Brain intraparenchymal hemorrhage following urgent cesarean section: a case report

Intracerebral hemorrhage in the postpartum period is an uncommon but potentially life-threatening condition. Hypertensive disorders of pregnancy remain the most frequent cause. However, rare case reports have described intracranial bleeding occurring after neuraxial anesthesia. However, the coexistence of multiple confounding factors, including hypertensive crises, individual cerebrovascular vulnerability, and family history of hemorrhagic events, complicates interpretation. Establishing causation is particularly challenging, as most available evidence consists of sporadic case descriptions. A healthy 34-year-old white woman at 36 + 5 weeks of a twin pregnancy underwent an urgent cesarean section under uneventful spinal anesthesia, with normal preoperative exams, stable intraoperative hemodynamics, and no neurological abnormalities. However, 6 hours after surgery, she developed sudden transient loss of consciousness. Brain computed tomography revealed a large left basal ganglia hematoma with mass effect, in the absence of aneurysms or arteriovenous malformations. During transfer for emergent evacuation, her systolic blood pressure increased to 150 mmHg despite antihypertensive therapy. Postoperatively, she required neurointensive care and exhibited severe right-sided hemiplegia, facial palsy, and mixed transcortical aphasia. Cerebral angiography was inconclusive, and she was transferred to rehabilitation with persistent deficits. This paper illustrates a case of severe postpartum intraparenchymal hemorrhage even in the absence of risk factors. The precise mechanism of the bleeding remained uncertain. Early recognition of neurological deterioration, rapid neuroimaging, and timely surgical intervention are essential to improve patient outcomes. This case reinforces the need for close postpartum monitoring, and underscores the importance of further research into the multifactorial mechanisms underlying puerperal intracranial hemorrhage.