1
|
Rajeshwari KS, Agarwal V, Satish S, Jayakumar KT. An unusual presentation of posterior reversible encephalopathy syndrome—a case report. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021. [DOI: 10.1186/s41983-020-00252-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Acute neurological emergencies in pregnant and postpartum women presenting as headache, visual disturbances, seizures, and elevated blood pressure are usually attributed to preeclampsia and eclampsia. However cerebral venous sinus thrombosis (CVST) and posterior reversible encephalopathy syndrome (PRES) are two important, rare conditions which should be considered. PRES is a rare neuroradiological syndrome characterised by vasogenic oedema of subcortical white matter, commonly involving posterior cerebral hemispheres. Preeclampsia and eclampsia are the common causes of PRES. However, late postpartum eclampsia concurrent to PRES is rare. Here, we report a rare case of PRES secondary to late postpartum eclampsia with atypical radiological findings.
Case presentation
A 25-year-old married woman with prior history of two spontaneous abortions presented to us on day 5 postpartum, post lower segment caesarean section (LSCS) with complaints of headache followed by one episode of new onset generalised tonic-clonic seizures. There was no history of seizures prior to the pregnancy and no history of hypertension or diabetes during any of her pregnancies. On examination, BP was 140/90 mm Hg and PR 98 bpm. Systemic examination revealed GCS 15/15, no focal neurological deficits, and bilateral flexor plantar response. Fundus examination was normal with no evidence of hypertensive retinopathy. Preliminary haematological and biochemical tests including antiphospholipid antibody (APLA) profile were done in view of prior abortions and were within normal limits. Lumbar puncture was done—normal study. EEG was normal. MRI with MRV was suggestive of atypical posterior encephalopathy. In view of late onset postpartum seizure, the patient was started on injection of magnesium sulphate, anti-hypertensives, and antiepileptics; following which, she improved and was discharged.
Conclusion
Though preeclampsia and eclampsia are usually screened entities, we should also follow women in puerperium for late postpartum eclampsia which is defined as seizures beyond 48 h of delivery up to 4 weeks postpartum. So it is important to follow-up postpartum women for complications like PRES because early detection and treatment can lessen the morbidity and mortality as they are completely reversible. Thus, health care professionals should be educated about the same. Apart from antenatal and intrapartum care, postpartum care should also be given equal importance.
Collapse
|
3
|
Zhang L, Wang Y, Shi L, Cao J, Li Z, Wáng YXJ. Late postpartum eclampsia complicated with posterior reversible encephalopathy syndrome: a case report and a literature review. Quant Imaging Med Surg 2016; 5:909-16. [PMID: 26807372 DOI: 10.3978/j.issn.2223-4292.2015.12.04] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a rare but serious clinical-neuroradiological entity characterized by headache, vomiting, visual disturbances, altered mental status, seizures, and unconsciousness associated with the characteristic imaging findings including sub-cortical vasogenic edema at the bilateral parietal and occipital lobes. We describe a case of 28-year-old PRES patient secondary to delayed maternal postpartum eclampsia. This patient was not initially diagnosed with pre-eclampsia and PRES. The diagnosis was established after magnetic resonance imaging. After treatment this patient's PRES resolved. Early diagnosis and treatment are the keys to reverse PRES. A literature review for PRES is provided in this report.
Collapse
Affiliation(s)
- Lihong Zhang
- 1 Department of Neurology, the Second Hospital of Hebei Medical University, Shijiazhuang 050000, China ; 2 Department of Ophthalmology, the Fourth Hospital of Shijiazhuang, Shijiazhuang 050011, China ; 3 Department of Radiology, 4 Department of Orthopedics, the First Hospital of Shijiazhuang, Shijiazhuang 050011, China ; 5 Department of Imaging and Interventional Radiology, the Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | - Yacong Wang
- 1 Department of Neurology, the Second Hospital of Hebei Medical University, Shijiazhuang 050000, China ; 2 Department of Ophthalmology, the Fourth Hospital of Shijiazhuang, Shijiazhuang 050011, China ; 3 Department of Radiology, 4 Department of Orthopedics, the First Hospital of Shijiazhuang, Shijiazhuang 050011, China ; 5 Department of Imaging and Interventional Radiology, the Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | - Liang Shi
- 1 Department of Neurology, the Second Hospital of Hebei Medical University, Shijiazhuang 050000, China ; 2 Department of Ophthalmology, the Fourth Hospital of Shijiazhuang, Shijiazhuang 050011, China ; 3 Department of Radiology, 4 Department of Orthopedics, the First Hospital of Shijiazhuang, Shijiazhuang 050011, China ; 5 Department of Imaging and Interventional Radiology, the Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | - Jianhui Cao
- 1 Department of Neurology, the Second Hospital of Hebei Medical University, Shijiazhuang 050000, China ; 2 Department of Ophthalmology, the Fourth Hospital of Shijiazhuang, Shijiazhuang 050011, China ; 3 Department of Radiology, 4 Department of Orthopedics, the First Hospital of Shijiazhuang, Shijiazhuang 050011, China ; 5 Department of Imaging and Interventional Radiology, the Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | - Zhenzhong Li
- 1 Department of Neurology, the Second Hospital of Hebei Medical University, Shijiazhuang 050000, China ; 2 Department of Ophthalmology, the Fourth Hospital of Shijiazhuang, Shijiazhuang 050011, China ; 3 Department of Radiology, 4 Department of Orthopedics, the First Hospital of Shijiazhuang, Shijiazhuang 050011, China ; 5 Department of Imaging and Interventional Radiology, the Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | - Yì-Xiáng J Wáng
- 1 Department of Neurology, the Second Hospital of Hebei Medical University, Shijiazhuang 050000, China ; 2 Department of Ophthalmology, the Fourth Hospital of Shijiazhuang, Shijiazhuang 050011, China ; 3 Department of Radiology, 4 Department of Orthopedics, the First Hospital of Shijiazhuang, Shijiazhuang 050011, China ; 5 Department of Imaging and Interventional Radiology, the Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| |
Collapse
|
6
|
[Late post-partum eclampsia: a case report]. ACTA ACUST UNITED AC 2009; 38:45-7. [PMID: 20022278 DOI: 10.1016/j.gyobfe.2009.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2009] [Accepted: 09/03/2009] [Indexed: 11/23/2022]
Abstract
Post-partum eclampsia is an unfrequent entity (11 to 44 % of eclampsia), which can sometimes occur late, beyond the 48th hour. We report a case of late post-partum eclampsia which occurred 12 days after an uncomplicated pregnancy and delivery. Post-partum eclampsia differs from antepartum by a pauci symptomatic or unexpected context. The mortality rate is comparable with that of the ante-partum eclampsia. Brain MRI appears to be the investigation of choice in case of uncertain diagnosis. Magnesium sulfate treatment should be considered under the same conditions as during pregnancy. Identifying and informing high-risk women would allow early diagnosis, which may improve the prognosis of this atypical type of eclampsia.
Collapse
|
9
|
Abstract
We present 2 cases of late postpartum eclampsia in adolescents presenting to the pediatric emergency department, neither of whom had any antepartum symptoms of preeclampsia. The purpose of this report is to discuss the importance of a high index of suspicion for preeclampsia in the postpartum adolescent who complains of headache as well as a need to recognize that seizures and more severe neurological sequelae occurring up to 3 weeks postpartum may be eclamptic in origin.
Collapse
Affiliation(s)
- Joseph B Cantey
- Division of Pediatric Emergency Medicine and Critical Care, Medical University of South Carolina, Charleston, SC 29425, USA
| | | | | |
Collapse
|
10
|
Hong JY, Jee YS, Lee IH, Shin JS, Choi HJ. Posterior Reversible Encephalopathy Syndrome after Cesarean Section under Spinal Anesthesia -A case report-. Korean J Anesthesiol 2007. [DOI: 10.4097/kjae.2007.52.6.s86] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Jeong-Yeon Hong
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital, Yonsei University College of Medicine, Korea
| | - Young Suck Jee
- Department of Anesthesiology and Pain Medicine, Cheil General Hospital & Women's Healthcare Center, Kwandong University College of Medicine, Korea
| | - In Ho Lee
- Department of Anesthesiology and Pain Medicine, Cheil General Hospital & Women's Healthcare Center, Kwandong University College of Medicine, Korea
| | - Joong Sik Shin
- Department of Obstetric and Gynecology, CHA General Hospital, College of Medicine, Pochon CHA University, Korea
| | - Hyuk Joong Choi
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Korea
| |
Collapse
|
11
|
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.
Collapse
Affiliation(s)
- Timothy L Williams
- Department of Pathology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, DHMC, Lebanon, NH 03756, USA.
| | | | | | | |
Collapse
|
12
|
Hirshfeld-Cytron J, Lam C, Karumanchi SA, Lindheimer M. Late Postpartum Eclampsia: Examples and Review. Obstet Gynecol Surv 2006; 61:471-80. [PMID: 16787550 DOI: 10.1097/01.ogx.0000219564.65999.0d] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Eclampsia, defined as the occurrence of seizures in pregnant women, usually in the setting of preeclampsia and in the absence of other neurologic disorders, occurs mainly before, during , or within 48 hours after delivery. When convulsions occur later postpartum, diagnosis is difficult and treatment disputed. We review the entity of late postpartum eclampsia and report 2 examples in which the serum levels of antiangiogenic and angiogenic proteins were measured.
Collapse
|
13
|
Pizon AF, Wolfson AB. Postpartum focal neurologic deficits: posterior leukoencephalopathy syndrome. J Emerg Med 2005; 29:163-6. [PMID: 16029827 DOI: 10.1016/j.jemermed.2005.02.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2004] [Revised: 01/03/2005] [Accepted: 02/09/2005] [Indexed: 10/25/2022]
Abstract
The postpartum patient who presents with focal neurologic deficits presents a wide range of diagnostic possibilities. We report the case of a previously healthy woman who presented 7 days postpartum with a focal deficit and who was ultimately diagnosed with eclampsia and posterior leukoencephalopathy syndrome (PLES). The hallmark of this entity is reversible parieto-occipital white matter edema as seen on magnetic resonance imaging (MRI). Advanced MRI techniques, such as echo-planar diffusion-weighted images and apparent diffusion coefficient maps, suggest cerebral artery dilatation as the underlying mechanism. Laboratory findings and computed tomography (CT) scans are typically unremarkable. PLES has a favorable prognosis if treated promptly and appropriately.
Collapse
Affiliation(s)
- Anthony F Pizon
- Department of Medical Toxicology, Banner Good Samaritan Medical Center, 925 East McDowell Road 2nd Floor, Phoenix, AZ 85006, USA
| | | |
Collapse
|
14
|
Akerman N, Hall W. A case of late postpartum seizures after epidural analgesia. Int J Obstet Anesth 2005; 14:163-6. [PMID: 15795151 DOI: 10.1016/j.ijoa.2004.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2004] [Revised: 10/01/2004] [Accepted: 10/01/2004] [Indexed: 10/25/2022]
Abstract
We present the case of a 29-year-old female who in her third pregnancy developed seizures seven days postpartum. The only symptoms preceding the seizures were headache and visual disturbance. There was no evidence of preeclampsia antepartum or postpartum. All clinical investigations were normal including computerised tomography, magnetic resonance imaging and lumbar puncture. All symptoms resolved within 24 h of the first seizure. In this case report we highlight the difficulties in establishing the cause of postpartum seizures.
Collapse
Affiliation(s)
- N Akerman
- Department of Obstetric Anaesthesia, St. James University Hospital, Leeds and Pontefract General Infirmary, UK.
| | | |
Collapse
|