Moyamoya Disease Diagnosed With Intracranial Hemorrhage After Cesarean Section Under Spinal Anesthesia: A Case Report

Moyamoya disease (MMD) is a rare non-inflammatory cerebral vasculopathy characterized by progressive stenosis of the internal carotid arteries, often bilaterally, and the formation of abnormal collateral vascular structures at the cranial base. A patient who underwent elective cesarean section (C/S) twice under spinal anesthesia and was diagnosed with MMD as a result of recurrent intracranial hemorrhage in the postpartum periods is presented. A 41-year-old female patient without any systemic comorbidity, gravida 2, parity 2, had her second cesarean section (C/S) operation under spinal anesthesia and was discharged on the third postoperative day without any problems. The patient had a mild headache that started from the occipital region and spread to the entire cranium on the same day. After applying to the emergency department at different times, she was discharged with conservative treatment. The patient had a severe headache and was admitted to the emergency room on the ninth postoperative day. The patient, who was diagnosed with intracranial hemorrhage after cranial imaging, was referred. Cranial angiography revealed advanced bilateral internal carotid artery symmetric occlusion and the basilar artery was preserved. According to the angiographic image, the patient was diagnosed with moyamoya disease and was followed up in the intensive care unit. The muscle strength of the patient, who had no cranial nerve pathology or lateralization findings, was evaluated as normal. Conservative management was applied in the intensive care unit. The patient was discharged with recommendations for neurosurgery and cardiovascular surgery after 12 days. In the postpartum period, especially in cases of headache that persists for a long time after dural puncture and does not have a postdural feature, intracranial hemorrhage should be considered until proven otherwise, and moyamoya disease also be considered in the differential diagnosis of intracranial hemorrhage. The approach to the patient in the perioperative period should focus on providing normotension, normocapnia, normothermia, and effective analgesia.