Spontaneous Multiple Cervical Artery Dissection in the Puerperium

Case Report A 31-year-old female with a past history of migraine presented with a transient episode of anosognosia, dysarthria and left hemiparesis 18 days after an uncomplicated caesarean section under general anaesthesia, planned beforehand due to a spina bifida defect. She complained of a sudden onset of posterior neck pain on the fifth day after childbirth, followed by repeated attacks of migraine with visual aura. Examinations performed at the emergency department, a brain CT and laboratory tests were all unremarkable. Cervical ultrasonography revealed a proximal occlusion of the right internal carotid artery (ICA), a distal left ICA occlusion and left vertebral artery (VA) stenosis. Digital-subtraction angiography showed a right ICA dissection with suprabulbar occlusion and a left ICA dissection as well as VAs with irregular walls (‘string of beads’ appearance suggesting vessel stenosis and pseudoaneurysm formation) ( fig. 1 a, c, e, g). Previous orthopaedic surgery contraindicated MRI, and anticoagulation therapy was started. The headaches progressively remitted. Four-month follow-up cerebral and renal digital-subtraction angiography showed a persistent right ICA occlusion, but all other arteries were normal ( fig. 1 b, d, f, h). Introduction Cervical artery dissection (CAD) is an important cause of stroke in young adults and can occur in multiple arteries in 13– 16% of cases. Surprisingly, CAD has rarely been reported as a cause of stroke in pregnancy/puerperium [1, 2] . We report a case of a young women presenting with a four-vessel CAD postpartum. Published online: November 4, 2011