Antepartum reversible cerebral vasoconstriction syndrome with pre-eclampsia and reversible posterior leukoencephalopathy

[Maternal mortality by stroke in France 2016-2018]

Between 2016 and 2018, twenty maternal deaths were associated with a stroke. The 20 deaths whose main cause was stroke represent 7.4% of all maternal deaths, i.e. a maternal mortality ratio (MMR) of 0.9 per 100,000 live births (95%CI 0.6-1.3). Among the 20 stroke deaths, it was hemorrhagic in 17 cases (85%), ischemic in 2 cases, and due to thrombophlebitis in 1 case. Stroke occurred during pregnancy in 8 women (40%) - one case before 12 weeks, 3 cases between 28 and 32 weeks, and 4 cases between 34 and 40 weeks; in 3 cases the stroke occurred intrapartum, and for the other 9 cases (45%) the stroke occurred postpartum between Day 1 and Day 15. Care was assessed as non-optimal in 10/19 (56%) of cases but mortality as possibly avoidable in 24% of cases (4/17 cases with conclusion established by the CNEMM) and not established in two cases. The potentially improvable elements identified were a delay in carrying out initial brain imaging in three cases (one case antepartum, two cases postpartum) and insufficient hemodynamic monitoring in intensive care in one case.

Reversible cerebral vasoconstriction syndrome in the postpartum period: A case report and review of the literature

Reversible cerebral vasoconstriction syndrome (RCVS) is a rare phenomenon that can present in the postpartum period. We show the experience of a 35-year-old patient who presented with headache after an uncomplicated pregnancy and vaginal delivery. She was initially diagnosed with pre-eclampsia, and subsequently with RCVS following discovery of multifocal vascular narrowing on magnetic resonance arteriography (MRA). Verapamil was initiated, and at 1 month there was improvement intracranially, but cervical vertebral arterial narrowing, likely dissection, was discovered. Verapamil was continued and aspirin was initiated. Follow-up imaging 5 months postpartum demonstrated near-complete resolution of previously noted abnormalities, which remained stable at reimaging at 10 months postpartum. In conclusion, the symptoms of RCVS can mimic or coexist with pre-eclampsia. Early intracranial imaging such as MRA can permit timely diagnosis and facilitate appropriate management and follow-up.

Eclampsia with hypothyroidism complicated with posterior reversible encephalopathy syndrome-a case report

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) is a rare neurological disorder with complex physiopathological mechanisms that have not been fully understood. Early identification is of great prognostic significance, of which the symptoms and radiological abnormalities can be completely reversed. If the diagnosis and treatment are delayed, ischemia and massive infarction may be developed in some patients. Posterior reversible encephalopathy syndrome (PRES) has been reported mainly in association with postpartum eclampsia, which have been rarely reported, while the association with hypothyroidism has not been reported at home or abroad.

CASE PRESENTATION

Here we report on a pregnant 29-year-old with multipara and a chief complication of hypothyroidism. She presented in the emergency department with frequent attacks of severe headache symptoms resulting from reversible cerebral vasoconstriction syndrome (RCVS), accompanied with prenatal eclampsia. PRES was determined by radiological examination.

CONCLUSION

To the best of our knowledge, this is the first case of PRES complicated by hypothyroidism and prepartum eclampsia.Clinicians should be alert for the co-occurence of eclampsia, PRES, and RCVS when patients have convulsions after a typical throbbing headache. Moreover, regular monitoring of thyroid function during pregnancy should also occupy certain special attention.

Brain Vascular Dysfunction in Mothers and Their Children Exposed to Preeclampsia

Preeclampsia is a maternal syndrome characterized by the new onset of hypertension and proteinuria after 20 weeks of gestation associated with multisystemic complications, including brain alterations. Indeed, brain complications associated with preeclampsia are the leading direct causes of fetal and maternal morbidity and mortality, especially in low- and middle-income countries. In addition to the well-recognized long-term adverse cardiovascular effects of preeclampsia, women who have had preeclampsia have higher risk of stroke, dementia, intracerebral white matter lesions, epilepsy, and perhaps also cognitive decline postpartum. Furthermore, increasing evidence has also associated preeclampsia with similar cognitive and cerebral disorders in the offspring. However, the mechanistic links between these associations remain unresolved. This article summarizes the current knowledge about the cerebrovascular complications elicited by preeclampsia and the potential pathophysiological mechanisms involved, emphasizing the impaired brain vascular function in the mother and their offspring.

Headaches in Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 3

PURPOSE

To provide updated evidence-based recommendations for the evaluation and treatment of primary and secondary headaches in pregnancy and postpartum.

TARGET POPULATION

Pregnant and postpartum patients with a history of or experiencing primary or new secondary headaches.

METHODS

This guideline was developed using an a priori protocol in conjunction with a writing team consisting of two specialists in obstetrics and gynecology appointed by the ACOG Committee on Clinical Practice Guidelines-Obstetrics and one external subject matter expert. ACOG medical librarians completed a comprehensive literature search for primary literature within Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements.

RECOMMENDATIONS

This Clinical Practice Guideline includes recommendations on interventions to prevent primary headache in individuals who are pregnant or attempting to become pregnant, postpartum, or breastfeeding; evaluation for symptomatic patients presenting with primary and secondary headaches during pregnancy; and treatment options for primary and secondary headaches during pregnancy and lactation. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence.

[A case of antepartum reversible cerebral vasoconstriction syndrome]

A 35-year-old pregnant woman with mild migraine experienced thunderclap headache at 37 weeks of gestation. Her cerebral MRA showed arterial segmental narrowing of right middle cerebral artery and bilateral posterior cerebral artery. When admitted, she had no sign of eclampsia/preeclampsia. After 4 days, she had premature rupture of the membrane and gave birth by caesarean section. Caesarean section immediately resolved the headache. The postpartum course of the patient and her baby was uneventfull. One month after her onset, her cerebral MRA showed improvement in arterial segmental narrowing of cerebral artery. We diagnosed reversible cerebral vasoconstriction syndrome (RCVS) assoiated with pregnancy. Pregnancy-related RCVS develops primarily during the puerperal period, but our case was a rare case that developed just before delivery and was successful with aggressive intervention. When antepartum RCVS develops, early cesarean section with epidural anesthesia in parallel with active treatment for headache may lead to good outcomes for both mother and child.

Anesthetic Management of Reversible Cerebral Vasoconstriction Syndrome During Vaginal Delivery: A Case Report

Reversible cerebral vasoconstriction syndrome (RCVS) is a rare group of vascular disorders characterized by severe headache with or without other neurologic symptoms. Pregnancy is known to precipitate RCVS, typically in the postpartum period. With improved recognition of this condition, RCVS is now increasingly identified in the antepartum period. Labor and vaginal delivery are characterized by fluctuations in hemodynamic and intracerebral pressures and present challenges for intrapartum anesthetic management. We report our experience with a patient with RCVS admitted for external cephalic version and subsequent vaginal delivery.

Neuroimaging During Pregnancy and the Postpartum Period

New onset or exacerbation of preexisting neurologic symptoms during pregnancy often necessitates brain or spinal cord imaging. Magnetic resonance techniques are preferred imaging modalities during pregnancy and the postpartum period. Ionizing radiation with computed tomography and intravenous contrast material with magnetic resonance or computed tomography should be avoided during pregnancy. New onset of headaches in the last trimester or in the postpartum period may indicate cerebrovascular disease or a mass lesion, for which brain imaging is necessary. The continuum of cerebrovascular complications of pregnancy and enlarging lesions may produce neurologic symptoms later in pregnancy and after delivery, necessitating imaging.

[Maternal mortality by stroke in France 2013-2015]

Between 2013 and 2015, 20 maternal deaths were associated with stroke. Stroke was the main cause of death in 16 cases (12 hemorrhagic strokes [75%], 1 ischemic stroke and three cerebral thrombophlebitis). In the four other cases, the stroke was a complication of another pathology. The 16 deaths directly related to stroke account for 5.7% of all maternal deaths (maternal mortality ratio of 0.7/100,000 live births vs. 0.9/100,000 over the period 2010-2012, NS). Stroke occurred during pregnancy in 8 cases (50%). Three patients died without giving birth and the 5 others gave birth by emergency caesarean section. In the remaining eight cases (50%), stroke occurred between day 0 and day 54 during the post-partum period. The mean age was 35.5 years, with 9 women being more than 35 years old (56%). One or more factors of sub-optimal care were present in 28% of the cases, and 8% of deaths were considered possibly or probably preventable. The last four strokes were associated with another pathology (eclampsia [n=2], hepatic cirrhosis [n=1], possible complication of spinal anesthesia [n=1]).

Headaches during pregnancy

Headache during pregnancy is frequent and challenging. A secondary headache is diagnosed in one third of women, and most causes are vascular and infectious disorders. Anamnestic and clinical features must be investigated, and brain imaging is often required. Primary headaches are commonly modified during pregnancy. Migraine is mainly improved in this context, especially migraine without aura. Particular cautions about treatment must be applied, and non-pharmacological measures must be preferred. Tension-type headache and cluster headache seem to be less hormone-dependent.

Antepartum eclampsia with reversible cerebral vasoconstriction and posterior reversible encephalopathy syndromes

A 39-year-old pregnant woman was experienced thunderclap headache due to reversible cerebral vasoconstriction syndrome (RCVS) as a prodromal symptom. Two days after, she was brought to our hospital after an eclamptic seizure at 35 weeks of gestation. After management with magnesium sulphate, a cesarean delivery was performed, and passed without eclamptic seizure recurrence with calcium channel blocker (CCB) administration for hypertension and prophylaxis of another seizure. Antepartum eclampsia is sometimes complicated by headache as a prodromal symptom. Cerebrovascular diseases in the perinatal period include eclampsia, RCVS and posterior reversible encephalopathy syndrome, which have potentially overlapping pathologies. Here, we first report a case of overlapping those three diseases in the antepartum period. Our best literature review showed that antepartum RCVS is severe and has complications besides thunderclap headache, and there is a case report which CCB administration was shown to be effective in the treatment of antepartum RCVS. If thunderclap headache is recognized, prediction of eclampsia and getting better course of RCVS with CCB administration may be possible.

Posterior reversible encephalopathy syndrome and reversible cerebral vasoconstriction syndrome associated spinal subdural hematoma: A case report

RATIONALE

Posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS) are separate clinical entities with distinct pathophysiological features. But in some special conditions PRES and RCVS can occur simultaneously.

PATIENT CONCERNS

We report the unique case of a 40-year-old female presented with crescendo headache, blurred vision, and recurrent generalized tonic-clonic seizure. She had a minor neck injury 1 week before but attracted no more attention. Neurological tests on admission yielded a Glasgow Coma Scale score of 13. No obvious focal neurological deficit apart from positive signs of meningeal irritation was presented.

DIAGNOSES

Xanthochromia and hemorrhagic cerebrospinal fluid with pleocytosis was found on lumbar puncture. Cranial computed tomography was negative but magnetic resonance imaging demonstrated bilateral areas of vasogenic edema in the parieto-occipital lobes and cerebellum consistent with PRES. An incidental subacute spinal subdural hematoma extending from the level of C6 to T1 was depicted by spinal magnetic resonance imaging, presumably as a complication of negligible neck trauma. Spinal digital subtraction angiography showed no evidence of spinal aneurysm, arteriovenous malformation, or dural arteriovenous fistula. Cerebral digital subtraction angiography showed segmental narrowing and dilatation of vessels, a potential feature of RCVS, involving the circle of Willis and their branches.

INTERVENTIONS

The patient was treated with nimodipine for vasodilation and other symptomatic therapies. The spinal subdural hematoma was not warranted for surgical intervention and managed with simple analgesics.

OUTCOMES

The patient experienced a dramatic improvement in neurological symptoms and was discharged without sequelae. Follow-up imaging showed complete resolution of all radiological changes.

LESSONS

Clinician should be aware of spinal subdural hematoma as the potential trigger in development of PRES and RCVS. We speculate that endothelial dysfunction and vascular tone dysregulation may be implicated to play the major pathophysiologic role.

Posterior Reversible Encephalopathy Syndrome and Reversible Cerebral Vasoconstriction Syndrome: Distinct Clinical Entities with Overlapping Pathophysiology

The clinical and radiologic manifestations of posterior reversible encephalopathy syndrome and reversible cerebral vasoconstriction syndrome are reviewed. The relationship between these entities is discussed. A hypothesis of a common underlying pathophysiology is proposed and substantiated based on the current medical literature.

Cesarean section under general anesthesia for antepartum reversible cerebral vasoconstriction syndrome: A case report

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by acute and usually severe headache related to multifocal vasoconstriction of cerebral arteries, reversible within 3 months. About 10% of RCVS are pregnancy-related, but only three cases of antepartum RCVS have been described. We report the case of a 26-year-old pregnant woman who presented at 36 weeks gestation with antepartum RCVS. Delivery was managed by cesarean section under general anesthesia. Though she developed focal neurologic deficits on the first postoperative day, these resolved at hospital discharge. This case highlights pre- and post-partum multidisciplinary management including cesarean section under general anesthesia.

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.

[Maternal death by stroke. Results from the French enquiry into maternal deaths, 2010-2012]

Stroke is a rare event during pregnancy (10/100,000) and can be ischemic (24%), hemorrhagic (74%) or both (2%). Pregnancy probably increases the risk even if it is discussed for arteriovenous malformation (AVM), aneurismal subarachnoid hemorrhage (SAH) and cavernomas. Between 2010 and 2012, 31 maternal deaths were associated with stroke. In 22 cases, stroke was the direct cause of death giving a maternal mortality ratio of 0,9/100,000 witch is not different from the former report (2007-2009). There were 2 cerebral thrombophlebitis, 2 ischemic strokes and 18 hemorrhagic strokes (4 SAH, 2 AVM). These deaths occurred during ongoing pregnancy in 5 cases (25%), after miscarriage in 1 case (5%) and in the post-partum period in 14 cases (70%). In this last situation, stroke occurred before delivery in 4 cases and during the post-partum period in 9 cases (1 to 9 days) (1 unknown). There were 7 vaginal deliveries (50%) and 6 emergency cesarean sections (43%) (1 unknown). Most of those deaths were considered to be unavoidable (13/17, 76%). Four deaths were considered by the experts as being possibly avoidable (delay diagnosis, diagnostic error, inadequate treatment, lake of interruption of the pregnancy). Analyzing those deaths remind that any sudden, severe and unusual headache must be explored and that pregnancy does not contraindicate any of the diagnostic examinations (TDM, angio-TDM, MRI) or invasive treatments (surgery, arterio-embolization, fibrinolysis) necessary for its management. Furthermore, the diagnosis of postdural puncture headache should not be establishedwithout imaging when the symptomatology is not absolutely typical.

Reversible cerebral vasoconstriction syndrome and posterior reversible encephalopathy syndrome associated with intracranial hypotension

BACKGROUND

Reversible cerebral vasoconstriction syndrome (RCVS) and posterior reversible encephalopathy syndrome (PRES) are both rare disorders. The pathophysiology of both diseases is not yet fully understood.

METHODS

We report the unique case of a 19-year-old comatose woman who was brought to the ER after a series of generalized tonic-clonic seizures 6 days post peridural anesthesia for cesarean section. Vital signs and initial laboratory testing including urine analysis and drug screening were unremarkable. Initial cranial CT scan showed an acute small subdural hematoma (17 mm length × 6 mm width × 30 mm height), cerebral edema with slit ventricles, and slight cerebellar tonsillar herniation as signs of intracranial hypotension. CT angiography depicted narrowing of the proximal intracranial vessels consistent with RCVS. MR imaging was also suggestive of both intracranial hypotension and RCVS and showed, in addition, vasogenic edema consistent with PRES. An extensive CSF leakage involving T1 to L2/L3 was confirmed by spinal MRI.

RESULTS

The patient underwent conservative therapy for intracranial hypotension (e.g., head-down position) as well as epidural blood patch, which led to regression of the clinical symptoms within a few days. Follow-up MRI showed complete resolution of all radiological changes.

CONCLUSIONS

In summary, our patient developed clinical and neuroradiological signs of intracranial hypotension and a combination of PRES and RCVS associated with a CSF leakage caused by peridural anesthesia; by treating the intracranial hypotension, the other syndromes resolved. From a clinical point of view, it is important to look for CSF leakage as a treatable possible cause of PRES and/or RCVS triggered by intracranial hypotension as in our patient postpartum. Moreover, it is vital to obtain a good history as, in cases of suspected CSF leakage with classic postural headache, a recent spinal/cranial procedure is typically present.

Acute onset of blindness associated with posterior reversible encephalopathy syndrome: a HELLP syndrome case report

Posterior reversible encephalopathy syndrome (PRES) is an uncommon disorder. PRES presents with clinical findings such as headache, seizures, visual disturbances, and altered consciousness. Here, we present a PRES case in the second trimester of pregnancy with intrauterine fetal demise. A 40-year-old woman, gravida 4 para 3, was diagnosed with HELLP syndrome based on the clinical and laboratorial findings. An emergent caesarean section was performed under magnesium sulphate (MgSO4) treatment. She had suffered vision loss with normal fundoscopic findings at postpartum period. All the clinical, laboratory and imaging findings (MRI) confirmed the diagnosis of PRES. Careful observation of the clinical findings and prompt treatment is necessary for pregnancies complicated by PRES to prevent undesirable outcomes.