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Case Reports
. 2020;14(5):177-182.
doi: 10.5797/jnet.cr.2019-0108. Epub 2020 Mar 11.

Reversible Cerebral Vasoconstriction Syndrome in Early Pregnancy Treated with Endovascular Therapy

Satoru Fujiwara  1 , Nobuyuki Ohara  1 , Tomoyuki Kono  1 , Ryoma Inui  1 , Hirotoshi Imamura  2 , Michi Kawamoto  1 , Nobuyuki Sakai  2 , Nobuo Kohara  1
Affiliations
Case Reports

Reversible Cerebral Vasoconstriction Syndrome in Early Pregnancy Treated with Endovascular Therapy

Satoru Fujiwara et al. J Neuroendovasc Ther. 2020.

Abstract

Objective: We report a case of reversible cerebral vasoconstriction syndrome (RCVS) that occurred during early pregnancy and improved by endovascular therapy (EVT).

Case presentation: A 30-year-old Japanese woman at 8 weeks' gestation presented with sudden occipital headache followed by left hemiparesis and convulsion. MRI on admission revealed acute infarction in the distribution of the right posterior cerebral artery (PCA), and MRA demonstrated multi-segmental vasoconstrictions in the posterior circulation. Since the episode and image findings were suggestive of RCVS and the patient was in the organogenesis period, intravenous magnesium sulfate was administered as a vasodilator. Her level of consciousness improved temporarily; however, she suddenly fell into a stupor on day 4 of the illness. Emergency MRI demonstrated a fresh infarction in the left side of pons, and the poorer visualization of the posterior circulation. We proposed selective intra-arterial infusion of nicardipine 1 mg over 1 minute through an indwelling microcatheter in the middle of the basilar artery. The left superior cerebellar artery (SCA) and P1 blood flow improved after the procedure. Her symptoms improved gradually, and follow-up MRA performed on day 15 was almost normal. Hence, we established a definite diagnosis of RCVS. She was discharged to recovery phase rehabilitation hospital with modified Rankin Scale 4 and National Institute of Health Stroke Scale (NIHSS) 5.

Conclusion: RCVS can occur in early pregnancy period, and EVT is a potential therapeutic option for RCVS in this condition.

Keywords: early pregnancy; endovascular therapy; intra-arterial infusion of nicardipine; reversible vasoconstriction syndrome.

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Conflict of interest statement

Nobuyuki Sakai received lecture fees from Stryker Japan K.K. and Biomedical Solutions, Inc.; Nobuyuki Sakai received a research grant from TERUMO Corporation; Nobuyuki Sakai received consigned research fund from DAIICHI SANKYO COMPANY, LIMITED, TERUMO Corporation, and JIMRO Co., Ltd. The remaining authors have no conflict of interest related to this work.

Figures

Fig. 1
Fig. 1. Magnetic resonance imaging on admission. Diffusion-weighted imaging revealed acute infarction in the distribution of right PCA. MRA demonstrated multi-segmental vasoconstrictions mainly in the posterior circulation, with distal segment of right PCA and left P1 segment was poorly depicted in particular. FLAIR showed thin cortical subarachnoid hemorrhage around right occipital lobe (arrow). FLAIR: fluid-attenuated inversion recovery; PCA: posterior cerebral artery
Fig. 2
Fig. 2. Imaging findings on the illness day 4. Emergency MRI taken when neurological symptoms worsen demonstrated a fresh infarction in the left side of pons, and the poorer visualization of the diffuse posterior circulation.
Fig. 3
Fig. 3. (a) DSA findings before and after the procedure. Initial DSA confirmed the severe stenosis of left P1 and superior cerebellar artery. (b) After selective intra-arterial infusion of nicardipine 1 mg through an indwelling microcatheter in basilar artery, the blood flow of left P1 and SCA improved. DSA: digital subtraction angiography; SCA: superior cerebellar artery
Fig. 4
Fig. 4. Imaging findings on the illness day 15. MRA was almost normal including posterior circulation.
Fig. 5
Fig. 5. Clinical course. ADL: activities of daily life; EVT: endovascular therapy; LEV: levetiracetam
See this image and copyright information in PMC

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