Double strike without stroke: a postpartum headache with too many causes

Pregnancy and postpartum are phases in the women's life where the thrombotic risk is increased both on the venous and on the arterial side.

We are presenting the case of a young woman at the third pregnancy, carried out without complications until delivery, whose postpartum was characterized by the occurrence of headache. Neuroimaging studies were performed, firstly brain computed tomography (CT) with CT Angiography and after brain Magnetic Resonance Imaging (MRI) with MR Angiography. The main finding was the simultaneous presence of two cerebrovascular vascular diseases, i.e. cerebral venous thrombosis (CVT) and left carotid dissection, without stroke. The neuroimaging features of both the diseases were analyzed and both CVT and dissection had neuroimaging markers of acute timing. After starting heparin therapy at anticoagulant dose the clinical symptoms disappeared within a few days.

CVT is a rare event with a peak in the late pregnancy and puerperium, but other arterial cerebrovascular events, as spontaneous dissection, have not an increased incidence in the postpartum. Headache is one of the main symptoms for all these cerebrovascular diseases, but usually stroke is the accompanying event. This is not always true and the presented case illustrates this unexpected occurrence.

Headache is a nonspecific and highly prevalent symptom and in the postpartum period it could raise the suspicion of CVT. Sometimes several different causes are found for the same symptom and concurrent acute cerebrovascular diseases might be considered. Neuroimaging investigations may help for diagnosis and timing concurrent thrombotic diseases, particularly DWI-MRI.