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Reversible Cerebral Vasoconstriction Syndrome and Ischemic Stroke Secondary to Peripartum Cardiomyopathy - Report a
Stephanie Hang1, Priyadarshini Dixit1, Dilnaz Alam1
1Internal Medicine, Saint Joseph Mercy Oakland Hospital, Pontiac, USA.
Insights
Peripartum cardiomyopathy can rarely lead to acute cardioembolic stroke and reversible cerebral vasospasms. Prompt, aggressive treatment is crucial for managing these rare, combined neurological and cardiac emergencies in postpartum women.
Area of Science:
- Cardiology
- Neurology
- Obstetrics
Background:
- Peripartum cardiomyopathy (PPCM) is a rare form of heart failure occurring in late pregnancy or early postpartum period.
- Acute cardioembolic stroke is an infrequent but serious complication of PPCM, often associated with intracardiac thrombus formation.
Observation:
- A 26-year-old woman presented with acute heart failure 10 days postpartum, diagnosed with PPCM (EF 22%) and an apical thrombus.
- She subsequently experienced an ischemic stroke, treated with IV tissue plasminogen activator and mechanical thrombectomy.
- Cerebral vasospasms in the left middle cerebral artery were identified and treated with nimodipine.
Findings:
- The case demonstrates a rare confluence of PPCM, cardioembolic stroke, and reversible cerebral vasospasms.
- Treatment involved a multi-faceted approach including thrombolysis, thrombectomy, and vasospasm management.
- Digoxin was used for rate control and cardiac output support due to hypotension and vasospasm concerns.
Implications:
- This case underscores the importance of recognizing rare presentations of PPCM.
- Early and aggressive intervention is critical for improving outcomes in patients with co-occurring stroke and vasospasm.
- Further research into the pathophysiology and optimal management strategies for these combined conditions is warranted.
Abstract:
Acute cardioembolic stroke is a rare presentation of peripartum cardiomyopathy. We present an unusual case of peripartum cardiomyopathy, that subsequently developed cardioembolic ischemic stroke and reversible cerebral vasospasms. A 26-year-old G1P1 caucasian woman presented to the emergency department 10 days after a spontaneous vaginal delivery with the clinical and physical presentation of acute heart failure. Brain natriuretic peptide (BNP) level was >8000 pg/mL. Transthoracic echocardiogram (TTE) demonstrated global left ventricular hypokinesis, reduced ejection fraction (EF) 22% with grade I diastolic dysfunction and apical thrombus. On hospital day two of her heart failure exacerbation admission, a code stroke was activated for aphasia and confusion. She received an IV tissue plasminogen activator (tPA) and underwent a mechanical thrombectomy. On hospital day three, she developed worsening of neurological symptoms, and a computed tomography (CT) angiogram revealed vasospasm in the region of the left middle cerebral artery (MCA), which subsequently resulted in nimodipine therapy. Furthermore, her hospital course was complicated by persistent hypotension, and with our concern for vasospasm that was noted in the CT angiogram instead of guideline-directed therapy for heart failure, digoxin was given to control heart rate and to improve cardiac output. Ultimately, her neurological symptoms improved, and she was discharged on hospital day 10. This case highlights the combination of rare presentations - postpartum cardiomyopathy, ischemic stroke, and reversible cerebral vasospasms, which suggests that the time and size of the stroke are of the essence in terms of promptness of aggressive treatment.
