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Case Reports
. 2025 Sep 27:19418744251384752.
doi: 10.1177/19418744251384752. Online ahead of print.

Delayed Diagnosis of Postpartum Subarachnoid Hemorrhage Caused by Vertebral Artery Aneurysm: A Case Initially Misdiagnosed as Post-Dural Puncture Headache

Nirmalya Ray  1 , Mithun Shekar  2 , Ritwick Mondal  3 , Shramana Deb  3 , Jayanta Roy  3 , Julián Benito-León  4   5   6   7
Affiliations
Case Reports

Delayed Diagnosis of Postpartum Subarachnoid Hemorrhage Caused by Vertebral Artery Aneurysm: A Case Initially Misdiagnosed as Post-Dural Puncture Headache

Nirmalya Ray et al. Neurohospitalist. .

Abstract

Background: Postpartum subarachnoid hemorrhage caused by aneurysm rupture is a rare but potentially life-threatening complication that can mimic a benign postpartum headache, especially after neuraxial anesthesia.

Case report: We describe a 40-year-old woman who developed a severe headache, predominantly located in the occipital and posterior neck region, following cesarean section under spinal anesthesia. Initially presumed to be post-dural puncture headache, her condition deteriorated by postoperative day 5, with coma and seizures. Cranial computed tomography revealed diffuse subarachnoid and intraventricular hemorrhage. Vascular imaging showed a dissecting aneurysm of the right vertebral artery (V4 segment), with the posterior inferior cerebellar artery arising from the aneurysm dome. She underwent endovascular coiling with parent vessel sacrifice. Her recovery was favorable, with only mild cerebellar ataxia at discharge. At the 3-year follow-up, she was neurologically intact.

Discussion: This case underscores the importance of considering aneurysmal subarachnoid hemorrhage in postpartum patients with atypical or worsening headache following neuraxial anesthesia. Early neuroimaging and timely intervention can lead to excellent outcomes.

Keywords: endovascular treatment; neurocritical care; parent vessel sacrifice; post-dural puncture headache; postpartum headache; seizures; spinal anesthesia; subarachnoid hemorrhage; vertebral artery dissecting aneurysm.

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Conflict of interest statement

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1.
Figure 1.
Axial Non-contrast Head CT Images (A and B) Show Diffuse Subarachnoid Hemorrhage in the Prepontine Cistern (A) and Intraventricular Hemorrhage Within the Fourth Ventricle (B). Oblique Sagittal Maximum Intensity Projection (C) and Coronal Volume-Rendered (D) CT Angiography Reconstructions Reveal a Dissecting Aneurysm (Arrow) Originating From the V4 Segment of the Right Vertebral Artery. The Right Posterior Inferior Cerebellar Artery (Arrowhead) Arises From the Mid-dome of the Aneurysm
Figure 2.
Figure 2.
Right Vertebral Artery Digital Subtraction Angiogram in Anteroposterior Projection (A) and Three-Dimensional Rotational Angiogram (C) Demonstrate a Dissecting Aneurysm (Arrow) Arising From the V4 Segment of the Right Vertebral Artery, With the Right Posterior Inferior Cerebellar Artery (PICA) Originating From the Aneurysm Dome (Arrowhead). Left Vertebral Artery Angiogram (B) Confirms the Codominance of Both Vertebral Arteries. Simultaneous Vertebral Artery Injections in Working Projection (D) Show the Same Findings as in Panels A and C. Post-procedure Angiograms (E and F) Demonstrate Dense Coil Embolization of the V4 Segment, With Complete Exclusion of the Aneurysm From the Circulation. The Basilar Artery and Its Branches Opacify Normally, and the Right PICA Remains Patent
Figure 3.
Figure 3.
Axial Non-contrast CT Head Showing a Wedge-Shaped Hypodensity (Asterisk) in the Medial Part of the Postero-Inferior Aspect of the Right Cerebellar Hemisphere, Suggestive of an Acute Infarct in the Right Posterior Inferior Cerebellar Artery Territory
See this image and copyright information in PMC

References

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