Post-partum posterior reversible encephalopathy syndrome requiring decompressive craniectomy: case report and review of the literature

The Spectrum of Posterior Reversible Encephalopathy Syndrome

Posterior reversible encephalopathy syndrome consists of acute to subacute symptoms which include seizures, encephalopathy, headaches, visual hallucinations or visual loss, and focal neurologic deficits in the setting of vasogenic brain edema. Both the clinical and radiographic findings are reversible in most, leading to a favorable neurologic prognosis. Less commonly, patients may have residual neurologic sequelae, often in cases with associated structural injury such as intracranial hemorrhage or stroke. A minority of patients develop a severe form, "malignant PRES" which can be fatal and may require intensive care unit care with aggressive therapies such as intubation, hyperosmolar therapy, ventriculostomy placement, or decompressive surgery.

Neurological Complications in Pregnancy and the Puerperium: Methodology for a Clinical Diagnosis

Neurological complications in pregnancy and the puerperium deserve particular attention from specialists due to the worsening of the clinical picture for both the mother and the fetus. This narrative review of existing data in the literature aims to analyze the most common "red flag symptoms" attributable to neurological complications such as pre-eclampsia (PE), eclampsia, HELLP syndrome, posterior reversible encephalopathy syndrome (PRES), cerebral vasoconstriction syndrome (RCVS), stroke, CVS thrombosis, pituitary apoplexy, amniotic fluid embolism and cerebral aneurysm rupture, with the aim of providing a rapid diagnostic algorithm useful for the early diagnosis and treatment of these complications. The data were derived through the use of PubMed. The results and conclusions of our review are that neurological complications of a vascular nature in pregnancy and the puerperium are conditions that are often difficult to diagnose and manage clinically. For the obstetrics specialist who is faced with these situations, it is always important to have a guide in mind in order to be able to unravel the difficulties of clinical reasoning and promptly arrive at a diagnostic hypothesis.

Don't Forget Rare Causes of Postpartum Headache! Cases Report and Literature Review

Headache is a common finding in the postpartum period, caused by a spectrum of different conditions. Most headaches in the postpartum period are self-limiting and benign in etiology, but there are some potentially serious causes to be considered. We disclose two cases of postpartum headache, initially considered as post-dural puncture headache (PDPH), that evolved into a harmful condition and showed that an expanded differential diagnosis for headache in the postpartum is mandatory, requiring a high level of attention from health professionals. In fact, a careful examination of the medical history, physical examination, and the recognition for the need for early neuroradiological imaging should increase diagnostic accuracy.

Risk factors of postoperative remote intracerebral hemorrhage after craniotomy for ruptured cerebral aneurysms

Objective

We aimed to identify the relation between perioperative cerebrospinal fluid (CSF) drain through lumbar drainage (LD) and development of postoperative (POP) remote intracerebral hemorrhage (rICH) in craniotomy to treat ruptured intracranial aneurysms.

Methods

We retrospectively reviewed consecutive patients who underwent craniotomy for ruptured cerebral aneurysms at the authors’ institution between 1998 and 2004. We subsequently compared the incidence and characteristics of POP rICH between the patients who had a perioperative LD and those who did not. All statistical analyses were conducted using the software package SPSS 19.0 (SPSS Inc., Chicago, IL, USA). A p value of <0.05 was considered statistically significant.

Results

We enrolled 688 patients, of which 80 patients (11.6%) received perioperative LD, and 608 did not. LD and non-LD groups were comparable because although clinical characteristics of the two groups were significantly different considering history of hypertension, timing of surgery, and closed system negative pressure suction drain (SD) placement, none of these three variables was an independent risk factor associated with POP rICH in multivariate analysis. POP rICH incidence was significantly higher in the LD goup (12.5%) than non-LD group (0.8%) (p=0.000) in univariate analysis. LD placement was the only independent risk factor associated with the development of rICH in multivariate logistic regression analysis.

Conclusions

POP rICH incidence was significantly higher in patients who were managed with perioperative LD than in those who did not. LD insertion in craniotomy for ruptured intracranial aneurysm, should be closely monitored to address the occurrence of POP rICH.

Malignant PRES and RCVS after brain surgery in the early postpartum period

The management of women with brain tumors in the early post-partum period may be demanding as the patho-physiological changes that occur during pregnancy may also manifest in the early post-partum period. The aim of our paper is to report a case of late-onset post-partum pre-eclampsia after brain tumor surgery, complicated by posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS). Hemicraniectomy and intensive care management were necessary to obtain a favorable neurological outcome. The inherent literature on the subject is also analyzed through a systematic research. This is the first case of supratentorial decompressive hemicraniectomy in post-partum PRES, while there has been only one other case of posterior fossa decompression described in this cohort of patients. PRES and RCVS can complicate the neurosurgical management of women in the postpartum period. A careful evaluation of the clinical presentation is necessary as in some particular cases an aggressive medical and surgical treatment is required to obtain a favorable outcome.