All pregnancy headaches are not pre-eclampsia – intracranial aneurysm in third trimester

Abstract

Objective Headaches in pregnancy are common and mostly diagnosed as pre-eclampsia. However an intracranial aneurysm can present in a similar way which can lead to a diagnostic dilemma. Here we present such a case where the cause for the headache was diagnosed to be an intracranial aneurysm.

Case report A 32 year old para 1 was admitted with severe bilateral periorbital and frontal headache for 3 days at 36 weeks. She also had flashes of light and rainbow colour (mainly blue) vision. She had a past medical history of Charcot-Marie-Tooth disease and Rheumatoid arthritis. On admission she was conscious and oriented, stable with moderate tachycardia. There was no proteinuria or worsening pedal edema. There were no focal neurological signs. The liver and renal function tests were within the normal range. An urgent medical review was sought who organised a CT venogram showed the presence of 11 mm right side intracranial aneurysm arising from the intracavernous/ophthalmic division of right Internal Carotid artery (ICA). There was no evidence of cerebral venous sinus thrombosis. She was transferred to tertiary care centre where she had a caesarean section the following day. She was treated with a flow diverter stenting of the Right ICA para opthalmic aneurysm. Post stenting angiogram demonstrated patency of the Right ICA. She was commenced on aspirin 75 mg daily for 6 months and Clopidogrel 75 mg daily for 12 months. She presented with persistent headache and fleeting right sided visual disturbances 2 months later. MRI demonstrated the flow diverter stent to be patent and the aneurysm to have thrombosed significantly.

Discussion Headaches are very common in pregnancy. Apart from pre eclampsia, other causes like Migraine, tension headache, hypertension, Sub Arachnoid Haemorrhage, drug related – nifedipine, medication overuse, Postdural tap, meningitis, CVT (expand), idiopathic intracranial hypertension, stroke and arteriovenous malformation should be excluded. A multidisciplinary approach involving neurosurgeons is necessary in situations such where risks of prematurity has to be discussed. The distribution rate of intracranial aneurysm in 1st, 2nd and 3rd trimester in pregnancy are 6%, 31% and 55% respectively, and in puerperal period is 8%. Patients with > 10 mm size aneurysm should be treated and planned LSCS should be done.

Conclusion Cerebral aneurysm is a, particularly when symptomatic, can have a catastrophic effect on the life of a pregnant mother and her baby. Prompt diagnosis and MDT approach will result in reducing the maternal morbidity and mortality.