American Journal of Emergency Medicine 33 (2015) 600.e1-600.e3

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American Journal of Emergency Medicine

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Case Report

Bilateral carotid and Vertebral artery dissection: a life-threatening cause of postpartum headache

Abstract

We report a case of a 31-year-old G4P4 woman who was 3-week status post vaginal delivery who presented to the emergency depart- ment (ED) with a worsening headache that developed 1 week after de- livery. She was initially seen in the ED at 2 weeks postpartum. At that time, a computed tomography (CT) without contrast revealed no signif- icant findings, and she was discharged with hydrocodone/acetamino- phen, which provided adequate pain relief. She returned to the ED one week later with an increased headache, left upper and lower extremity numbness, and left facial numbness for 24 hours. CT and magnetic res- onance angiogram was performed and found bilateral carotid and bilat- eral vertebral artery dissection. Because postpartum headaches are most commonly benign, our case highlights the importance of consider- ing Life-threatening causes for headaches in postpartum patients with neurologic symptoms.

Headache is a common complaint in the emergency department (ED). One study found that “symptoms involving head and neck pain” were the sixth most common presenting complaint in the ED, making up 2.2% of visits in all age groups [1]. The differential diagnosis for head- aches is broad; however, most cases are not dangerous or life- threatening. Headaches are also one of the most common complaints in the postpartum period [2]. The reported incidence of postpartum headache ranges from 11% to 80% [3]. Approximately 50% of those head- aches are attributed to migraines [4]. Differentiating dangerous or life- threatening causes of headache can be challenging. Spontaneous cervi- cal artery dissection involves the carotid or vertebral arteries and is an extremely rare cause for headaches in postpartum patients. Arterial

dissection implies a separation of the layers of an artery leading to intru- sion of blood between the layers of an arterial wall [5].

A 31-year-old G4P4 caucasian woman was 3-weeks status postvaginal delivery and presented to the ED with a 2-week history of a worsening headache. The onset of the headache was gradual and ini- tially migratory. However, it became increasingly unilateral on the right. The headache was intermittently associated with blurry vision in both eyes, varying visual changes, and occasional partial loss of visual field. One week prior to her presentation, she was evaluated at an ED for the same complaint. At that time, a computed tomography (CT) of the head without contrast was performed and showed no acute intracranial pa- thology. She was discharged home with hydrocodone-acetaminophen, which provided adequate pain control until 24 hours prior to her return ED visit. At the time of her return presentation, her headache had become increasingly right sided and was associated with left upper extremity, Left lower extremity, and left facial numbness. There were no vision changes at the time of presentation. The patient had a medical history of endome- triosis and anemia. Surgical history was significant for 2 exploratory lap- aroscopies. Her medications included hydrocodone-acetaminophen, triamcinolone nasal, acetaminophen, and prenatal vitamins, and she de- nied any drug allergies. Vital signs on presentation were as follows: tem- perature, 36.4?C; pulse, 76 beats/min; respirations, 16 breaths/min; blood pressure, 129/85 mm Hg; and oxygen saturation, of 99% on room air. Physical examination revealed an alert and oriented woman in no acute distress. Sensation examination revealed decreased sensation of the left facial branch of cranial nerve V, and entire left upper and lower extremi- ties. Sensation to pinprick was preserved throughout. Strength testing in all extremities was normal. The remainder of her Cranial nerves were in- tact. The rest of the examination was unremarkable. All laboratory studies

Fig. 1. Computed tomographic scan sagittal view of left Carotid artery dissection.

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Fig. 2. Computed tomographic scan sagittal view of the right carotid artery dissection.

were within normal limits. A CT of the head without contrast on her re- turn ED visit revealed increased attenuation involving the distal M1 and proximal M2 segments of the right Middle cerebral artery, which was consistent with acute thrombus. Subsequently, a magnetic resonance imaging and magnetic resonance angiogram of the head revealed increased signal intensity in the right temporal and parietal regions in- volving the cortex and subcortical white matter. In addition, there was increased signal intensity involving the internal carotid and verte- bral arteries bilaterally with associated compromise of their respec- tive lumens. There was near-complete occlusion of the right Internal carotid artery at its origin. CT angiogram confirmed narrowing of bi- lateral carotid artery and left vertebral artery, suggestive of bilateral internal carotid and left vertebral artery dissection (Figs. 1, 2, and 4). The magnetic resonance angiogram revealed a classic owl eye sign (Fig. 3) on the right vertebral artery indicative of artery dissection. The patient was started on heparin 1000 U/h and transferred to an- other institution for care.

Postpartum cervical artery dissection is a very rare but serious con- dition. Only 32 cases of postpartum cervical artery dissection have been previously reported in the literature. Of those, 24 patients reported one of the cervical arteries dissected, whereas 3 involved 2 arteries, 3 in- volved 3 arteries, and only 1 patient reported all 4 arteries dissected. The most common symptom among these patients was headache or mi- graine [6]. Of the 32 cases, there was no correlation of cervical artery dis- section to the length of labor or whether delivery was completed vaginally or through cesarean. However, neck pain and headache are present in 60% to 90% of these cases [6]. The cause of the patient’s dissection is unknown; however, Valsalva maneuver during labor and hemodynamic and hormonal changes related to pregnancy are Potential causes.

Continuous refractory headache in postpartum patients with neuro- logic symptoms and no history of migraine that is unrelieved by analge- sics or change in position should have diagnostic imaging to detect the presence of other causes such as cervical artery dissection.

Fig. 3. A T₁-weighted magnetic resonance image demonstrating the classic owl eye seen in the right vertebral artery dissection.

E.L. Simon et al. / American Journal of Emergency Medicine 33 (2015) 600.e1-600.e3 600.e3

Fig. 4. Computed tomographic scan lower arrow (blue) reveals a normal left vertebral artery at C2 and C3. The upper arrow (red) reveals the compromised left vertebral artery at C1.

Erin L. Simon, DO

Emergency Medicine Department, Akron General

Medical Center, Akron, OH Corresponding author. Akron General Medical Center 1 Akron General Ave., Akron, OH 44307

E-mail address: [email protected]

Greg Griffin, BS Evan Bosman

Emergency Medicine Research, Akron General Medical Center, Akron, OH

http://dx.doi.org/10.1016/j.ajem.2014.09.017

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