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Nighoghossian N, Picot M, Baraza C, Felten D, Hermier M. Angiopathie cérébrale aiguë réversible du post-partum. Rev Neurol (Paris) 2006; 162:1014-8. [PMID: 17028571 DOI: 10.1016/s0035-3787(06)75114-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Acute cerebral angiopathy is a rare neuro-vascular complication in postpartum. In this setting, the implication of vasoconstrictive drugs used for lactation or deliverance hemorrhage inhibition has been established. This review aimed 1) to describe, epidemiologic, clinical and diagnostic features of this pathological condition. 2) To put in perspective this condition within the scope of neurovascular clinical syndrome of pregnancy.
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Affiliation(s)
- N Nighoghossian
- Service de Neurologie B, PR P Trouillas, Hôpital Neurologique Pierre Wertheimer, Bron, France.
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52
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Moussouttas M, Abubakr A, Grewal RP, Papamitsakis N. Eclamptic subarachnoid haemorrhage without hypertension. J Clin Neurosci 2006; 13:474-6. [PMID: 16678728 DOI: 10.1016/j.jocn.2005.05.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2005] [Accepted: 05/03/2005] [Indexed: 11/21/2022]
Abstract
Subarachnoid haemorrhage in pregnancy is often the result of aneurysmal rupture or severe hypertension. A young woman with postpartum eclampsia and 'normal' blood pressure developed sudden-onset head pain, and was found to have minor biconvexity subarachnoid hemorrhages. Serial angiograms of the cervicocranial vessels revealed no evidence of aneurysm or arteriovenous malformation. A follow-up angiogram revealed diffuse vessel narrowing, consistent with postpartum angiopathy. Treatment consisted only of nimodipine for the prevention of vasospasm. The patient made an excellent recovery, without residual neurological deficits.
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Affiliation(s)
- Michael Moussouttas
- NJ Neuroscience Institute, JFK Medical Center, Edison, New Jersey 08818, USA.
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53
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Williams TL, Lukovits TG, Harris BT, Harker Rhodes C. A fatal case of postpartum cerebral angiopathy with literature review. Arch Gynecol Obstet 2006; 275:67-77. [PMID: 16832640 DOI: 10.1007/s00404-006-0194-3] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2006] [Accepted: 06/06/2006] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Postpartum cerebral angiopathy (PCA) is a rare and pathophysiologically ill-characterized cerebral vasoconstriction syndrome, occurring within 30 days of a usually uncomplicated pregnancy and delivery. Its onset has been associated with the use of vasoactive medications, particularly ergot alkaloids. Other cases have occurred in the absence of these medications, prompting conjecture into possible overlap between PCA and other conditions known to cause cerebral vasoconstriction, including primary angiitis of the central nervous system and postpartum eclampsia. The vast majority of cases follow a relatively benign course; however, a fatal case has been reported. Histopathologic findings in PCA, so far limited to the fatal case and two more recent biopsies, have been nonspecific. OBJECTIVE Here we present a second fatal case of PCA, including pre- and post-mortem histopathologic analysis. We also include a review of all PCA cases reported in the English literature. METHODS Criteria for the clinical diagnosis of PCA are proposed and used to select case reports from the medical literature. Data pertaining to patient characteristics, clinical symptomatology, cerebral imaging findings, and clinical outcomes are compared between cases associated with the postpartum use of vasoactive medications and spontaneous cases. CONCLUSIONS We conclude that histopathologic findings in PCA are nonspecific and secondary to ischemic brain injury. Functional vasoconstriction is the most likely primary pathophysiologic process in PCA. The etiology in cases associated with medications may be due to idiosyncratic reactions to these agents. Significant overlap in symptomatology and clinical features exists between spontaneous cases and late postpartum eclampsia.
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Affiliation(s)
- Timothy L Williams
- Department of Pathology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, DHMC, Lebanon, NH 03756, USA.
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54
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Abstract
Thunderclap headache (TCH) is head pain that begins suddenly and is severe at onset. TCH might be the first sign of subarachnoid haemorrhage, unruptured intracranial aneurysm, cerebral venous sinus thrombosis, cervical artery dissection, acute hypertensive crisis, spontaneous intracranial hypotension, ischaemic stroke, retroclival haematoma, pituitary apoplexy, third ventricle colloid cyst, and intracranial infection. Primary thunderclap headache is diagnosed when no underlying cause is discovered. Patients with TCH who have evidence of reversible, segmental, cerebral vasoconstriction of circle of Willis arteries and normal or near-normal results on cerebrospinal fluid assessment are thought to have reversible cerebral vasoconstriction syndrome. Herein, we discuss the differential diagnosis of TCH, diagnostic criteria for the primary disorder, and proper assessment of patients. We also offer pathophysiological considerations for primary TCH.
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Affiliation(s)
- Todd J Schwedt
- Department of Neurology, Mayo Clinic College of Medicine, Scottsdale, AZ 85259, USA
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55
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Abstract
The risks of ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage are not increased in the 9 months of gestation except for a high risk in the 2 days prior and 1 day postpartum. The remaining 6 weeks postpartum also have an increased risk of ischemic stroke and intracerebral hemorrhage, though less than the peripartum period. Although there are some rare causes of stroke specific to pregnancy and the postpartum period, eclampsia, cardiomyopathy, postpartum cerebral venous thrombosis, and, possibly, paradoxical embolism warrant special consideration. The diagnostic and therapeutic approaches to stroke during pregnancy and the postpartum period are similar to the approaches in the nonpregnant woman with some minor modifications based on consideration of the welfare of the fetus. There is a theoretical risk of magnetic resonance imaging exposure during the first and second trimester but the benefit to the mother of obtaining the information may outweigh the risk. Available evidence suggests that low-dose aspirin (<150 mg/day) during the second and third trimesters is safe for both mother and fetus. Postpartum use of low-dose aspirin by breast-feeding mother is also safe for infant. While proper counseling is imperative, a history of pregnancy-related stroke should not be a contraindication for subsequent pregnancy.
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Affiliation(s)
- Ann K Helms
- Department of Neurology, Medical College of Wisconsin, Madison, WI, USA
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56
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Spitzer C, Mull M, Rohde V, Kosinski CM. Non-traumatic cortical subarachnoid haemorrhage: diagnostic work-up and aetiological background. Neuroradiology 2005; 47:525-31. [PMID: 15971064 DOI: 10.1007/s00234-005-1384-6] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2005] [Accepted: 02/16/2005] [Indexed: 10/25/2022]
Abstract
Only 15% of all subarachnoid haemorrhages (SAHs) are not of aneurysmal origin. Among those, circumscribed SAHs along the cortical convexity are rare and have only been described in singular case reports so far. Here, we present a collection of 12 cases of SAH along the convexity, of non-traumatic origin. Over a period of 10 years, 12 cases of circumscribed SAH along the convexity were identified at our clinic. The clinical presentations, neuroradiological SAH characteristics, further diagnostic work-up to identify the underlying aetiologies, the therapy and clinical outcome were analysed. The patients' chief complaints were unspecific cephalgia, focal or generalised seizures and focal neurological deficits. Typical signs of basal SAH, such as nuchal rigidity, thunderclap-headache or alteration of consciousness, were rare. Magnetic resonance imaging (MRI) and digital subtraction angiography (DSA) revealed different aetiologies, namely postpartal posterior encephalopathy (three), cerebral vasculitis (two), dural sinus thrombosis (two), cortical venous thrombosis (one), intracerebral abscesses (one) and cerebral cavernoma (one). Two cases remained unresolved. Treatment of the underlying disease and symptomatic medication led to good clinical outcome in almost all cases. On the basis of these findings, we demonstrate that the clinical presentation, localisation and aetiology of cortical SAH differ clearly from other SAHs. A diagnostic work-up with MRI and eventually DSA is essential. Mostly, the causative disease can be identified, and specific treatment allows a favourable outcome.
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Affiliation(s)
- C Spitzer
- Department of Neurology, University Hospital of RWTH Aachen, Germany
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57
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Duncan IC. Cerebral Vasospasm and Intracerebral Haemorrhage in a Case of Pregnancy-Related Thrombotic Thrombocytopoenic Purpura/Haemolytic Uraemic Syndrome. Interv Neuroradiol 2005; 11:173-8. [DOI: 10.1177/159101990501100209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2005] [Accepted: 04/30/2005] [Indexed: 11/17/2022] Open
Abstract
We report a case of a woman with pregnancy-related thrombotic thrombocytopoenic purpura/haemolytic uraemic syndrome (TTP/HUS) who developed cerebral vasospasm similar to that seen in the other pregnancy-related thrombotic microangiopathic syndromes of eclampsia and HELLP syndrome. A further complication in this case was the development of a focal intracerebral haemorrhage necessitating surgical removal. Despite a successful evacuation of the haematoma and several plasma exchange treatments she developed recurrent haemolysis and thrombocytopoenia with an eventual fatal outcome due to severe pulmonary and gastrointestinal haemorrhage.
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Affiliation(s)
- I. C. Duncan
- Unitas Interventional Unit;Lyttelton, South Africa
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58
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Song JK, Fisher S, Seifert TD, Cacayorin ED, Alexandrov AV, Malkoff MD, Grotta JC, Campbell MS. Postpartum cerebral angiopathy: atypical features and treatment with intracranial balloon angioplasty. Neuroradiology 2004; 46:1022-6. [PMID: 15570420 DOI: 10.1007/s00234-003-1129-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2003] [Accepted: 10/02/2003] [Indexed: 10/26/2022]
Abstract
Postpartum cerebral angiopathy (PCA) is an uncommon cause of ischemic and hemorrhagic stroke in young women. It is usually clinically benign and not relapsing. We describe a patient with nonhemorrhagic PCA who had an atypical progressive neurological deficit from bilateral hemisphere watershed ischemia despite treatment with aggressive medical therapy and intracranial balloon angioplasty.
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Affiliation(s)
- J K Song
- Center for Endovascular Surgery, Hyman-Newman Institute for Neurology and Neurosurgery, 1000 Tenth Avenue, New York, NY 10019, USA.
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59
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Abstract
Stroke in pregnancy and the puerperium is a rare but serious cause of maternal and fetal mortality. Pregnancy-associated maternal changes should remain additional considerations in the evaluation and treatment of the pregnant patient who has stroke and not preclude a comprehensive stroke evaluation. Instead, the approach to the pregnant patient who has stroke should include the evaluation of general causes of stroke in the young, with the additional consideration of the rare pregnancy-specific causes. Understanding the potential maternal and fetal risks of diagnostic testing and treatment is crucial to appropriate decision making when caring for the pregnant patient who has stroke.
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Affiliation(s)
- Tanya N Turan
- Department of Neurology, Emory University School of Medicine, Department of Neurology, 639 Pierce Drive, Atlanta, GA 30322, USA
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60
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Konstantinopoulos PA, Mousa S, Khairallah R, Mtanos G. Postpartum cerebral angiopathy: an important diagnostic consideration in the postpartum period. Am J Obstet Gynecol 2004; 191:375-7. [PMID: 15295399 DOI: 10.1016/j.ajog.2004.03.028] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A 32-year-old woman, gravida 4, para 2, presented with a severe headache 5 days after she had a vaginal delivery with epidural anesthesia. Nine days later she had neurologic symptoms develop. Magnetic resonance imaging and cerebral angiogram were abnormal with evidence of a vasculitis consistent with postpartum cerebral angiopathy. The patient received both methylprednisolone and cyclophosphamide pulses with improvement of her symptoms. This is an important diagnosis for obstetricians to consider because it may result in serious neurologic damage if it is not diagnosed and treated early.
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61
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Abstract
Stroke during pregnancy is a special category of stroke in young women. Although the absolute risk is small, there are diverse causes, including those inherent to the pregnant state, that may have a significant impact on maternal and fetal outcome. Severe pre-eclampsia and eclampsia are commonly associated with ischemic and hemorrhagic stroke, but must not be presumed the sole cause of stroke in pregnant women. Magnesium sulfate is the treatment of choice to prevent eclampsia. Randomized clinical trials in pregnant women are not available to provide guidance for the treatment of ischemic and hemorrhagic stroke in pregnant women. Various antithrombotic agents may be safely used during specific stages of pregnancy for treatment and prevention of ischemic stroke, with low-dose aspirin, unfractionated heparin, and low molecular weight heparin the preferred agents. Low molecular weight heparin may be safer than unfractionated heparin. Treatment of parenchymatous intracerebral hemorrhage and subarachnoid hemorrhage during pregnancy and the puerperium must be individualized. Aneurysms may be treated with neurosurgical clipping or endovascular coiling, depending on neurosurgical considerations. Cesarean or vaginal delivery may be used depending on the timing of delivery, adequacy of aneurysm occlusion, and risk to mother and fetus. Arteriovenous malformations are best treated in a multimodal fashion at a specialized treatment center.
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Affiliation(s)
- Michael A. Sloan
- Center for Stroke Research, Department of Neurological Sciences, Rush Medical College, 1645 West Jackson Boulevard, Suite 400, Chicago, IL 60612, USA.
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62
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Geocadin RG, Razumovsky AY, Wityk RJ, Bhardwaj A, Ulatowski JA. Intracerebral hemorrhage and postpartum cerebral vasculopathy. J Neurol Sci 2002; 205:29-34. [PMID: 12409180 DOI: 10.1016/s0022-510x(02)00245-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Intracerebral hemorrhage (ICH) associated with pregnancy commonly occurs in the postpartum period in the setting of preeclampsia/eclampsia. We describe the clinical course of two patients with ICH due to postpartum cerebral vasculopathy in the absence of toxemia. METHODS We reviewed two cases with ICH and postpartum vasculopathy in our hospital (1996-2001) and compared them with seven similar case reports from the literature. RESULTS Mean age of all patients is 28.7+/-5.6 years (mean+/-S.D.). Toxemia of pregnancy was absent in all cases. ICHs were cortical in eight and putaminal in one patient. Erythrocyte sedimentation rate was elevated in two. Two cases rehemorrhaged during the same admission. No cerebral infarctions were reported. All patients had diffuse vasculopathy on conventional catheter angiography, with no clinical manifestations or laboratory data supportive of extracerebral or systemic vasculitis. Eight patients were treated with corticosteroids, two with additional cytotoxic agents and one with nimodipine alone. Improvement on follow-up cerebral angiography (catheter or MRA) and transcranial Doppler ultrasonography (TCD) was noted in eight cases. One did not have follow-up cerebral imaging but had an excellent clinical outcome. All cases had good to excellent functional recovery. CONCLUSIONS Postpartum ICH in the absence of toxemia may be associated with isolated cerebral vasculopathy. The clinical course and functional outcome is good to excellent. This entity appears to be distinct from cerebral vasculitis, which is usually associated with poor outcome.
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Affiliation(s)
- Romergryko G Geocadin
- Department of Neurology, Neurosciences Critical Care Division, Johns Hopkins Medical Institutions, Meyer 8-140, 600 N. Wolfe Street, Baltimore, MD 21287, USA.
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63
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Kubo S, Nakata H, Tatsumi T, Yoshimine T. Headache associated with postpartum cerebral angiopathy: monitoring with transcranial color-coded sonography. Headache 2002; 42:297-300. [PMID: 12010389 DOI: 10.1046/j.1526-4610.2002.02087.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We report a case of postpartum cerebral angiopathy with headache; a rare entity that affects women within the early postpartum period. Cerebral angiography revealed multiple segmental narrowings of major cerebral arteries. The patient was monitored with transcranial color-coded sonography of the middle cerebral artery. Abnormally increased flow velocity within the middle cerebral artery decreased following initiation of steroid therapy, and the patient's headache improved dramatically.
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Affiliation(s)
- Shigeki Kubo
- Department of Neurosurgery, Takarazuka Municipal Hospital, Japan
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64
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Chalela JA, Kasner SE, McGarvey M, Alsop DC, Detre JA. Continuous arterial spin labeling perfusion magnetic resonance imaging findings in postpartum vasculopathy. J Neuroimaging 2001; 11:444-6. [PMID: 11677889 DOI: 10.1111/j.1552-6569.2001.tb00078.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Postpartum vasculopathy (PPV) is a rare heterogeneous nonatherosclerotic vasculopathy that occurs in the puerperium. It occurs spontaneously but may be triggered by vasoconstrictor substances. The angiographic findings vary and include narrowing of the intracranial arteries and vasospasm. The angiographic findings and the occurrence of ischemic infarcts suggest that cerebral blood flow (CBF) is impaired in PPV. The purpose of this study is to determine CBF in patients with PPV. The authors conducted a case study of 3 patients with clinical and laboratory criteria for PPV examined during a 2-year period. Clinical examination, computed tomography imaging, structural magnetic resonance imaging (MRI), cerebral angiography, and continuous arterial spin labeling perfusion (CASL-PI) MRI were performed in all patients. Mean global CBF was determined, and perfusion maps were visually inspected. The CBF values and perfusion maps were correlated with the clinical symptoms and the neuroimaging findings. Three women were studied (22, 34, and 36 years old). The median time of presentation was 4 days postpartum. One presented with intracranial hemorrhage and diffuse arterial narrowing, the other 2 with stroke-like lesions, encephalopathy, and segmental narrowing mainly in the posterior circulation. CASL-PI was performed within 1 week of symptom onset in all 3 patients. Global mean CBF values were 51.8, 39.3, and 41.8 cc/100 g/min. Although global CBF was mildly diminished, it was above ischemic levels. Visual inspection of the CASL-PI perfusion maps did not reveal areas of focal hypoperfusion or hyperperfusion. In this series of patients with PPV, CBF was close to normal. Although angiography often reveals diffuse arterial narrowing, the CBF values encountered in this study do not support a state of generalized or focal oligoemia. Vasomotor tone may change intermittently in patients with PPV.
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Affiliation(s)
- J A Chalela
- Department of Neurology, Hospital of the University of Pennsylvania, USA.
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65
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Zunker P, Happe S, Georgiadis AL, Louwen F, Georgiadis D, Ringelstein EB, Holzgreve W. Maternal cerebral hemodynamics in pregnancy-related hypertension. A prospective transcranial Doppler study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2000; 16:179-187. [PMID: 11117090 DOI: 10.1046/j.1469-0705.2000.00194.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
AIM To compare maternal cerebral hemodynamics, as assessed by transcranial Doppler studies, with the clinical and radiological findings in different types of pregnancy-related hypertension and to determine their pathophysiology. METHODS A prospective study of 66 consecutive pregnant women with hypertensive disorders (eclampsia, n = 3; pre-eclampsia, n = 41; isolated hemolysis, elevated liver enzymes, and low platelet count (HELLP)-syndrome, n = 12; pre-eclampsia superimposed on chronic hypertension, n = 5; chronic hypertension, n = 5) and 21 women with uncomplicated pregnancies. Mean blood flow velocities (Vmean) were assessed serially by means of transcranial Doppler in all basal arteries and correlated with changes in mean arterial blood pressure (MABP) and the clinical course. RESULTS Patients with the pre-eclampsia/eclampsia syndrome showed significantly elevated Vmean values as compared to controls. In the course of the illness Vmean over the whole length of all insonated basal arteries rose simultaneously. The three eclamptic patients showed the highest Vmean values (156, 182, 192 cm/s, respectively), of the middle cerebral artery (MCA) while MABP was 135, 135, and 150 mmHg, respectively. In pre-eclamptic patients the maximal Vmean MCA ranged from 80 (67, 93) to 145 (114, 151) cm/s [median (25th, 75th percentile)] depending on the severity of clinical presentation. In patients with isolated HELLP-syndrome changes in Vmean were either mild (5/12 cases) or absent (7/12 cases). CONCLUSIONS Considerable differences in cerebral hemodynamics were observed in the various types of pregnancy-related hypertensive disorders examined in this study. Our findings in patients with pre-eclampsia/eclampsia syndrome suggest a breakdown of autoregulation with hyperperfusion and vasogenic edema being the most probable pathophysiological mechanism.
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Affiliation(s)
- P Zunker
- Department of Neurology, University Hospital of Kiel, Niemannsweg 147, D-24105 Kiel, Germany
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