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.