Reversible Cerebral Vasoconstriction Syndrome: A Severe Neurological Complication in Postpartum Period

A 38-year-old woman 12 days after delivery of her second pregnancy was admitted to emergency room for a severe occipital headache started 3 days before, associated with confusion, nausea, vomiting and walking impairment. Neurological examination showed left hemiparesis, hypoesthesia in left arm and leg. Brain computer tomography images showed a large intraparenchymal hematoma in the right frontoparietal lobes with mass effect on adjacent subarachnoid spaces and on lateral ventricle. The third day during hospitalization, the patient experienced a sudden worsening of the neurological symptoms and a severe headache peaking within 1 minute (min); a new brain computed tomography and brain magnetic revealed another small intraparenchymal hematoma in the left parietal lobe with increase of the amount of subarachnoid hemorrhage. Digital subtraction angiography discloses multifocal narrowing of the middle and small arteries in both anterior and posterior circulation with a relative spare of large vessels. Postpartum reversible cerebral vasoconstriction syndrome with intracranial hemorrhage is a rare clinical condition that can be misdiagnosed with other dramatic neurological diseases such as eclamptic encephalopathy, cortical venous thrombosis, primary angiitis of the central nervous system or posterior reversible encephalopathy syndrome with whom may share predisposing factors and neurological presentation but clinical course, treatment and prognosis is quite different and emergency physicians and neurologists should consider this diagnosis in postpartum patients with hemorrhage.