Long lasting vasospasm associated with bromocriptine-induced postpartum cerebral angiopathy; detected on transcranial doppler ultrasonography.

Abstract

Background: Postpartum cerebral angiopathy is a rare entity generally characterized by headache , vomiting , seizures, and focal neurological signs following a normal pregnancy. Vasospasm is thought to be the underlying phenomenon. To date, there have been several reports of PCA in relation to the use of ergonovine, sympathomimetic drugs, and bromocriptine. Clinical signs may be misleading, suggesting suspicious subarachnoid hemorrhage, but computed tomographic scan does not reveal any bleeding; moreover, the cerebrospinal fluid usually remains normal or reveals a moderate pleocytosis. In such a case, TCD is available to make a different diagnosis.

Case: A 32-year-old woman presented with an episode of transient left side weakness and dysarthria for about 15 minutes 5 days prior to the admission to our hospital, and a headache worsened day by day. She became pregnant a second time. The second pregnancy was uncomplicated, and she gave birth to a healthy baby 28 days before the admission to our hospital. She received oral bormocriptine mesylate for the lactation suppression 17 days after the delivery in doses of 2.5 mg twice a day. The patient was admitted to other general hospital due to a headache, nausea, and transient left side hemiparesis and dysarthria 27 days after giving birth. A neurologic examination revealed no hemiparesis and dysarthria, but hyperreflexia on left side. The neck stiffness and Kernig signs were equivocal. FLAIR image showed focal high-signal areas on right frontal white matter. Cerebral angiography revealed no definite vascular lesions except the suspicious mild stenosis on both middle cerebral arteries & CSF study was normal. But, TCD disclosed diffused arterial vasospasm. She was transfered to our hospital, where examination revealed no neurological deficit except mild neck stiffness with headache. On the fourth day in our hospital, her headache was more worsened and mild left side weakness on upper and lower extremities and dysarthria was recurred as well. At that time, TCD revealed diffuse intracerebral vasospastic condition again and an elevated red blood cell count (up to 4,500 cells /ml) was detected in CSF. Brain MRI showed that it was progression to focal high signal areas on right frontal white matter. Cerebral angiography revealed stenosis in both proximal middle cerebral arteries and irregular arterial narrowing in the cortical branches consistent with a diffuse vasospastic condition or vasculitis, but no aneurysm and vascular anomaly. Therefore, we could diagnose this case as bromocriptin induced postpartum cerebral angiopathy. Conclusion: Postpartum cerebral angiopathy is a benign, reversible clinicoradiologic syndrome. The clinical outcome is good. It is important of a different diagnosis because PCA is similar that clinical symptoms and radiologic finds of subarachnoid hemorrhage and other vasculitis. In this case, TCD can help us to make to a diagnosis. Moreover, we might suggest that clinicians should be aware of the possibility of concomittent subarachnoid hemorrhage when the headaches and neurological deficits are recurrent or long lasting despite of the withdrawal of bromocriptine.