Fatal Reversible Cerebral Vasoconstriction Syndrome: A Complication of Postpartum Haemorrhagic Shock

Reversible cerebral vasoconstriction syndrome (RCVS) is a rare but serious cerebrovascular disorder characterised by transient narrowing of the cerebral arteries, triggered by internal or external stressors. We present a case of RCVS in a 28-year-old female patient 10 days postpartum, after a haemorrhagic shock. The initial acute management of the abdominal haemorrhagic shock syndrome included massive transfusion of blood products along with vasopressors and crystalloids. Although her condition stabilised initially, she later exhibited severe neurological deficits of unknown cause, prompting further investigations and imaging. An immediate native computed tomography (CT) scan revealed an infarct demarcation in the posterior territory of the right middle cerebral artery (MCA) and the watershed zones bilaterally, accompanied by oedema of the right cerebral hemisphere. Intracranial CT angiography showed severe arterial narrowing, which was most pronounced in the right MCA and its branches. Digital subtraction angiography (DSA) confirmed marked intracranial vasospasm consistent with the diagnosis of a RCVS. Intra-arterial spasmolysis was performed, but the patient's neurological condition continued to deteriorate. A further CT scan showed progressive brain oedema and new infarct demarcation in the basal ganglia on the right side with persistent vasospasm. The spasmolysis was repeated with only moderate success. Magnetic resonance imaging (MRI) of the brain and spine was performed to evaluate the prognosis and exclude additional causes of the severe vasospasm. There, progressive infarct demarcation due to the persistent refractory vasospasm and signs of a secondary hypoxic encephalopathy were identified. Despite aggressive interventions, the patient's condition deteriorated, and she passed away six days after the haemorrhagic event, highlighting the severity of RCVS in this context. This case underscores the need for prompt recognition, rapid intervention, and comprehensive management strategies for patients with severe vasospasm following postpartum haemorrhagic shock. It also highlights the impact of intracranial vasospasm resulting in RCVS as a potential critical complication of life-saving treatments such as massive transfusion and vasoactive drug administration, particularly in postpartum women.