Post Partum Cervicocephalic Artery Dissection
It is not clear whether there is a link between childbirth and postpartum cervicocephalic arterial dissection. Spontaneous post partum cervicocephalic artery dissection can occur in women with uneventful pregnancies and deliveries, both vaginally and via planned Caesarean sections. Observational studies have also found an increased co-occurrence of conditions such as reversible cerebral vasoconstriction syndrome, posterior reversible encephalopathy syndrome and subarachnoid haemorrhage, in comparison with non-postpartum cases of cervicocephalic artery dissection.
CT scan of head or MR cerebral angiography can confirm cervicocephalic artery dissection, with MR scanning allowing better radiographic evaluation of associated cerebral infarction.
At present, there is no evidence-based guidance on the best short or long-term management of cervicocephalic artery dissection and there is ongoing debate as to whether anticoagulation or antiplatelet therapy is best, particularly in the acute phase. A 2008 meta-analysis of 34 non-randomised studies involving 762 patients and a 2009 prospective study of 298 patients each showed no treatment difference in either adverse haemorrhagic effects or stroke reduction. Another observational study of 250 patients with cervicocephalic artery dissection complicated by acute ischaemic stroke or transient ischaemic attack found that, on the contrary, anticoagulation was better than antiplatelet therapy at reducing the 6-month stroke recurrence rates. An international randomised controlled trial comparing antiplatelet therapy with anticoagulation is currently underway (Cervical Artery Dissection in Stroke Study Trial Investigators 2007, CADISS). The non-randomised arm of the trial reported no difference in stroke prevention between the two therapies. In the context of post partum cervicocephalic artery dissection, mothers who wish to breast feed should avoid aspirin due to concerns regarding Reye's syndrome in the nursing infant. As previously mentioned, both heparin and warfarin are safe in breast feeding.