecol 2000;183:83-8.