A headache-free reversible cerebral vasoconstriction syndrome (RCVS) with symptomatic brain stem ischemia at late pregnancy as a rare manifestation of RCVS resolved with termination of pregnancy by semi-urgent cesarean section

Abstract

A 32-year-old pregnant woman in her 39th week of pregnancy presented at the emergency room complaining of sudden-onset dizziness with gaze disturbance and was admitted to our hospital. Her past medical history included hypertension, diabetes mellitus and infarction in the right medulla oblongata 18 months prior to this event. Magnetic resonance (MR) angiography showed multiple irregular stenosis of the intracranial arterial system. Although MR images revealed no fresh ischemic or hemorrhagic lesions, she was diagnosed with reversible cerebral vasoconstriction syndrome (RVCS) associated with pregnancy. Cesarean section immediately resolved the headache-free ischemic RCVS. The postpartum course of the patient was uneventful as well as that of her baby. Follow-up MR angiography showed improvement of intracranial vasoconstriction and follow-up MR imaging showed improvement of a left medial pontine ischemic lesion on diffusion-weighted image. This report describes a rare manifestation of pregnancy-related RCVS.

Figure 1:

Pre-pregnant axial sections of T2-weighted image (upper row) and fluid attenuation inversion recovery (lower row) show a small infarction scar in the right medulla oblongata and mild leukoaraiosis in the cerebral white matter.

Figure 2:

In comparison with the examination 11 months before admission (A), magnetic resonance angiographies show emergence (B) and disappearance (C and D) of multiple stenotic changes especially in the middle cerebral arteries and in the left vertebral artery.

Figure 3:

Serial magnetic resonance images (A–D) show emergence (B and C) and disappearance (C and D) of left medial pontine ischemic lesion. Upper: FLAIR, lower: DWI.