Case Studies

Puerperal Extracranial Vertebral Artery Dissection and
Nonaneurysmal Subarachnoid Hemorrhage
James W. Garrard, MBChB,* Renata F. Simm, MD,† Edson Bor-Seng-Shu, PhD,†
and Ricardo C. Nogueira, PhD†

Previously reported only a few times before, we present a case of extracranial
vertebral dissection and spontaneous frontoparietal subarachnoid hemorrhage (SAH)
in the puerperium, discussing possible mechanisms and difficulties in management. A 35-year-old woman presented 10 days postcaesarean section with neck
pain and vertigo with normal initial investigations. Following recurrent vertigo,
headache, and ataxia, imaging revealed a frontoparietal SAH and vertebral artery
dissection. The patient was consequently treated with aspirin, and then following a return of symptoms 3 weeks later, warfarin therapy was continued for 6
months. The possible underlying mechanisms for this case are discussed, including reversible cervical vasoconstriction syndrome and posterior reversible
encephalopathy syndrome, although neither was identified. The small SAH alongside recurrent posterior circulation symptoms resulted in the initiation of
antithrombotic therapy. This report supports studies demonstrating higher incidence of cervicocephalic arterial dissection in the puerperium. Moreover, the
heterogeneous presentation and manifestations of such cases require individualized treatment, and warrant studies into underlying mechanisms behind
extracranial dissection and nonaneurysmal SAH. Key Words: Puerperium—
vertebral artery dissection—subarachnoid hemorrhage—cervicocephalic artery
dissection—stroke—reversible cervical vasoconstriction syndrome.
© 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Introduction
Cervicocephalic arterial dissection (CCAD) is a wellknown cause of stroke in patients under 50, rarely during
From the *Department of Cardiovascular Sciences Department, University of Leicester, Leicester, United Kingdom; and †Department
of Neurosurgery and Neurosonology, Hospital das Clínicas da
Universidade de São Paulo, São Paulo, Brazil.
Received June 26, 2015; revision received September 27, 2015;
accepted October 6, 2015.
Address correspondence to James W Garrard, MBChB, Department
of Cardiovascular Sciences, University of Leicester, Robert Kilpatrick
Building, Leicester Royal Infirmary, Leicester LE1 5WW, UK. E-mail:
j1garr@outlook.com.
1052-3057/$ - see front matter
© 2015 National Stroke Association. Published by Elsevier Inc. All
rights reserved.
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2015.10.006

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the puerperium.1 The occurrence of subarachnoid hemorrhage (SAH) alongside CCAD can be found as a
complication of dissection, with nonaneurysmal SAH only
reported a few times.2 We present a case of extracranial
vertebral dissection and spontaneous frontoparietal SAH,
discussing possible mechanisms and difficulties in
management.

Case
A 35-year-old woman presented to the emergency department 10 days postelective caesarean section with
sudden-onset, severe right-sided neck pain and vertigo.
Initially, neurological examination and investigations,
including cranial computerized tomography, were
normal.

Journal of Stroke and Cerebrovascular Diseases, Vol. 25, No. 2 (February), 2016: pp e12–e14

PUERPERAL DISSECTION AND HEMORRHAGE

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Figure 1. Images using different modalities to
show SAH, cervical dissection, and cerebellar
infarct. (A, i-iii) Selected frames from cranial CT
showing evidence of a small, subarachnoid hemorrhage in the frontoparietal lobe. (B, i,ii) Selected
images from digital cerebral angiography showing
a vertebral artery dissection in the right vertebral artery and an occlusion of V2 without the
presence of any aneurysms. (C) Cranial MRI
segment showing an infarcted lesion of the cerebellar vermis. Abbreviations: CT, computed
tomography; MRI, magnetic resonance imaging;
SAH, subarachnoid hemorrhage.

Twelve hours later, the patient was admitted to intensive care following a further episode of vertigo, thunderclap
headache, and ataxia. Computerized tomography demonstrated a small frontoparietal SAH (Fig 1, A). Digital
subtraction angiography (DSA) demonstrated right vertebral artery dissection at V2 (Fig 1B), excluding cerebral
vasoconstriction–dilatation and aneurysms. Magnetic resonance imaging (MRI) demonstrated an ischemic lesion
within the cerebellar vermis (Fig 1, C).
Repeated transcranial Doppler examination excluded
embolic activity, basilar hemodynamic compromise, or cerebral vasoconstriction. The patient was discharged to an
infirmary and low-dose aspirin (75 mg) was started 1 week
after ictus.
Three weeks after initial presentation, the patient experienced recurrence of vertigo, although no further
abnormalities were evident on investigation (MRI with
angiography). Warfarin was commenced for 6 months,
with no further episodes.

Discussion
The incidence of CCAD in the puerperium is rare and
poorly understood; moreover, the few reports of coexistent SAH and CCAD occur in the context of an aneurysm,
reversible cervical vasoconstriction syndrome (RCVS), or

posterior reversible encephalopathy syndrome.2-4 RCVS
was our main hypothesis based on the location of SAH,
presence of dissection, and, most importantly, recurrent
thunderclap headaches. RCVS was not confirmed in this
case because the DSA showed no evidence for cerebral
vasoconstriction–dilatation; however, vasoconstriction is
known to progress from distal to proximal arteries in RCVS
and may have been missed in this case due to the early
timing of the DSA. Owing to hemorrhage location, which
was unlikely for an aneurysm, MRI with angiography
was chosen for follow-up investigation. MRI results and
a normotensive patient ruled out posterior reversible encephalopathy syndrome, and other etiologies including
intracranial extension of the dissection and central venous
thrombosis were considered; however, hemorrhage location and repeat imaging did not support such diagnosis.2,5
Managing rare cases can be difficult in the absence of
consensus. Although antithrombotic treatment is recommended in ischemic stroke secondary to CCAD,6 such
therapy is contraindicated in SAH6 and surgical intervention of identified aneurysm is considered the primary
management.7 Low-dose aspirin was initiated at day 7
once vertebral artery occlusion risk was deemed greater
than that of rebleed. Although anticoagulation is not beneficial compared to aspirin in CCAD,8 the recurring
symptoms in this case suggested ongoing transient

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ischemic phenomenon and a failure of antiplatelet therapy;
hence, anticoagulation was initiated.
This report supports studies demonstrating higher incidence of CCAD in the puerperium.3 Moreover, the
heterogeneous presentation and manifestations of such
cases require individualized treatment, and warrant studies
into underlying mechanisms behind extracranial dissection and nonaneurysmal SAH.

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J.W. GARRARD ET AL.
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