Long-term Consequences of the Posterior Reversible Encephalopathy Syndrome in Eclampsia and Preeclampsia: A Review of the Obstetric and Nonobstetric Literature

Investigating the Link Between Subjective Depth Perception Deficits and Objective Stereoscopic Vision Deficits in Individuals With Acquired Brain Injury

Individuals with acquired brain injury have reported subjective complaints of depth perception deficits, but few have undergone objective assessments to confirm these deficits. As a result, the literature currently lacks reports detailing the correlation between subjective depth perception deficits and objective stereoscopic vision deficits in individuals with acquired brain injury, particularly those cases that are characterized by a clearly defined lesion. To investigate this relationship, we recruited three individuals with acquired brain injury who experienced depth perception deficits and related difficulties in their daily lives. We had them take neurologic, ophthalmological, and neuropsychological examinations. We also had them take two types of stereoscopic vision tests: a Howard-Dolman-type stereoscopic vision test and the Topcon New Objective Stereo Test. Then, we compared the results with those of two control groups: a group with damage to the right hemisphere of the brain and a group of healthy controls. Performance on the two stereoscopic vision tests was severely impaired in the three patients. One of the patients also presented with cerebral diplopia. We identified the potential neural basis of these deficits in the cuneus and the posterior section of the superior parietal lobule, which play a role in vergence fusion and are located in the caudal region of the dorso-dorsal visual pathway, which is known to be crucial not only for visual spatial perception, but also for reaching, grasping, and making hand postures in the further course of that pathway.

Experimental Models of Posterior Reversible Encephalopathy Syndrome: A Review From Pathophysiology to Therapeutic Targets

Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiological entity characterized by nonspecific symptomatology (eg, headache, visual disturbances, encephalopathy, and seizures) and classically cortical and subcortical vasogenic edema predominantly affecting the parietooccipital region. PRES etiologies are usually dichotomized into toxic PRES (eg, antineoplastic drugs, illicit drugs) and clinical condition-associated PRES (eg, acute hypertension, dysimmune disorders). Although the pathophysiology of PRES remains elusive, 2 main pathogenic hypotheses have been suggested: cerebral hyperperfusion due to acute hypertension and cerebral hypoperfusion related to endothelial dysfunction. Research into the pathogenesis of PRES has emerged through the development of animal models in the last decade. The motivation for developing a suitable PRES model is 2-fold: to fill in knowledge gaps of the pathophysiological mechanisms involved, and to open new perspectives for clinical assessment of pharmacological targets to improve therapeutic management of PRES. All current models of PRES have a hypertensive background, on which other triggers (acute hypertension, inflammatory, drug toxicity) have been added to address specific facets of PRES (eg, seizures). The initial model consisted in inducing a reduced uterine perfusion pressure that mimics preeclampsia, a leading cause of PRES. More recently, a model of stroke-prone spontaneously hypertensive rats on high-salt diet, originally developed for hypertensive small vessel disease and vascular cognitive impairment, has been studied in PRES. This review aims to discuss, depending on the research objective, the benefits and limitations of current experimental approaches and thus to define the desirable characteristics for studying the pathophysiology of PRES and developing new therapies.

Posterior Reversible Encephalopathy Syndrome in Pediatric Hematopoietic Stem Cell Transplantation with Beta Major Thalassemia: The Association between the PRES Occurrence and Class of Beta Major Thalassemia

INTRODUCTION

Allogeneic hematopoietic stem cell transplantation (HSCT) is the only definitive curative option for β-major thalassemia patients (β-MT). Posterior reversible encephalopathy syndrome (PRES) is a pervasive neurological complication which typically occurs following HSCT. β-MT patients are prone to a higher PRES incidence due to long-term immunosuppression; thus, it is imperative that these patients are closely monitored for PRES after HSCT.

PATIENTS AND METHODS

We included 148 pediatric patients with β-MT who underwent HSCT between March 2015 and August 2022 in Children's Medical Center. Patients in this study were divided into two groups. The association between PRES and class of β-MT and other risk factors were assessed and the overall survival rate was determined.

RESULTS

Fourteen out of 112 patients (12%) with class I and II β-MT developed PRES. However, PRES occurred in 11 out of 36 patients (30.5%) with β-MT-III. Our results indicated that there was a significant association between class III β-MT and the occurrence of (P = .004). Additionally, acute graft-versus-host disease (aGVHD) occurred in 80% and 44.7% of patients in the PRES and non-PRES groups, respectively (P = .001). The results of the Kaplan-Meier analysis revealed that the 5-year overall survival (OS) was 75.6% in the PRES group versus 95% in the non-PRES group, which was statistically significant (P = .001).

CONCLUSION

Based on our results, pediatric β-MT III patients are at a higher risk of developing PRES. Additionally, pediatric β-MT patients with a history of aGVHD, regardless of disease class, are more likely to develop PRES. Considering these results, PRES has a higher chance of being the etiology of symptoms and should be considered more often in these patients.

Posterior reversible encephalopathy syndrome in a patient with late postpartum eclampsia

RATIONALE

Posterior reversible encephalopathy syndrome (PRES) is a rare complication commonly associated with headache and acute changes in blood pressure that results from a variety of causes, culminating in vasogenic cerebral edema in the occipital and parietal lobes of the brain.

PATIENT CONCERNS

We report here a woman who suffered from headache, generalized tonic-clonic seizures, and cortical blindness in the late postpartum period.

DIAGNOSES

Posterior reversible encephalopathy syndrome.

INTERVENTIONS

The patient was treated with amlodipine besylate tablets for hypertension, dehydration with mannitol and glycerin fructose, and antispasmodic treatment with sodium valproate and oxcarbazepine.

OUTCOMES

On day 2, the patient became conscious, headache and vision improved. One week later, symptoms and signs disappeared, blood pressure returned to normal, and brain MRI lesions disappeared in re-examination.

LESSONS

Eclampsia associated with PRES is reversible in most cases, but it is a serious and potentially life-threatening obstetric emergency. If adequate treatment is provided in a timely manner, most women will make a full recovery. Attention needs to be paid to timely and adequate treatment, as well as appropriate follow-up and support for patients with PRES.

Magnetic resonance spectroscopy and liquid chromatography-mass spectrometry metabolomics study may differentiate pre-eclampsia from gestational hypertension

OBJECTIVE

To investigate the findings of magnetic resonance imaging (MRI), magnetic resonance spectroscopy (MRS), and serum metabolomics for differentiating pre-eclampsia (PE) from gestational hypertension (GH).

METHODS

This prospective study enrolled 176 subjects including a primary cohort with healthy non-pregnant women (HN, n = 35), healthy pregnant women (HP, n = 20), GH (n = 27), and PE (n = 39) and a validation cohort with HP (n = 22), GH (n = 22), and PE (n = 11). T1 signal intensity index (T1SI), apparent diffusion coefficient (ADC) value, and the metabolites on MRS were compared. The differentiating performances of single and combined MRI and MRS parameters for PE were evaluated. Serum liquid chromatography-mass spectrometry (LC-MS) metabolomics was investigated by sparse projection to latent structures discriminant analysis.

RESULTS

Increased T1SI, lactate/creatine (Lac/Cr), and glutamine and glutamate (Glx)/Cr and decreased ADC value and myo-inositol (mI)/Cr in basal ganglia were found in PE patients. T1SI, ADC, Lac/Cr, Glx/Cr, and mI/Cr yielded an area under the curves (AUC) of 0.90, 0.80, 0.94, 0.96, and 0.94 in the primary cohort, and of 0.87, 0.81, 0.91, 0.84, and 0.83 in the validation cohort, respectively. A combination of Lac/Cr, Glx/Cr, and mI/Cr yielded the highest AUC of 0.98 in the primary cohort and 0.97 in the validation cohort. Serum metabolomics analysis showed 12 differential metabolites, which are involved in pyruvate metabolism, alanine metabolism, glycolysis, gluconeogenesis, and glutamate metabolism.

CONCLUSIONS

MRS is expected to be a noninvasive and effective tool for monitoring GH patients to avoid the development of PE.

KEY POINTS

• Increased T1SI and decreased ADC value in the basal ganglia were found in PE patients than in GH patients. • Increased Lac/Cr and Glx/Cr, and decreased mI/Cr in the basal ganglia were found in PE patients than in GH patients. • LC-MS metabolomics showed that the major differential metabolic pathways between PE and GH were pyruvate metabolism, alanine metabolism, glycolysis, gluconeogenesis, and glutamate metabolism.

Pre-eclampsia

Pre-eclampsia is a life-threatening disease of pregnancy unique to humans and a leading cause of maternal and neonatal morbidity and mortality. Women who survive pre-eclampsia have reduced life expectancy, with increased risks of stroke, cardiovascular disease and diabetes, while babies from a pre-eclamptic pregnancy have increased risks of preterm birth, perinatal death and neurodevelopmental disability and cardiovascular and metabolic disease later in life. Pre-eclampsia is a complex multisystem disease, diagnosed by sudden-onset hypertension (>20 weeks of gestation) and at least one other associated complication, including proteinuria, maternal organ dysfunction or uteroplacental dysfunction. Pre-eclampsia is found only when a placenta is or was recently present and is classified as preterm (delivery <37 weeks of gestation), term (delivery ≥37 weeks of gestation) and postpartum pre-eclampsia. The maternal syndrome of pre-eclampsia is driven by a dysfunctional placenta, which releases factors into maternal blood causing systemic inflammation and widespread maternal endothelial dysfunction. Available treatments target maternal hypertension and seizures, but the only 'cure' for pre-eclampsia is delivery of the dysfunctional placenta and baby, often prematurely. Despite decades of research, the aetiology of pre-eclampsia, particularly of term and postpartum pre-eclampsia, remains poorly defined. Significant advances have been made in the prediction and prevention of preterm pre-eclampsia, which is predicted in early pregnancy through combined screening and is prevented with daily low-dose aspirin, starting before 16 weeks of gestation. By contrast, the prediction of term and postpartum pre-eclampsia is limited and there are no preventive treatments. Future research must investigate the pathogenesis of pre-eclampsia, in particular of term and postpartum pre-eclampsia, and evaluate new prognostic tests and treatments in adequately powered clinical trials.

Characteristics of the Maternal Jugular Venous Pulse Waveform by Combined Doppler-Electrocardiogram Assessment

Standardized combined Doppler-electrocardiogram assessment was performed longitudinally at three different locations of internal jugular veins between 12 wk of gestation and 6 wk postnatally in 24 uncomplicated pregnancies. All images were classified as typical or non-typical based on the presence of the physiologic deflections A, X, H and C. Linear mixed models with random intercepts of typical images were used to investigate gestational changes in venous pulse transit time and venous impedance index. Unequivocal identification of venous pulse transit time and venous impedance index was possible in 2617 of 3798 (69%) and 2234 of 3798 (59%) images, respectively. The best identification rate (80%, 1018/1266) was at the right distal internal jugular vein. Venous pulse transit time increased with gestational age at all locations; venous impedance index decreased at the right sided internal jugular vein. Maternal jugular venous pulse waveform by combined Doppler-electrocardiogram allows unequivocal identification of A-deflection and calculation of venous pulse transit time and venous impedance index in around two-thirds of assessments, with the highest success rate at the right distal internal jugular vein. Gestational evolutions of venous pulse transit time and venous impedance index are similar to those reported at the level of renal interlobar and hepatic veins.

C-L Case Conference: A 33-year-old Bhutanese Woman with Postpartum Hallucinations

We present the care of a 33-year-old pre-eclamptic Bhutanese woman who presented with post-partum hallucinations. We discuss our concern for postpartum psychosis versus a culturally appropriate phenomenon, with her diagnostic picture complicated by our use of interpreters and the intersection of culture and medicine. Top experts in the consultation-liaison (CL) field provide guidance for this clinical scenario based on their experience and a review of the available literature. This case highlights both the impact of language barriers and the challenges of interpreting psychiatric symptoms within a cultural context. Key teaching points include differential diagnoses for postpartum hallucinations, the importance of interpreting patient presentations within their unique cultural contexts and identities, and the impact of language interpretation on patient care. Specifically, we offer guidance on differentiating postpartum psychosis from a culturally appropriate phenomenon.

Eclampsia in the 21st century

The reported incidence of eclampsia is 1.6 to 10 per 10,000 deliveries in developed countries, whereas it is 50 to 151 per 10,000 deliveries in developing countries. In addition, low-resource countries have substantially higher rates of maternal and perinatal mortalities and morbidities. This disparity in incidence and pregnancy outcomes may be related to universal access to prenatal care, early detection of preeclampsia, timely delivery, and availability of healthcare resources in developed countries compared to developing countries. Because of its infrequency in developed countries, many obstetrical providers and maternity units have minimal to no experience in the acute management of eclampsia and its complications. Therefore, clear protocols for prevention of eclampsia in those with severe preeclampsia and acute treatment of eclamptic seizures at all levels of healthcare are required for better maternal and neonatal outcomes. Eclamptic seizure will occur in 2% of women with preeclampsia with severe features who are not receiving magnesium sulfate and in <0.6% in those receiving magnesium sulfate. The pathogenesis of an eclamptic seizure is not well understood; however, the blood-brain barrier disruption with the passage of fluid, ions, and plasma protein into the brain parenchyma remains the leading theory. New data suggest that blood-brain barrier permeability may increase by circulating factors found in preeclamptic women plasma, such as vascular endothelial growth factor and placental growth factor. The management of an eclamptic seizure will include supportive care to prevent serious maternal injury, magnesium sulfate for prevention of recurrent seizures, and promoting delivery. Although routine imagining following an eclamptic seizure is not recommended, the classic finding is referred to as the posterior reversible encephalopathy syndrome. Most patients with posterior reversible encephalopathy syndrome will show complete resolution of the imaging finding within 1 to 2 weeks, but routine imaging follow-up is unnecessary unless there are findings of intracranial hemorrhage, infraction, or ongoing neurologic deficit. Eclampsia is associated with increased risk of maternal mortality and morbidity, such as placental abruption, disseminated intravascular coagulation, pulmonary edema, aspiration pneumonia, cardiopulmonary arrest, and acute renal failure. Furthermore, a history of eclamptic seizures may be related to long-term cardiovascular risk and cognitive difficulties related to memory and concentration years after the index pregnancy. Finally, limited data suggest that placental growth factor levels in women with preeclampsia are superior to clinical markers in prediction of adverse pregnancy outcomes. This data may be extrapolated to the prediction of eclampsia in future studies. This summary of available evidence provides data and expert opinion on possible pathogenesis of eclampsia, imaging findings, differential diagnosis, and stepwise approach regarding the management of eclampsia before delivery and after delivery as well as current recommendations for the prevention of eclamptic seizures in women with preeclampsia.

Clinical and Imaging Data-Based Model for Predicting Reversible Posterior Leukoencephalopathy Syndrome (RPLS) in Pregnant Women With Severe Preeclampsia or Eclampsia and Analysis of Perinatal Outcomes

OBJECTIVE

This study aimed to investigate the risk factors of reversible posterior leukoencephalopathy syndrome (RPLS) in pregnant women with severe preeclampsia or eclampsia (SPE/E) based on a predicting model and to analyze the perinatal outcomes.

METHODS

From January 2015 to March 2020, 78 pregnant women data diagnosed with severe preeclampsia or eclampsia with cranial magnetic resonance imaging (MRI) and transcranial Doppler (TCD) screening in Xiangyang No. 1 People's Hospital and Jiangsu Province Hospital of Chinese Medicine were analyzed retrospectively. They were divided into the RPLS group (n = 33) and non-RPLS group (n = 45) based on the MRI results. The general clinical data (blood pressure, BMI, symptoms, and so forth), laboratory examination, TCD results, and perinatal outcomes in the two groups were compared. The risk factors of severe preeclampsia or eclampsia complicated with RPLS were analyzed by multivariate logistic regression. The prediction model and decision curve (DCA) were established according to the clinical-imaging data.

RESULTS

The univariate analysis showed that poor placental perfusion, hypertension emergency, use of two or more oral antihypertensive drugs, headache, white blood cell (WBC) count, platelet (PLT) count, lactate dehydrogenase (LDH), alanine aminotransferase (ALT), uric acid (UA), serum albumin (ALB), average flow velocity, and resistance index of the posterior cerebral and basilar arteries were significantly different in the RPLS group compared with the non-RPLS group (all P < 0.05). The multivariate logistic regression analysis showed that hypertensive emergency, headache, WBC, PLT, ALT, and average flow velocity of the basilar artery (BAAFV) were the risk factors in the RPLS group. The aforementioned clinical-imaging data modeling (general data model, laboratory examination model, TCD model, and combined model) showed that the combined model predicted RPLS better. DCA also confirmed that the net benefit of the combined model was higher. In addition, the incidence of postpartum hemorrhage, stillbirth, and preterm infants was higher in the RPLS group than in the non-RPLS group (all P < 0.05).

CONCLUSIONS

More postpartum complications were detected in pregnant women with severe preeclampsia or eclampsia complicated with RPLS. Hypertensive emergency, headache, WBC, PLT, ALT, and BAAFV were the important risk factors for RPLS. The combined model had a better effect in predicting RPLS.

The pathophysiologic, diagnostic, and therapeutic aspects of posterior reversible encephalopathy syndrome during pregnancy

Posterior reversible encephalopathy syndrome (PRES) is a neurological condition with a wide range of symptoms, including visual disturbances, headache, vomiting, seizures, and altered consciousness. This review describes the pathophysiology of PRES, as well as the clinical, diagnostic, and therapeutic intervention during pregnancy. The gold standard for diagnosis of PRES is Magnetic Resonance Imaging (MRI), helping to differentiate it from other similar conditions. The aim of this paper is to review the principal aspects of PRES, general care, blood pressure control, and seizures prevention while avoiding potential injuries to the mother and fetus in the event of pregnancy. We concluded that PRES can be effectively treated and reversed if prompt diagnostic action is made, and adequate care is initiated.

The association of posterior reversible encephalopathy syndrome with COVID-19: A systematic review

The rise in Coronavirus disease 2019 (COVID-19) cases is revealing its unique neurological manifestations. In light of the emerging evidence, a possible association with Posterior Reversible Encephalopathy Syndrome (PRES) is being consistently reported. We conducted a systematic literature search on four databases namely Pubmed/MEDLINE, Cochrane, Google Scholar, and Science Direct. After rigorous screening as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a total of 34 articles describing 56 cases were selected as a part of this review. The mean age of the patients was 56.6 ± 15.3 years. The most common clinical presentation of PRES was altered mental status (58.9%) followed by seizures (46.4%) and visual disturbances (23.2%) while hypertension and diabetes mellitus were the most commonly reported comorbidities. 91.1% of the cases reported Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) findings suggestive of PRES in the brain. Symptomatic management was employed in most of the cases to control seizures and blood pressure, and 44 patients (78.5%) fully or partially recovered. The most likely underlying mechanism involves COVID-19 mediated cytokine storm syndrome that leads to endothelial damage and increased permeability of the cerebral vessels, thus causing the characteristic edema of PRES. High neuronal and glial cell expression of Angiotensin Converting Enzyme-2 (ACE-2) receptors also suggests the possibility of direct viral damage. Since timely diagnosis and treatment reports a good prognosis, it is vital for physicians and neurologists to be well-versed with this association.

Coexisting posterior reversible encephalopathy syndrome and ischemic hepatopathy: A case report

Posterior reversible encephalopathy syndrome (PRES) is acute neurologic symptoms with specific radiologic findings. This unique case shows coexisting PRES with acute liver injury, which could suggest common pathophysiologic process.

Posterior Reversible Encephalopathy Syndrome (PRES) in Palliative Medicine: Case Report and Discussion

Posterior reversible encephalopathy syndrome (PRES) is associated with seizures, visual disturbances, headache, and altered mental status. Given its presentation, the diagnosis can be mistaken for other severe conditions. Palliative medicine consultants should be aware of PRES and be prepared to counsel families on the treatment and prognosis of this syndrome.

Posterior Reversible Encephalopathy Syndrome (PRES) in a Patient with Opioid Use Disorder

Posterior Reversible Encephalopathy Syndrome (PRES) is a characteristic clinical radiographic syndrome with diffuse structural alteration of cerebral white matter secondary to myelin damage with diverse and multifactorial etiologies. It can present with acutely altered mentation, somnolence or occasionally stupor, vision impairment, seizures, and sudden or chronic headaches that are not focal. The pathophysiology remains unclear, but mechanisms involving endothelial injury and dysregulation of cerebral autoregulation have been purported. We report the case of a 36-year-old male with a history of heroin use disorder, who was admitted to our hospital for opioid withdrawal. CT head without contrast and MRI with and without gadolinium showed significant white matter disease in both cerebral hemispheres and cerebellum. He was diagnosed with Posterior Reversible Encephalopathy Syndrome secondary to heroin use and managed on the medical floor in collaboration with the neurology team. His clinical symptoms improved and he was discharged after six weeks. To our knowledge, this case did not present with the risk factors for PRES reported in the literature. For patients with heroin use disorder who present with an altered mental status, PRES should be highly suspected. The diagnosis and management require collaboration between psychiatry and neurology.

Stroke in Pregnancy: A Multidisciplinary Approach

Pregnancy confers a substantially increased risk of stroke, especially during the third trimester and until 6 weeks postpartum. Hypertensive disorders of pregnancy and gestational hypercoagulability are important contributors to obstetric stroke. Preeclampsia and eclampsia confer risk for future cardiovascular disease. Hemorrhagic stroke is the most common type of obstetric stroke. Ischemic stroke can result from cardiomyopathy, paradoxical embolism, posterior reversible encephalopathy, reversible cerebral vasoconstriction syndrome, and dissections. Cerebral venous sinus thrombosis is a frequent complication of pregnancy.

Neurology of Preeclampsia and Related Disorders: an Update in Neuro-obstetrics

PURPOSE OF REVIEW

Preeclampsia and related hypertensive disorders of pregnancy affect up to 10% of pregnancies. Neurological complications are common and neurologists often become involved in the care of obstetric patients with preeclampsia. Here, we review the definition(s), epidemiology, clinical features, and pathophysiology of preeclampsia, focusing on maternal neurological complications and headache as a common presenting symptom of preeclampsia.

RECENT FINDINGS

Neurological symptoms are early and disease-defining features of preeclampsia. Neurological complications of preeclampsia may include headaches, visual symptoms, cerebral edema, seizures, or acute cerebrovascular disorders such as intracerebral hemorrhage or reversible cerebral vasoconstriction syndrome. A history of migraine is an independent risk factor for vascular diseases during pregnancy, including preeclampsia and maternal stroke. The pathophysiology of both preeclampsia and migraine is complex, and the mechanisms linking the two are not fully understood. Overlapping clinical and pathophysiological features of migraine and preeclampsia include inflammation, vascular endothelial dysfunction, and changes in vasoreactivity. Neurological complications are recognized as a major contributor to maternal morbidity and mortality. Pregnant and postpartum women commonly present with headache, and red flags in the clinical history and examination should prompt urgent neuroimaging and laboratory evaluation. A focused headache history should be elicited from patients as part of routine obstetrical care to identify patients at an increased risk of preeclampsia and related hypertensive disorders of pregnancy. Collaborative models of care and scientific investigation in the emerging field of neuro-obstetrics have the common goal of reducing the risk of maternal neurological morbidity and mortality from preeclampsia.

Cognitive impairment in preeclampsia complicated by eclampsia and pulmonary edema after delivery

INTRODUCTION

We aimed to assess cognitive function in women with preeclampsia stratified by severity, before and after onset of disease.

MATERIAL AND METHODS

Prospective study performed at a referral hospital in Cape Town, South Africa. Pregnant women between 20 and 42 weeks of gestation with eclampsia, pulmonary edema and preeclampsia without severe features, and a normotensive pregnancy were approached. Women were included at diagnosis of preeclampsia or at admission for delivery (women with normotensive pregnancies). Two cognitive assessments, the Cognitive Failure Questionnaire to assess the cognitive function subjectively before inclusion in the study, and Montreal Cognitive Assessment to assess the current cognitive function objectively before discharge from the hospital after delivery, were performed.

RESULTS

We included 61 women with eclampsia, 28 with preeclampsia complicated by pulmonary edema, 38 with preeclampsia without severe features, and 26 with normotensive pregnancies. There was no difference in cognitive function from early pregnancy between groups. Women with eclampsia and preeclampsia complicated by pulmonary edema scored lower on the Montreal Cognitive Assessment at time of discharge compared with women with normotensive pregnancies. The results were attenuated in pulmonary edema after adjustment for confounders.

CONCLUSIONS

Women with preeclampsia complicated by pulmonary edema and in particular eclampsia had impaired cognitive function after onset of disease compared with women with normotensive pregnancies. The impairment did not seem to be present before onset of disease. Women with preeclampsia without severe features did not have impaired cognitive function.

Neuropathophysiology of preeclampsia and eclampsia: A review of cerebral hemodynamic principles in hypertensive disorders of pregnancy

Preeclampsia and eclampsia are hypertensive disorders of pregnancy associated with abnormal placental vascular development. The systemic angiogenic imbalance, endothelial dysfunction and proinflammatory state caused by abnormal placental development results in abnormalities in renal, hepatic, pulmonary and neurologic function. Neurosensory symptoms related to pregnancy induced hypertension (PIH), the most devastating of which are intracranial hemorrhage and seizure, are among the leading causes of maternal and perinatal morbidity and mortality globally, yet risk stratification strategies and targeted therapies remain elusive. Current treatment for preeclampsia with severe features is limited to delivery, antihypertensive therapy, and magnesium sulfate seizure prophylaxis. Magnesium sulfate reduces seizure rates among severe preeclamptics, but predisposes patients to weakness, uterine atony, pulmonary edema and respiratory depression. Therefore, this drug should ideally be administered only to the subset of preeclamptics who are at increased risk for neurologic complications. While there are no objective methods validated to predict eclampsia, we hypothesize that measurement of optic nerve sheath diameters, optic disc height and middle cerebral artery transcranial doppler resistance indices may be useful in identifying subclinical cerebral edema, potentially allowing us to recognize those patients at highest risk for seizures. This summary of the current literature provides an initial framework for developing more sophisticated and noninvasive methods for identifying, monitoring and treating parturients who are at highest risk for neurologic complications from preeclampsia.

Eclampsia-Induced Posterior Reversible Encephalopathy Syndrome in a Donor Oocyte Recipient

Objective: Posterior reversible encephalopathy syndrome (PRES) has been robustly associated with preeclampsia, hyperperfusion or endothelial dysfunction suggested as possible mechanisms. In this article, we report an illustrative case of this complication in a patient with risk factors for hypertensive disorders in pregnancy, including advanced maternal age and donor oocyte fertilization. Case report: We present a case of a 40-year-old pregnant, donor oocyte recipient with sudden decreased visual acuity accompanied by hypertension, proteinuria and tonic-clonic seizures. Magnetic resonance imaging (MRI) of the brain showed bilateral lesions in the parieto-occipital regions suggestive of vasogenic edema, leading us to suspect posterior reversible encephalopathy syndrome. The patient underwent an emergency cesarean section and labetalol and magnesium sulfate were administered intravenously. The neurological symptoms and radiological findings resolved following delivery and the patient's blood pressure normalized, supporting the diagnosis of posterior reversible encephalopathy syndrome. Conclusion: Pregnancy by donor oocyte fertilization may entail a higher risk of eclampsia and associated posterior reversible encephalopathy syndrome.

Neurotoxicity in pre-eclampsia involves oxidative injury, exacerbated cholinergic activity and impaired proteolytic and purinergic activities in cortex and cerebellum

Women with a history of pre-eclampsia (PE) tend to have a higher risk of developing cardiovascular and neurological diseases later in life. Imbalance in oxidative markers and purinergic enzymes have been implicated in the pathogenesis of neurological disease. This study investigated the effect of PE on oxidative imbalance, purinergic enzyme inhibitory activity, acetylcholinesterase and chymotrypsin activities in the brain of PE rat model at post-partum/post-natal day (PP/PND) 60. Pregnant rats divided into early-onset and late-onset groups were administered with Nω-nitro-l-arginine methyl through drinking water at gestational days 8-17. Rats were allowed free access to water throughout the pregnancy and allowed to deliver on their own. The mother and the pups were euthanized at PP and PND 60, respectively, the cortex and the cerebellum excised, homogenized and stored for analyses of the enzymes. Results showed an increase in nitric oxide and malondialdehyde with a concomitant decrease in reduced glutathione and superoxide dismutase, an indication of oxidative damage. Also, there was an increase in acetylcholinesterase activity with a decrease in chymotrypsin, adenylpyrophosphatase and ecto-nucleoside triphosphate diphosphohydrolase activities in both the cortex and the cerebellum of the mother and the pups at PND 60. These results indicate the involvement of oxidative stress, increased cholinergic activity and depleted proteolytic and purinergic activities in PE-induced neurotoxicity.

Malignant hypertension: diagnosis, treatment and prognosis with experience from the Bordeaux cohort

BACKGROUND

Malignant hypertension, the most severe form of hypertension, is defined by high blood pressure and acute ischemic organ damage. It has a worse prognosis than other forms of hypertension, especially in black patients. New tools to assess organ damage, especially that of the heart and brain, are now available and may contribute to a better evaluation of these patients. This report improves knowledge of the characteristics of involved organs to facilitate diagnosis and to evaluate the effectiveness of our treatment protocol.

METHOD

The Bordeaux registry, started in 1995, recruited 168 patients. In addition to evaluations of their eyes and kidneys, these patients had a systematic evaluation of their hearts with ECG and echocardiography and, since 2007, a systematic brain MRI. Blood pressure was lowered with a protocol based on blockers of the renin-angiotensin system started at a very low-dose with forced titration over 48 h. Only an oral route was used for antihypertensive medication.

RESULTS

Systematic MRIs found significant brain damage in 93% of patients. Heart involvement was highly prevalent: 82% had left ventricular mass more than 60 g/m, and 56% had systolic dysfunction (estimated by global longitudinal strain). Renal involvement and thrombotic microangiopathy were respectively present in 55 and 15% of patients. Median follow-up was 48 months. Renal survival at 5 years was 90.8%, similar to other studies.

CONCLUSION

Malignant hypertension is a systemic disease causing severe damage to the brain, heart, kidneys and eyes, even in absence of symptoms. Renin-angiotensin system blockers seem to be the cornerstone of treatment.

[Posterior reversible encephalopathy syndrome: a case report]

L'encéphalopathie postérieure réversible (EPR) est une entité radio-clinique associant une atteinte réversible du système nerveux central à une imagerie encéphalique typique. Il existe une grande variabilité dans la présentation clinique de ce syndrome et des aspects en imagerie parfois atypiques. L'EPR est une complication neurologique inhabituelle survenant au cours de la grossesse ou en post-partum, en dehors de toute pathologie préexistante de la grossesse dont l'œdème vasogénique par rupture de la barrière hémato encéphalique paraît être l'acteur principal. Nous rapportons l'observation d'une patiente primipare présentant des crises convulsives généralisées tonico-cloniques associées à un pic hypertensif, survenant au cours du troisième trimestre de grossesse. L'imagerie par résonance magnétique (IRM) cérébrale était en faveur d'une encéphalopathie postérieure réversible. L'EPR doit être évoqué devant tout signe d'appel neurologique, vu l'évolution favorable sans séquelles sous un traitement précoce et rapide.

Meta-analysis of cognitive functioning in patients following kidney transplantation

Background

There is mixed evidence regarding the nature of cognitive function in patients who have undergone renal transplantation. The aim of this meta-analysis was to examine which cognitive domains are impacted following kidney transplantation and how performance compares with non-transplanted patients or healthy controls/normative data.

Method

A systematic search was conducted using keywords within three databases (Embase, MEDLINE and PsychINFO), yielding 458 unique studies, 10 of which met the inclusion criteria. Neuropsychological tests were grouped into nine cognitive domains and three separate analyses were undertaken within each domain: (i) within subjects pre- versus post-transplant, (ii) transplanted versus non-transplanted patients and (iii) transplanted versus healthy matched controls and standardized normative data.

Results

Transplanted patients showed moderate to large improvements in the domains of general cognitive status (g = 0.526), information and motor speed (g = 0.558), spatial reasoning (g = 0.376), verbal memory (g = 0.759) and visual memory (g = 0.690) when compared with their pre-operative scores. Test scores in the same five domains were significantly better in post-transplanted patients when compared with dialysis-dependant or conservatively managed chronic kidney disease patients. However, post-transplanted patients’ performance was significantly low compared with that of healthy controls (and standardized normative data) in the domains of executive functioning (g = −0.283), verbal fluency (g = −0.657) and language (g = −0.573).

Conclusions

Two key issues arise from this review. First, domain-specific cognitive improvement occurs in patients after successful transplantation. Nevertheless, transplanted patients still performed significantly below healthy controls in some domains. Second, there are important shortcomings in existing studies; the length of follow-up is typically short and only limited neuropsychological test batteries are employed. These factors are important in order to support the recovery of cognitive function among patients following renal transplant.

Stroke in Pregnancy: An Update

Pregnancy confers a substantially increased risk of stroke in women. The period of highest risk of stroke is the peripartum/postpartum phase, coinciding with the highest risk for hypertensive disorders of pregnancy and peak gestational hypercoagulability. Hemorrhagic stroke is the most common type of obstetric stroke. Hypertensive disorders of pregnancy are important contributors to obstetric stroke and predispose women to premature cardiovascular disease. The rate of stroke associated with hypertensive disorders of pregnancy has increased in the United States. Other conditions associated with obstetric stroke include posterior reversible encephalopathy, reversible cerebral vasoconstriction syndrome, and cerebral venous sinus thrombosis.

Maternal Stroke: an Update

PURPOSE OF THE REVIEW

Maternal morbidity and mortality is rising in the USA, and maternal stroke is a major contributor. Here, we review the epidemiology, risk factors, and current recommendations for diagnosis and acute treatment of ischemic and hemorrhagic stroke during pregnancy and postpartum, focusing on recent evidence.

RECENT FINDINGS

The incidence of maternal stroke has risen in recent years, possibly due to increasing rates of hypertensive disorders of pregnancy. The risk of maternal stroke is highest in the peripartum and early postpartum period. Preeclampsia is highly associated with reversible cerebral vasoconstriction syndrome and posterior reversible encephalopathy syndrome and is also associated with long-term increased risk of stroke and vascular dementia. Hypertensive disorders of pregnancy, migraine, and infections are risk factors for maternal stroke. Limited data suggest that thrombolytics and endovascular reperfusion therapy are safe and effective in pregnant women with ischemic stroke, but few data are available regarding safety of thrombolytics in the postpartum period. New consensus guidelines are now available to assist with management of ischemic and hemorrhagic stroke in pregnancy. Many gaps remain in our understanding of maternal stroke. While risk factors have been identified, there are no prediction tools to help identify which women might be at highest risk for postpartum stroke and require closer monitoring. The risk of recurrent maternal stroke has not been adequately quantified, limiting clinicians' ability to counsel patients. The complex pathophysiology of preeclampsia and its effects on the cerebral vasculature require further targeted study. An increased focus on the prevention, recognition, and optimal treatment of maternal stroke will be critical to reducing maternal morbidity and mortality.

Non-obstetric complications in preeclampsia

Preeclampsia is a multisystem disorder of pregnancy that remains a leading cause of maternal and foetal morbidity and mortality. It is still an underestimated risk factor for future cardiovascular, cerebrovascular, and kidney disease, developing often in the perimenopausal period of a woman's life. It remains unclear whether preeclampsia is an individual risk factor for future cardiovascular, cerebrovascular, and renal events or an early marker of women with high-risk profiles for these diseases. Risk factors for cardiovascular disorders and preeclampsia are very similar and include the following: obesity, dyslipidaemia, insulin resistance, pro-inflammatory and hypercoagulable state, and endothelial dysfunction. Thus, the pregnancy can only be a trigger for cardiovascular alterations that manifest in development of preeclampsia. On the other hand, there is strong evidence that changes in cardiovascular, endothelial, and metabolic systems occurring in the course of preeclampsia may not fully recover after delivery and can be a cause of future disease, especially in the presence of other metabolic risk factors regarding, for example, perimenopause. In this review the authors present current knowledge about short- and long-term maternal consequences of preeclampsia, such as: cardiovascular disease, cerebrovascular incidents (posterior reversible encephalopathy and stroke), kidney injury (including the risk of end-stage renal disease), liver failure, and coagulopathy (thrombocytopenia and disseminated intravascular coagulation).

Postpartum Posterior Reversible Encephalopathy Syndrome (PRES): Three Case Reports and Literature Review

Posterior reversible encephalopathy syndrome is a rare complication generally associated with headache and acute changes in blood pressure. Delay in the diagnosis and treatment may result in death or in irreversible neurological sequelae. We present three cases of PRES occurring in young women during puerperium. We report a literature review ranged from January 1990 to June 2015 describing clinical features, diagnostic and medical approach, and maternal outcome.

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

Posterior reversible encephalopathy syndrome (PRES) is an uncommon but potentially devastating syndrome if not recognized and treated appropriately. As the name implies, recognition of the condition and proper management may reverse the clinical and radiological findings. However, diagnosis is not always straightforward. We present the case of a 24-year-old female who was 4 days post-partum and presented with headache, neck pain, and new-onset seizures. She had undergone epidural anesthesia during labor, and initial imaging was suggestive of intracranial hypotension versus pachymeningitis. Despite initial conservative therapy including anti-epileptic drugs, magnesium therapy, empiric antibiotics, and Trendelenburg positioning, the patient continued to deteriorate. Follow-up imaging was suggestive of PRES with signs of intracranial hypertension. The patient underwent a decompressive suboccipital craniectomy for refractory and severe PRES and later fully recovered. This case highlights the sometimes difficult diagnosis of PRES, possible association with pregnancy, eclampsia/preeclampsia and/or cerebrospinal fluid drainage, and the rare but life-saving need for decompression in severe cases.

Posterior reversible encephalopathy syndrome (PRES) and infection: a systematic review of the literature

Posterior reversible encephalopathy syndrome (PRES) is an encephalopathy characterized by a rapid onset of symptoms including headache, seizures, confusion, blurred vision, and nausea associated with a typical magnetic resonance imaging appearance of reversible subcortical vasogenic edema prominent and not exclusive of parieto-occipital lobes. Vasogenic edema is caused by a blood-brain barrier leak induced by endothelial damage or a severe arterial hypertension exceeding the limits of cerebral blood flow autoregulation. Although the exact pathophysiological mechanism is still unclear, frequent conditions that may induce PRES include severe hypertension, eclampsia/pre-eclampsia, acute kidney diseases and failure, immunosuppressive therapy, solid organ, or bone marrow transplantation. Conversely to other conditions, which may induce PRES, the link between severe infection or sepsis and PRES, often associated with gram-positive bacteria, is still poorly understood and less well known. Clinicians from multiple disciplines, such as neurologists and internists, may encounter during their profession patients with severe infection or sepsis and should consider the possible association between PRES and these conditions. We systematically reviewed the literature about this association in order to provide a helpful clinical insight of such complex pathophysiological mechanism, highlighting the importance of recognizing PRES in such a complex clinical scenario.

Changes in the structure and function of the brain years after Pre-eclampsia

Pre-eclampsia (PE) is a pregnancy specific syndrome that affects multiple organs including the brain. PE resolves after delivery of the placenta. Nonetheless, PE is a predisposing factor for cardiovascular disorders and hypertension later in life. These conditions are associated with a cognitive decline and dementia later in life. Studies have suggested that there may be long term pathological changes within the brain of the woman after PE/eclampsia and PE may be a risk marker for early cerebrovascular impairment. The aim of this review is to provide an insight into the possible long-term effect of PE and eclampsia on the brain structure and function with the probability of PE being a risk factor for neurodegenerative development. Long term effects of PE include cognitive impairment such as memory loss, attention deficit and motor speed impairment. Also, the pathology of the brain seems to be much affected later in life in women with history of PE/eclampsia. Certain changes in the structure and function of the brain observed among women with history of PE/eclampsia are similar to neurological disease like Alzheimer's disease (AD) and dementia.

Transient cortical blindness in posterior reversible encephalopathy syndrome after postpartum eclampsia

Posterior reversible encephalopathy syndrome (PRES) is a clinical condition that can cause different ophthalmological and neurological symptoms. Preeclampsia toxemia or eclampsia is one of the leading causes of PRES. Herein, we present a study of a 35-year old woman who gave birth to healthy twins at 35 weeks of gestation by cesarean section because of threatened preterm delivery. On the 1^st postoperative day, the woman developed a severe headache, arterial hypertension, tachycardia, generalized tonic-clonic seizures, and loss of consciousness that persisted for about 2 min. A provisional diagnosis of eclampsia was made, and the woman was then quickly transferred to the intensive care unit where she was treated with antihypertensive therapy, magnesium sulphate, and diazepam. Following stabilization of the general condition, the patient noticed sudden bilateral blindness. An ophthalmological examination revealed significant bilateral loss of vision at the level of insecured light perception, normal pupillary responses to a light stimulus, and normal fundus findings. On this basis, an ophthalmologist made the diagnosis to cortical blindness. Radiographic analysis showed an edematous change in the occipital and parietal brain regions, thus suggesting a diagnosis of PRES. In conclusion, cortical blindness is a clinically striking ophthalmic disorder that may occur in PRES associated with postpartum eclampsia.

Posterior Reversible Encephalopathy Syndrome with Status Epilepticus Following Surgery for Lumbar Stenosis and Spondylolisthesis

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiologic condition encountered in many different clinical settings; it generally occurs in the context of hypertensive crisis, immunosuppressive therapy, or autoimmune diseases. It is characterized by headache, stupor, seizures, and visual alterations. Magnetic resonance imaging findings include white matter changes preferentially in the parieto-occipital regions. Although pathogenesis is not fully elucidated, vasoconstriction and brain hypoperfusion seem to be the cause of brain ischemia and vasogenic edema. Cerebrospinal fluid hypotension is also a reported plausible pathogenic mechanism.

CASE DESCRIPTION

We present a case of PRES following laminectomy and fixation for L4-5 lumbar stenosis and spondylolisthesis. The patient presented with status epilepticus immediately after surgery that lasted 5 days. Brain magnetic resonance imaging showed fluid attenuated inversion recovery and T2 hyperintensities in the bilateral parietal and occipital lobes and external capsules. On the basis of postoperative lumbar images, we hypothesized that an unnoticed cerebrospinal fluid leak might have contributed to development of PRES. The patient developed multiple postoperative complications but ultimately recovered after treatment for severe hypertension and seizures.

CONCLUSIONS

Prompt recognition and treatment of this potentially life-threatening syndrome is necessary to increase the likelihood of favorable outcome. Spinal surgeons need to be aware of the possibility of neurologic deterioration after spinal surgery and be alert about the occurrence of a dural leak, either recognized or unnoticed, as the plausible mechanism triggering PRES.

Posterior reversible encephalopathy in the intensive care unit

Posterior reversible encephalopathy syndrome (PRES) is increasingly diagnosed in the emergency department, and medical and surgical intensive care units. PRES is characterized by acute onset of neurologic symptoms in the setting of blood pressure fluctuations, eclampsia, autoimmune disease, transplantation, renal failure, or exposure to immunosuppressive or cytotoxic drugs, triggers known to admit patients to the intensive care unit (ICU). Although the exact pathophysiology remains unknown, there is growing consensus that PRES results from endothelial dysfunction. Because of the heterogeneous nature of the disorder, it is probable that different mechanisms of endothelial injury are etiologically important in different clinical situations. The presence of bilateral vasogenic edema on brain imaging, particularly in parieto-occipital regions, is of great diagnostic utility but PRES remains a clinical diagnosis. Although largely reversible, PRES can result in irreversible neurologic injury and even death. The range of clinical and radiographic manifestations of the syndrome is probably broader than previously thought, and it is imperative that clinicians become familiar with the full spectrum of the disorder, as prompt recognition and elimination of an inciting factor improve outcome. PRES may be the most frequent toxic-metabolic encephalopathy seen in the ICU.

Cerebral Biomarkers in Women With Preeclampsia Are Still Elevated 1 Year Postpartum

BACKGROUND

There is evidence of cerebral involvement among women with preeclampsia. Levels of the cerebral biomarkers neuron-specific enolase (NSE) and S100B are elevated during pregnancy in women developing preeclampsia. It is although not known if these biomarkers return to normal range postpartum. The aim with this study was to compare levels of S100B and NSE during pregnancy and 1 year postpartum in women who have had preeclampsia to women with normal pregnancies.

METHODS

This study was a longitudinal study of cases (n = 53) with preeclampsia and controls (n = 58) consisted of normal pregnant women in matched gestational weeks. Plasma samples were collected at inclusion during pregnancy and 1 year postpartum. Plasma samples were analyzed for levels of S100B and NSE by enzyme-linked immunosorbent assays kits.

RESULTS

Levels of NSE and S100B in women with preeclampsia were higher during pregnancy than in women with normal pregnancies. One year postpartum, women who have had preeclampsia still had a higher median level of both NSE (5.07 vs. 4.28 µg/l, P < 0.05) and S100B (0.07 vs. 0.06 µg/l, P < 0.05) compared to women with previous normal pregnancies. High levels of NSE and S100B postpartum remained associated with previous preeclampsia after adjustment for confounding factors. Levels of NSE correlated to S100B during pregnancy and postpartum.

CONCLUSIONS

Levels of NSE and S100B are still elevated 1 year postpartum in women who have had preeclampsia in contrast to women with previous normal pregnancies. We hypothesize that there might be a persistent cerebral involvement among women with preeclampsia even 1 year postpartum.

Reversible posterior encephalopathy syndrome associated with late onset postpartum eclampsia: A case report

Late onset postpartum eclampsia (LPE) is defined by its onset at >48 h after delivery. Reversible posterior encephalopathy syndrome (RPES) associated with LPE is uncommon, with the majority of RPES cases having a late postpartum onset within 4 weeks after childbirth. The present study reported the case of a 15-year old female presenting with convulsions that began 5 weeks after delivery. A magnetic resonance imaging scan of the brain revealed multiple lesions in the cortex, subcortical region and deep white matter of the bilateral cerebellum, and occipital, frontal and parietal lobes. The clinical manifestations and radiological abnormalities were readily resolved subsequent to antihypertension and anticonvulsion treatment. In conclusion, the present rare case indicates that LPE should be considered as a potential diagnosis even at 4 weeks after delivery. Furthermore, clinicians should familiarize with the reversible radioimaging features of RPES, since early recognition and adequate treatment are important to the outcome of patients.

Diagnosis of Acute Neurologic Emergencies in Pregnant and Postpartum Women

Acute neurologic symptoms in pregnant and postpartum women may be caused by exacerbation of a preexisting neurologic condition, the initial presentation of a non-pregnancy-related problem, or a new neurologic problem. Pregnant and postpartum patients with headache and neurologic symptoms are often diagnosed with preeclampsia or eclampsia; however, other etiologies must also be considered. A team approach with close communication between emergency physicians, neurologists, maternal-fetal medicine specialists, and radiologists is the key to obtaining best outcomes. This article reviews the clinical features and differential diagnosis of acute serious neurologic conditions in pregnancy and the puerperium, focusing on diagnosis.

[Posterior reversible encephalopathy syndrome]

Posterior reversible encephalopathy syndrome refers to a neurological disorder characterized by headache, disorders of consciousness, visual disturbances, epileptic seizures, and subcortical vasogenic edema. About two thirds of patients develop neurological symptoms, which are associated with blood pressure fluctuations. One hypothesis is that hypertensive episodes cause autoregulatory failure, and values above the upper limit of cerebral autoregulation result in a breakthrough followed by hyperperfusion and blood-brain barrier dysfunction. In another hypothesis, endothelial dysfunction triggered by numerous factors including preeclampsia, immunosuppressive agents, chemotherapeutics, sepsis, or autoimmune disorders is thought to be the key pathomechanism. Endo- or exogenic toxic agents including pharmacological substances, cytokines, or bacterial toxins are supposed to trigger endothelial activation and dysfunction resulting in the release of vasoconstrictors, pro-inflammatory mediators, and vascular leakage. Diagnosis is usually based on clinical and neuroimaging findings that frequently show a bilateral, symmetric, and parietooccipital pattern. However, the diagnosis can often only be confirmed during the course of disease after excluding important differential diagnoses. Currently, there is no specific treatment available. Lowering of arterial blood pressure and eliminating the underlying cause usually leads to an improvement of clinical and neuroradiological findings. Admission to a critical care unit is required in about 40 % of patients due to complicating conditions including status epilepticus, cerebral vasoconstriction, ischemia, or intracerebral hemorrhage. Prognosis is favorable; in the majority of patients neurological deficits and imaging findings resolve completely.

Hypertensive disorders of pregnancy: what the physician needs to know

Hypertension developing during pregnancy may be caused by a variety of different pathophysiological mechanisms. The occurrence of proteinuric hypertension during the second half of pregnancy identifies a group of women whose hypertensive disorder is most likely to be caused by the pregnancy itself and for whom the risk of complications, including maternal mortality, is highest. Physicians identifying patients with hypertension in pregnancy need to discriminate between pre-eclampsia and other forms of hypertensive disease. Pre-eclamptic disease requires obstetric intervention before it will resolve and it must be managed in a multidisciplinary environment. The principles of diagnosis and management of these different entities are outlined in this review.

Cerebrovascular Dysfunction in Preeclamptic Pregnancies

Preeclampsia is a hypertensive, multisystem disorder of pregnancy that affects several organ systems, including the maternal brain. Cerebrovascular dysfunction during preeclampsia can lead to cerebral edema, seizures, stroke, and potentially maternal mortality. This review will discuss the effects of preeclampsia on the cerebrovasculature that may adversely affect the maternal brain, including cerebral blood flow (CBF) autoregulation and blood-brain barrier disruption and the resultant clinical outcomes including posterior reversible encephalopathy syndrome (PRES) and maternal stroke. Potential long-term cognitive outcomes of preeclampsia and the role of the cerebrovasculature are also reviewed.