Research Article| Volume 375, P130-136, April 15, 2017

Reversible cerebral vasoconstriction syndrome in puerperium: A prospective study

Published:January 21, 2017DOI:


      • Reversible cerebral vasoconstriction syndrome (RCVS) belongs to the list of possible complications of puerperium.
      • Its main presenting symptom is thunderclap headache.
      • Headache is a frequent complaint of puerperium.
      • We prospectively searched RCVS in 900 puerperae during the first month post-partum.
      • Overall thunderclap headache was recorded in 3.4% of puerperae.
      • RCVS was documented in only one case (0.1%).


      Background and aim of the study

      Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by severe “thunderclap” headache, with or without associated neurological symptoms and neuroimaging findings of reversible vasoconstriction of cerebral arteries.
      Puerperium is a recognized precipitant, but the incidence of puerperal RCVS is unknown. We conducted a prospective study to assess incidence, risk factors and clinical features of RCVS.

      Material and method

      Nine-hundred consecutive puerperae were prospectively enrolled within three days of delivery. Past medical history, basal demographic, anthropometric and biological variables were recorded. Transcranial Colour Coded Sonography (TCCS) was performed to assess early signs of vasospasm in brain vessels. A structured telephone interview was planned in all subjects one month postdelivery.


      Thunderclap headache was recorded in 8 subjects (0.9%) on the first visit. At the one month follow-up interview 27 more patients reported having had at least one episode of thunderclap headache. In these 33 (3.8%) patients the course was spontaneously benign.
      One patient presented to the Emergency ward with throbbing thunderclap headache three weeks after delivery. Diagnostic work-up ended up in the diagnosis of RCVS, the outcome was favourable


      In normally coursing pregnancies and after uncomplicated delivery the risk of puerperal RCVS is negligible (0.1%). On the other way thunderclap headache may occur in a measurable proportion of (3.4%), although in the vast majority of cases (33/34 = 97%) it is of benign course. Transcranial Doppler sonography may be helpful to pick up those cases in whom further neuroradiological investigation is warranted.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the Neurological Sciences
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Headache classification subcommittee of the International Headache Society
        The international classification of headache disorders.
        Cephalalgia. 2004; 24: 1-160
        • Ducros A.
        • Boukobza M.
        • Porcher R.
        • Sarov M.
        • Valade D.
        • Bousser M.G.
        The clinical and radiological spectrum of reversible cerebral vasoconstriction syndrome: a prospective series of 67 patients.
        Brain. 2007; 130: 3091-3101
        • Calabrese L.H.
        • Dodick D.W.
        • Schwedt T.J.
        • Singhal A.
        Narrative review: reversible cerebral vasocontriction syndromes.
        Ann. Intern. Med. 2007; 146: 34-44
        • Singhal A.B.
        • Hajj-Ali R.A.
        • Topcuoglu M.A.
        • et al.
        Reversible cerebral vasoconstriction syndromes: analysis of 139 cases.
        Arch. Neurol. 2011; 68: 1005-1012
        • Ducros A.
        Reversible cerebral vasoconstriction syndrome.
        Lancet Neurol. 2012; 11: 906-917
        • Dodick D.W.
        • Brown Jr., R.D.
        • Britton J.W.
        • Huston 3rd., J.
        Nonaneurysmal thunderclap headache with diff use, multifocal, segmental, and reversible vasospasm.
        Cephalalgia. 1999; 19: 118-123
        • Miller T.R.
        • Shivashankar R.
        • Mossa-Basha M.
        • Gandhi D.
        Reversible cerebral vasoconstriction syndrome, part 1: epidemiology, pathogenesis, and clinical course.
        AJNR. 2015; 36: 1392-1399
        • Ducros A.
        • Fielder U.
        • Porcher R.
        • Boukobza M.
        • Stapf C.
        • Bousser M.G.
        Hemorrhagic manifestations of reversible cerebral vasoconstriction syndrome: frequency, features, and risk factors.
        Stroke. 2010; 41: 2505-2511
        • Skeik N.
        • Porten B.R.
        • Kadkhodayan Y.
        • McDonald W.
        • Lahham F.
        Postpartum reversible cerebral vasoconstriction syndrome: review and analysis of the current data.
        Vasc. Med. 2015; 20: 256-265
        • Yancy H.
        • Lee-Iannotti J.K.
        • Schwedt T.J.
        • Dodick D.W.
        Reversible cerebral vasoconstriction syndrome.
        Headache. 2013; 53: 570-576
        • Fugate J.E.
        • Amerisio S.F.
        • Ortiz G.
        • Schottlaender L.V.
        • Wijdicks E.F.M.
        • Flemming K.D.
        • Rabinstein A.A.
        Variable presentations of postpartum angiopathy.
        Stroke. 2012; 43: 670-676
        • Williams T.L.
        • Lukovits T.G.
        • Harris B.T.
        • Harker Rhodes C.
        A fatal case of postpartum cerebral angiopathy with literature review.
        Arch. Gynecol. Obstet. 2007; 275: 67-77
        • Ruzic Y.
        • Tran-Van D.
        • Omarjee A.
        • Boukerrou M.
        • Winer A.
        Intracerebral haemorrhage and postpartum cerebral angiopathy associated with the administration of sulprostone and norepinephrine.
        Ann. Fr. Anesth. Reanim. 2012; 31: 78-81
        • Akhter T.
        • Larsson A.
        • Larsson M.
        • Wikström A.K.
        • Naessen T.
        Artery wall layer dimensions during normal pregnancy: a longitudinal study using noninvasive high-frequency ultrasound.
        Am. J. Physiol. Heart Circ. Physiol. 2013; 304: H229-H234
        • Del Zotto E.
        • Giossi A.
        • Volonghi I.
        • Costa P.
        • Padovani A.
        • Pezzini A.
        Ischemic stroke during pregnancy and puerperium.
        Stroke Res. Treat. 2011 jan 27; 2011: 6060780
        • Cantu-Brito C.
        • Arauz A.
        • Aburto Y.
        • Barinagarrementeria F.
        • Ruiz-sandoval J.L.
        • Baizabal-carvallo J.F.
        Cerebrovascular complications during pregnancy and postpartum: clinical and prognosis observations in 240 Hispanic women.
        Eur. J. Neurol. 2011; 18: 819-825
        • Lim S.Y.
        • Evangelou N.
        • Jurgens S.
        Postpartum headache: diagnostic considerations.
        Pract. Neurol. 2014; 14: 92-99
        • Fugate J.E.
        • Wijdicks E.F.
        • Parisi J.E.
        • et al.
        Fulminant postpartum cerebral vasoconstriction syndrome.
        Arch. Neurol. 2012; 69: 111-117
        • Singhal A.B.
        • Taylor Kimberly W.
        • Schaefer P.W.
        • Hedley-Whyte E.
        Case 8-2009: a 36-year-old woman with headache, hypertension, and seizure 2 weeks post partum.
        N. Engl. J. Med. 2009; 360: 1126-1137
        • Bartels E.
        Color-coded Duplex Ultrasonography of the Cerebral Vessels 7 Atlas and Manual.
        Schattauer, Stuttgart1999
        • Felberg R.A.
        • Christou I.
        • Demchuk A.M.
        • Malkoff M.
        • Alexandrov A.V.
        Screening for intracranial stenosis with transcranial Doppler: the accuracy of mean flow velocity thresholds.
        J. Neuroimaging. 2002; 12: 1-6
        • Lindegaard K.F.
        • Nornes H.
        • Bakke S.J.
        • Sorteberg W.
        • Nakstad P.
        Cerebral vasospasm diagnosis by means of angiography and blood velocity measurements.
        Acta Neurochir. 1989; 100: 12-24
        • Brass L.M.
        • Pavlakis S.G.
        • DeVivo D.
        • Piomelli S.
        • Mohr J.P.
        Transcranial Doppler measurements of the middle cerebral artery. Effect of hematocrit.
        Stroke. 1988; 19: 1466-1469
        • Miller T.R.
        • Shivashankar R.
        • Mossa-Basha M.
        • Gandhi D.
        Reversible cerebral vasoconstriction syndrome, part 2: diagnostic work-up, imaging evaluation, and differential diagnosis.
        AJNR. 2015; 36: 1580-1588
        • Albano B.
        • Del Sette M.
        • Roccatagliata L.
        • Gandolfo C.
        • Primavera A.
        Cortical subarachnoid hemorrhage associated with reversible cerebral vasoconstriction syndrome after elective triplet cesarean delivery.
        Neurol. Sci. 2011 Jun; 32: 497-501
        • Chen S.P.
        • Fuh J.L.
        • Chang F.C.
        • Lirng J.F.
        • Shia B.C.
        • Wang S.J.
        Transcranial color Doppler study for reversible cerebral vasoconstriction syndromes.
        Ann. Neurol. 2008; 63: 751-757
        • Fugate J.E.
        • Rabinstein A.A.
        Posterior reversible encephalopathy syndrome: clinical and radiological manifestations, pathophysiology and outstanding questions.
        Lancet Neurol. 2015; 14: 914-925
        • Schwedt T.J.
        • Matharu M.S.
        • Dodick D.
        Thundereclap headache.
        Lancet Neurol. 2006; 5: 621-631