Case Report:
A 38-year-old woman had a normal pregnancy and gave birth to her second
baby by vaginal delivery without preeclampsia or other complications.
She had no significant medical history, and there was no family history
of aneurysmal SAH or migraine. She had no history of taking medicine.
She initially had severe stiff shoulder and then begun to experience
sudden thunderclap headaches with epigastric pain on the 18th day after
delivery. At the time of visiting our emergency department, her
consciousness was clear and had no neurological deficits. The
thunderclap headache and stiff shoulder improved. Laboratory
investigations were all within normal limits, including blood cell
count, liver enzyme levels, renal function and electrolytes and no
coagulation abnormality. Urinalysis revealed no proteinuria. The
neuroradiological findings at the onset were shown in Figure 1. Computed
tomography (CT, Aquilion PRIME, Canon Medical Systems Corporation)
showed interhemispheric subarachnoid hemorrhage covering the cortical
surface of the frontoparietal lobe (Figure 1A). Magnetic resonance image
(MRI, Achieva 3.0T TX Quasar, Philips) fluid-attenuated inversion
recovery (FLAIR; repetition time (TR)=13000 ms, echo time (TE)= 140 ms,
field of view (FOV)=210 mm, matrix size=512*512, slice thickness=6 mm,
slice gap=0.6mm, NSA=1) revealed high-intensity area in the bilateral
basal ganglia and right occipital cortex (Figure 1B). Magnetic resonance
angiography (MRA; TR=25 ms, TE=3.4 ms, FOV=200 mm, matrix size=512*512,
slice thickness=1.1mm, gapless, NSA=1, flip angle=20-degree, Scan
technique=Inversion recovery) showed segmental narrowing and dilatation,
called “sausage of the strings”, in the bilateral middle and posterior
cerebral artery (Figure 1C). Cervical MRA showed irregular stenosis of
the left vertebral artery (VA) at the level of third-fourth cervical
vertebra (Figure 1D). Neither infarction nor brain aneurysm was
detected. In the evaluation of the three-dimensional black blood
T1-weighted imaging using the motion-sensitized driven equilibrium
three-dimensional turbo spin echo (MSDE; TR=shortest, TE=shortest,
FOV=230mm, matrix size=512*512, slice thickness= 0.7mm, gapless, NSA=2,
flip angle=90-degree, Scan technique=spin echo) sequence method, coronal
(Figure 1E) and axial view (Figure 1F) revealed a periluminal rim,
called crescent sign, suggested an intramural hematoma (IMH) consistent
with the extracranial vertebral artery stenosis area (Figure 1E, F). We
speculated that RCVS, PRES and CAD occurred almost at about the same
time. We treated her with rest and intensive hypotension without
antithrombotic therapy. After discharge, her clinical course was good
with no progression. After three months, CT and MRI revealed the
disappearance of SAH and FLAIR high intensity legion (Figure 2A). MRA
showed improvement of segmental narrowing (Figure 2B). Cervical MRA
revealed normal left VA (Figure 2C) and MSDE (Figure 2D, E) showed no
abnormal signal. These results indicate that these conditions were
reversible, and we have judged these reversible lesions as multiple
phenomena of postpartum stroke occurred at the same time.