Case summary

In this report, Di Filippo and colleagues describe a previously healthy 34-year-old woman with a twin pregnancy who underwent urgent cesarean section at 36 + 5 weeks under uncomplicated spinal anesthesia.

The perioperative course was initially uneventful. Preoperative laboratory studies, coagulation profile, neurological examination, and intraoperative hemodynamics were normal. Six hours after surgery, however, the patient experienced sudden loss of consciousness while speaking with her husband.

Emergency brain CT revealed a large left basal ganglia intraparenchymal hemorrhage measuring 6.4 × 3.7 × 4.7 cm with surrounding edema, ventricular compression, and 5 mm midline shift (Fig. 1, page 3). No aneurysm or vascular malformation was identified. During transfer for neurosurgical intervention, blood pressure rose to 150/90 mmHg despite antihypertensive treatment.

The patient underwent urgent surgical evacuation of the hematoma slightly more than 2 hours after symptom onset (Fig. 2, page 4). Postoperatively, she required neurointensive care and developed severe right-sided hemiplegia, facial nerve palsy, mixed transcortical aphasia, dysphagia, and sphincter dysfunction. Cerebral angiography remained inconclusive.

At 6-month follow-up, substantial neurological recovery had occurred, although mild right-sided weakness and residual aphasia persisted. The authors discuss the uncertain relationship between postpartum physiological changes, transient hypertensive surges, and possible neuraxial anesthesia–related mechanisms contributing to hemorrhage.

Why this case matters

Demonstrates severe postpartum intracerebral hemorrhage in the absence of classic risk factors
Highlights diagnostic challenges of acute neurological deterioration after cesarean delivery
Reinforces the importance of rapid neuroimaging and neurosurgical intervention
Explores the controversial association between neuraxial anesthesia and intracranial hemorrhage

Clinical Take-Home Message

Sudden neurological deterioration after cesarean delivery—even in normotensive patients with uncomplicated spinal anesthesia—should prompt immediate neuroimaging to exclude intracerebral hemorrhage and enable urgent neurosurgical management.

Question

What was the most critical factor enabling timely management in this case?

A. Prophylactic anticoagulation
B. Early recognition and emergent CT imaging
C. Absence of hypertension
D. Elective cesarean delivery

Correct answer: B. Early recognition and emergent CT imaging

Explanation:
Rapid recognition of neurological decline and immediate CT imaging allowed prompt neurosurgical intervention, likely improving survival and long-term neurological recovery.

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