Vertebral Artery Dissection
Complicating Pregnancy and
Puerperium:
Case report and review of the
literature
Reza Pour N, Chuah S, Vo T,
Department of Obstetric and Gynaecology,
Liverpool Hospital, South Western Local Health District, Sydney
INTRODUCTION:
• Vascular dissections occur rarely during pregnancy. Spontaneous
extracranial vertebral artery dissection (VAD) itself is very rare in
general.
• The majority of pregnancy-related cerebrovascular diseases (CVD)
occur during delivery or 6 weeks immediately after delivery. Recent
data suggest that this increased risk may actually extend as long as
12 weeks postpartum.
• Risk factors for CVD: preeclampsia,
eclampsia,
chronic kidney disease,
black race,
pregnancy related hematologic disorders,
advanced age
CLINICAL PRESENTATION:
•
•
•
•
•
•
Clinical presentation varies
from patient to patient.
Spontaneous VAD can present
as:
Headache
Neck pain
Diplopia
Transient ischaemic attack
(TIA)
Horner’s syndrome
Ischemic stroke
ETIOLOGY
Traumatic events
Chiropactic manipulation
Predisposing factors
Chronic hypertension +/atherosclerosis
Pregnancy related risk
factors
Progesterone
collagen synthesis
Yoga
Marfan’s syndrome
Exercise
Fibromuscular dysplasia
Violent coughing
Rapid head turning
Vasculitis and cystic medial
necrosis
Oral contraceptives
Migraine
cardiac output
Shear stress
on the vessel wall
weaken the tunica
media of vessel
walls
greater risk of
media rupture
CASE DESCRIPTION
Case 1:
•
•
•
•
32-year-old
G1P0
38+2/40
No significant past
medical history
• Low risk, midwifery
antenatal care
INTRAPARTUM HISTORY
Timing
Symptoms & Signs
BP (mmHg)
CTG
Actions
On arrival
Early labour
130/70
Reassuring
monitor at BU
During BU
admission
-Dizziness
-Severe frontal
headache
-blurry vision
150/110
Variable
decelerations
Labetalo,l PO, STAT
15 minutes later
-Stronger
contractions
-Unremarkable
examination
238/120
Variable
decelerations
Hydralazine IV, STAT
15 minutes later
No neurological
symptoms
140/80
Reassuring
Close observation
2 hours later
Eclamptic seizure
230/120
Variability
complex variable
decelerations
Bradycardia
(66bpm)
-Loading dose
MgS04
-Hydralazine IV,
STAT
-Emergency LSCS
A healthy male baby, BW 2.46 kg,
APGAR scores of 4-7-10
POSTNATAL HISTORY
Timing
Symptoms &
Signs
BP
(mmHg)
Investigations
Actions
Immediate
Post-CS
Intubated for 12hrs
Unstable
Plt : 180
Cr: 69
ALT : 69
AST : 101
-ICU admission
-BP management
-Maintenance
MgSO4 infusion
48hrs postCS
-L sided neck pain
-Occipital headache
(refractory to simple
analgesia)
Unstable
-CT Head: NAD
-CTA neck: L VAD
-MRI: confirmed Dx
Low dose Aspirin
D10 post-CS
asymptomatic
Stable
-Vasculitis screen:
NAD
-Placenta
histopathology: NAD
-Discharged home
-triple agents oral
antihypertensive
-aspirin
-OPD follow up
CTA of neck, Focal stenosis with thickened wall and an intramural
thrombus of left vertebral artery at the level of C3.
L Vertebral Art
MRI Brain, confirmed the presence of a short segment vertebral
artery dissection at the level of C3.
• After a detailed history, she reported sudden onset of left sided
neck pain four days prior to the hospital presentation and had neck
massage two days after the onset of pain, resulted in worsening of
the symptoms which required taking regular simple analgesia.
Case 2:
• 33-year-old
• G2P0, TOP x 1
• No significant personal or
family history
• She received appropriate
antenatal care in the midwives
clinic.
ANTENATAL HISTORY
Timing
Symptoms &
Signs
BP (mmHg)
Investigations
Actions
35+5/40
- FMs
- Mild headache
- Pedal oedema
133/85
CTG reassuring
PET bloods normal
-Discharged home
-ANC follow up
36/40
-constant occipital
headache
-flashing lights in her
visual field
155/105
-CTG reassuring
-Growth USS normal
-PET bloods normal
- Urine PCR (296)
-Admit to the ANW
-Expectant
management of
preeclampsia
-Oral Labetalol
36+2/40
right-sided neck pain -refractory
high DBP
-fluctuant SBP
MRI neck: R VAD
- Em LSCS under
Spinal
-ICU admission
-Heparin infusion
(6hrs post-op)
Healthy female baby, BW 2.9kg,
APGAR of 9 at 10 minutes
MRA neck, coronal view of the vertebral arteries confirms
a 11mm C2-C3 right vertebral artery dissection
MRI Brain, Axial view of the vertebral arteries, no
evidence of posterior circulation cerebral infarct
POSTNATAL HISTORY
Timing
Symptoms &
Signs
Vital signs
Investigations
Actions
D2 post-CS -lower
abdominal pain
-severely tender
and peritonitic
abdomen
Haemodynamica - Hb despite
lly unstable
blood transfusion
-CT abdo/pelvis:
haematoma of
rectus muscle +
several areas of
acute bleeding
-Heparin infusion was
ceased
-Explorative laparotomy:
haematoma evacuation
- Low dose Aspirin: the
next day post-op
D7 Post-CS Increasing
abdominal
symptoms.
Temp 38 C
-Repeat CT abdo:
rectus sheath +
extraperitoneal
haematoma
-IV antibiotics
-CT-guided aspiration of
pelvic collection
D15 postCS
-afebrile
-stable
- Aspirate MCS:
negative
-discharged home
-Low dose Aspirin
-Oral antibiotics
-oral antihypertensive
Improving
symptoms
FOLLOW-UP PLAN
• Repeat MRI in 3 months postpartum
• Cease Aspirin if the dissection stable or
resolved
• Prophylactic antiplatlet or antithrombotic
therapy through the next pregnancy
DISCUSSION
• The actual incidence of VAD in the pregnancy and
post
partum
period
in
association
with
preeclampsia/eclampsia is unknown as the current
literature consists of case series and reports only.
• Because of collateral circulation, unilateral vertebral artery
dissections may go unrecognized and may be more common
than suspected. The outcome for most patients is benign,
reflecting the adequacy of the collateral circulation in young
patients. However, arterial compromise can result in brain
injury by several mechanisms.
• One case was found to have posterior circulation stroke
as a result of bilateral VAD and labour was induced at
37 weeks gestation for preeclampsia.
• Another patient at 38 weeks with severe neck pain that
persisted after induction for elevated blood pressure
and arteriography showed R VAD postpartum.
• A single case of lethal VAD in pregnancy with
subsequent massive subarachnoid haemorrhage (SAH)
has been reported that was confirmed by autopsy.
Spontaneous arterial dissection results from rupture and separation of the media
creating a false lumen within the vessel wall without a traumatic or iatrogenic cause.
Passage of blood into this false lumen forces the intimal-medial layer towards the
true lumen of the vessel, causing partial or full obstruction of flow, ultimately
leading to an ischaemic event.
• Diagnosis: CT or MRI angiography
• Treatment: anticoagulation or antiplatelet therapy
For a minimum of 3-6 months
• Reason for treatment: prevent future ischaemic events,
allow the dissection to heal on its own
• Safe MOD: UNKNOWN!
We recommend LSCS
CONCLUSION
•
We had 2 cases of VAD in the context of hypertensive disorders of pregnancy with an
acceptable outcome. A high level of vigilance is required particularly with preeclamptic
patients presenting with head/neck pain to allow an early diagnosis. This is as we
hypothesise, early and aggressive management of vertebral artery dissection may potentially
prevent further neurological complications.
•
However, post operative recovery of our second patient was complicated by side effects of
anticoagulant that required further procedural interventions and prolonged hospital stay.
•
The use of anticoagulants may be questionable if antiplatelet therapy is effective enough to
prevent future ischaemic events specifically in an obstetric patient after caesarean delivery
due to possible devastating complications.
•
There is an undeniable need for further studies to find the best management of vertebral
artery dissection in pregnant and postpartum population. Since the incidence is very low,
such a study would require the involvement of many different clinical centres and would take
many years to accomplish.
•
There is limited data on which mode of delivery is the safest. In our limited experience, we
recommend caesarean section to hasten delivery so that we can reduce the period of
elevated BP that theoretically may increase extension of the dissection and the subsequent
neurological complications.
REFERENCES
1.
Mass S, Cardonick E, Haas S, Gopalani S, Leuzzi R. Bilateral vertebral artery dissection causing a
cerebrovascular accident in pregnancy. J Reprod Med. 1999;44:887-890
2.
Cenkowski M, daSilva M, Bordun KA, Hussain F, Kirkpatrick ID, Jassal DS. Spontaneus dissection of the
coronary and vertebral arteries post-partum: case report and review of the literature. BMC Pregnancy
Childbirth. 2012 Nov 2;12:122.
3.
Hovsepian DA, Sriram N, Kamel H, Fink ME, Navi BB. Acute Cerebrovascular Disease Occuring After
Hospital Discharge for Labor and Delivery. Stroke. 2014 Jul;45(7):1947-50.
Glauser J, Hastings OM, Mervart M, et al: Dissection of vertebral arteries: Case report and discussion. J
Emerg Med. 1994;12:307-315
4.
5.
Tuluc M, Brown D, Goldman B. Lethal Vertebral Artery Dissection in Pregnancy A Case Report and
Review of the Literature. Arch Pathol Lab Med. 2006 Apr;130(4):533-5
6.
O'Rourke N, Wollman L, Camann W. Bilateral spontaneous vertebral artery dissection: management
during labor and vaginal delivery. Int J Obstet Anesth. 2004 Jan;13(1):44-6.
7.
Moroz L, Airoldi J, Almario C et al. Prophylactic treatment during pregnancy for women with a history of
vertebral artery dissection. American J of Obstetric and Gynaecology. 2006; 195; 104