Exposure to vasoactive substances is another established
risk factor, selleckchem and RCVS may occur in the postpartum period particularly when epinephrine is used in epidural anesthesia for labor.[10] Other presenting symptoms may include transient or focal neurological findings and rarely seizures. Vascular neuroimaging reveals multifocal intracranial arterial vasoconstriction, although these abnormalities may only be seen several days after onset and be missed on an MRA performed shortly after headache onset.[10] RCVS may also be accompanied by RPLS, cervical artery dissection, and cortical SAH. Aside from CVT, RPLS, RCVS, and cervical artery dissection, the puerperium reflects a general period of hypercoagulability that
places the postpartum woman at a higher risk of stroke than the general population, which includes cardioembolism.[11] The relative risk in the 6-week postpartum period is 8.7 (95% confidence interval 4.6-16.7) for ischemic stroke and 28.3 (95% confidence interval 13.0-61.4) for hemorrhagic stroke.[12] Hemorrhagic stroke would be more likely to present with headache, especially thunderclap headache, but the lack of focal neurological deficits renders would have rendered these diagnoses less likely. Nonetheless, other vasculopathies, including cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL),[13] are known to have a predilection for presenting in the peripartum period, www.selleckchem.com/products/birinapant-tl32711.html and had the initial family history been available, this
may have been higher on the differential diagnosis before neuroimaging. Pituitary apoplexy is always in the differential diagnosis of thunderclap headache,[14] with particular relevance in pregnancy, where the pituitary gland may expand as much as 136% in size[15] because of an increase in lactotrophs, with an accompanying increase in vascularity.[16] Bay 11-7085 The postpartum period usually reflects a period of time where the pituitary gland diminishes in size, but had the patient also presented with vomiting, altered mental status, visual or oculomotor deficits, or signs of pituitary insufficiency, it would have been a more likely diagnosis. This condition is always a possibility when approaching the patient with acute headache in the postpartum period, especially when epidural anesthesia has been administered. The clinical hallmark of this condition is an orthostatic headache, which was lacking in this patient. Although thunderclap headache may occur at the onset of spontaneous intracranial hypotension, there is not a known association with PDPH. Bacterial meningitis seems rare in the postpartum period, but epidural and spinal anesthesia appears to be a major risk factor.