CT findings in eclampsia

Posterior reversible encephalopathy syndrome (PRES): Is DWI a prognosis factor?

INTRODUCTION

Posterior reversible encephalopathy syndrome is a clinicoradiologic entity with typical MR imaging showing a white matter vasogenic edema predominantly affecting the occipital and parietal lobes of the brain. The aim of this article is evaluated the importance of DWI as a prognosis factor in patients with PRES.

MATERIALS AND METHODS

We reviewed data from 70 patients with PRES (35 with restricted DWI and 35 with no DWI abnormalities), that were admitted to Hospital São Lucas-PUCRS. These two groups were evaluated in age, sex, previous diseases and past medical history, use of medications, the neurologic manifestations, the highest blood pressure during the neurologic presentation and the highest creatinine during the period of observation.

RESULTS

Evaluating 70 patients with PRES with a mean age of 25.4 years old (range from 2 to 74 years old; 55 female and 15 male) we identified 35 cases were brain MRI presents with restricted DWI. Restricted DWI was associated with higher mortality in 90 days (14.2% vs 0.0%; p: 0.027).

CONCLUSIONS

Few articles present new data that will help clinicians in therapeutic decisions or that modify the knowledge of this syndrome. We suggested that restricted DWI is associated with a worst prognosis in PRES.

Plasma levels of S100B in preeclampsia and association with possible central nervous system effects

BACKGROUND

S100B is supposed to be a peripheral biomarker of central nervous system (CNS) injury. The purpose of this study was to compare levels of S100B in women with preeclampsia with levels in healthy pregnant control subjects and furthermore to analyze levels of S100B in relation to possible CNS effects.

METHODS

A cross-sectional case–control study in antenatal care centers in Uppsala, Sweden, was performed. Fifty-three women with preeclampsia and 58 healthy pregnant women were recruited at similar gestational length; women with preeclampsia were recruited at time of diagnosis, and control subjects were recruited during their routine visit to an antenatal clinic. Plasma samples were collected, and levels of S100B were analyzed with an enzyme-linked immunosorbent assay. Information about demographic and clinical characteristics, including symptoms related to CNS affection, was collected from the medical records. The main outcome measures were plasma levels of S100B and possible CNS effects.

RESULTS

Levels of S100B were significantly higher among women with preeclampsia than among control subjects (0.12 µg/L vs. 0.07 µg/L; P < 0.001). In preeclampsia, there was a significant association between high levels of S100B and visual disturbances (P < 0.05).

CONCLUSIONS

S100B is increased among women with preeclampsia, and high levels of S100B associate with visual disturbances, which might reflect CNS affection in women with preeclampsia.

Posterior reversible encephalopathy syndrome: differences between pregnant and non-pregnant patients

Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiologic entity not yet understood, that presents with transient neurologic symptoms and particular radiological findings. Few papers show the differences between pregnant and non-pregnant patients. We review the cases of 38 women diagnosed with PRES, in order to find significant differences between pregnant (18) and non-pregnant (20) patients. We found differences among the age of patients (25.83 years old in pregnant and 29.31 years old in non pregnant; P=0.001); in the mean of highest systolic blood pressure, that was higher in non-pregnant group (185:162 mmHg; P=0.121); and in creatinine levels that was higher in non-pregnant group (3.47:1.04 mg/dL; P=0.001). To our knowledge, just a few papers analyzed whether PRES syndrome presented in the same way in pregnant and non-pregnant patients. The differences and the possible pathophisiology of this syndrome still remain enigmatic.

Gemcitabine monotherapy associated with posterior reversible encephalopathy syndrome

Posterior reversible encephalopathy syndrome is a clinicoradiologic entity that may present with headaches, altered mental status, seizures and visual loss as well as specific neuroimaging findings. We report a case of a 74-year-old woman receiving adjuvant gemcitabine chemotherapy as monotherapy for a stage IIa pancreatic adenocarcinoma, who developed posterior reversible encephalopathy syndrome.

Posterior reversible encephalopathy syndrome

Posterior reversible encephalopathy syndrome (PRES) is characterized by headache, altered mental status, visual disturbances, and seizures. Radiological features typically include edema of the posterior cerebral regions, especially of the parietooccipital lobes. Atypical imaging features, such as involvement of anterior cerebral regions, deep white matter, and the brain stem are also frequently seen. Vasoconstriction is common in vascular imaging. Different conditions have been associated with PRES, but toxemia of pregnancy, solid organ or bone marrow transplantation, immunosuppressive treatment, cancer chemotherapy, autoimmune diseases, and hypertension are most commonly described. The pathophysiology of PRES is unclear and different hypotheses are being discussed. Posterior reversible encephalopathy syndrome is best managed by monitoring and treatment in the setting of a neurointensive care unit. The prognosis is usually benign with complete reversal of clinical symptoms within several days, when adequate treatment is immediately initiated. Treatment of severe hypertension, seizures, and withdrawal of causative agents represent the hallmarks of specific therapy in PRES. Delay in diagnosis and treatment may lead to permanent neurological sequelae. Therefore, awareness of PRES is of crucial importance for the intensivist.

Hemorrhage in posterior reversible encephalopathy syndrome: imaging and clinical features

BACKGROUND AND PURPOSE

Hemorrhage is known to occur in posterior reversible encephalopathy syndrome (PRES), but the characteristics have not been analyzed in detail. The purpose of this study was to evaluate the imaging and clinical features of hemorrhage in PRES.

MATERIALS AND METHODS

Retrospective assessment of 151 patients with PRES was performed, and 23 patients were identified who had intracranial hemorrhage at toxicity. Hemorrhage types were identified and tabulated, including minute focal hemorrhages (<5 mm), sulcal subarachnoid hemorrhage, and focal hematoma. Clinical features of hemorrhage and nonhemorrhage PRES groups were evaluated, including toxicity blood pressure, coagulation profile/platelet counts, coagulation-altering medication, and clinical conditions associated with PRES. Toxicity mean arterial pressure (MAP) groups were defined as normal (<106 mm Hg), mildly hypertensive (106-116 mm Hg), or severely hypertensive (>116 mm Hg).

RESULTS

The overall incidence of hemorrhage was 15.2%, with borderline statistical significance noted between the observed clinical associations (P = .07). Hemorrhage was significantly more common (P = .02) after allogeneic bone marrow transplantation (allo-BMT) than after solid-organ transplantation. The 3 hemorrhage types were noted with equal frequency. A single hemorrhage type was found in 16 patients, with multiple types noted in 7. Patients undergoing therapeutic anticoagulation were statistically more likely to develop hemorrhage (P = .04). No difference in hemorrhage incidence was found among the 3 blood pressure subgroups (range, 14.9%-15.9%).

CONCLUSIONS

Three distinct types of hemorrhage (minute hemorrhage, sulcal subarachnoid hemorrhage, hematoma) were identified in PRES with equal frequency. The greatest hemorrhage frequency was seen after allo-BMT and in patients undergoing therapeutic anticoagulation. Hemorrhage rate was independent of the toxicity blood pressure.

Posterior reversible encephalopathy syndrome, part 1: fundamental imaging and clinical features

Posterior reversible encephalopathy syndrome (PRES) is a neurotoxic state coupled with a unique CT or MR imaging appearance. Recognized in the setting of a number of complex conditions (preeclampsia/eclampsia, allogeneic bone marrow transplantation, organ transplantation, autoimmune disease and high dose chemotherapy) the imaging, clinical and laboratory features of this toxic state are becoming better elucidated. This review summarizes the basic and advanced imaging features of PRES, along with pertinent features of the clinical and laboratory presentation and available histopathology. Many common imaging/clinical/laboratory observations are present among these patients, despite the perception of widely different associated clinical conditions.

Brainstem ischemia and preeclampsia

Diffuse neurological manifestations of preeclampsia are due to endothelial involvement that lead to ischemia, hemorrhage, or edema. We analyzed clinical and radiological features and the course of brainstem ischemic strokes in a preeclampsia patient. We report a case of severe preeclampsia in a 30-year-old woman who was admitted 10 hr after a vaginal delivery at home. The pregnancy was at 39 wk, with no prenatal care. At her admission, she was conscious, and she had tetraparesia, swinging deep tendon reflex testing, drowsiness, and dysarthria; the BP was at 160/100 mmHg and 4 + proteinuria; magnetic resonance imaging revealed brainstem ischemic stroke. The evolution was favorable with symptomatic treatment. The patient was discharged on the 16th day; 2 months later she had a normal recovery. Brainstem strokes are rare. They are frequently due to hemorrhage; sometimes, they can also be ischemic. Their course is favorable.

[Neurologic aspects of eclampsia]

The difficult types of preeclampsia and eclampsia are presented with the neurological symptoms. The break of cerebral autoregulation mechanism plays the most important role in pathogenesis of cerebral vasospasm. Nevertheless, eclampsia isn't just an ordinary hypertensive encephalopathy because other pathogenic mechanisms are involved in its appearance. The main neuropathologic changes are multifocal vasogenic edema, perivascular multiple microinfarctions and petechial hemorrhages. Neurological clinical manifestations are convulsions, headache, visual disturbances and rarely other discrete focal neurological symptoms. Eclampsia is a high-risk factor for onset of hemorrhagic or ischemic stroke. This is a reason why neurological diagnostic tests are sometimes needed. The method of choice for evaluation of complicated eclampsia is computerized brain topography that shows multiple areas of hypodensity in occipitoparietal regions. These changes are focal vasogenic cerebral edema. For differential diagnosis of eclampsia and stroke other diagnostic methods can be used--fundoscopic exam, magnetic resonance brain imaging, cerebral angiography and cerebrospinal fluid exam. The therapy of eclampsia considers using of magnesium sulfate, antihypertensive, anticonvulsive and antiedematous drugs.

Neuroimaging of delayed eclampsia. Report of 3 cases and review of the literature

Computed tomography and magnetic resonance imaging findings consistent with eclampsia were recently encountered in 3 patients who developed severe headache days to weeks after uncomplicated delivery. The neurologic presentation was nonspecific, and pre-eclamptic symptoms were not present, including significant hypertension. Variable expression of pre-eclampsia occurred during the course of their observation. Conventional angiography obtained in 2 patients because of a concern for aneurysm demonstrated central and peripheral vasospasm. Magnetic resonance angiography demonstrated central vasospasm in the third patient.

Adhesion molecules in Wilms tumor (part I)

Adhesion molekues are glicoprotees which have extracellular, transmembranous and intracytoplasmatic part. They show their basic role is in cell interaction in the tissue on one side and between cells and matrix on the other side. They have an important role in stabile integrity of tumor tissue, as well as in differenciation, prolifferation, apoptosis and metastatic spread of tumorous cells. Since there is very little known facts about adhesion molecule detection and about its significance in Wilms tumor, our intention was to collect all known achievements which could be of importance for better understanding of tumors nature and successful treatment. Especially because of well known fact that in 15% Wilms tumors there are b-catenin mutations, which indicates that there is a disorder in Wnt signal paththat plays an important role in Wilms tumor genesis.

Hemorrhagic moyamoya disease during pregnancy

BACKGROUND

Intracranial hemorrhage in pregnant patients with Moyamoya disease is rare. We review the case of one such patient who presented with pre-eclampsia and a catastrophic intracerebral hemorrhage in order to highlight the associated management difficulties.

METHODS

A case of a pregnant (31 weeks) female brought to the emergency department with hypertension and a progressive decrease in her level of consciousness is presented. She rapidly developed a dilated right pupil and left extensor posturing. A CT scan of her head showed a large putamenal intracerebral hemorrhage. She was intubated, ventilated and given intravenous mannitol and magnesium sulfate. She underwent a simultaneous craniotomy and Cesarean section. Post-operatively the patient's ICP and jugular venous saturation were monitored in the intensive care unit.

RESULTS

The patient delivered a 1185 g infant who did well. The patient's ICP was well controlled until the tenth post-operative day when she developed malignant brain edema and died.

CONCLUSION

This case highlights three important points. First, simultaneous craniotomy and Cesarean section can be performed. Second, intraoperative control of bleeding Moyamoya vessels is described. Third, the difficult post-operative management of these cases is highlighted. The literature regarding Moyamoya disease and pregnancy is reviewed and some recommendations for the management of this rare but potentially deadly condition are presented.

Eclamptic encephalopathy: imaging and pathogenetic considerations

Eclampsia is a rare condition peculiar to pregnant and puerperal women, characterized by clinical pre-eclampsia (hypertension, proteinuria, edema) and generalized seizures. Three cases of eclamptic encephalopathy are reported: CT and MRI demonstrated transient abnormalities in the cortical and subcortical regions of the posterior areas of the brain - namely, parieto-occipital lobes - associated with occasional involvement of basal ganglia and/or brainstem. Pathogenesis is still unclear. Strict similarity with the pathological findings characterizing hypertensive encephalopathy suggests that a focal impairment in cerebral autoregulation may be the cause of vasodilation and fluid extravasation leading to hydrostatic edema; selective involvement of posterior areas could be explained by their lesser degree of adrenergic innervation supporting circulatory autoregulation mechanisms.

Incidence and causes of strokes associated with pregnancy and puerperium. A study in public hospitals of Ile de France. Stroke in Pregnancy Study Group

BACKGROUND AND PURPOSE

The incidence, causes, and prognosis of nonhemorrhagic strokes and intraparenchymal hemorrhages occurring in association with pregnancy or puerperium are poorly understood.

METHODS

We carried out a retrospective (1989 through 1991) and prospective (1992) study in 63 public maternities (348,295 deliveries) of the region of Ile de France (10,660,554 inhabitants) and in the neurology, neurosurgery, and intensive care units of the same geographic area. Records of women who suffered a cerebrovascular event during pregnancy or the first 2 weeks postpartum were reviewed by two study neurologists. Stroke was defined according to the criteria of the World Health Organization.

RESULTS

Thirty-one cases of strokes were identified, including 15 nonhemorrhagic strokes (including strokelike deficits associated with eclampsia) and 16 intraparenchymal hemorrhages, assessed in all cases by CT scan and/or MRI. The incidence of nonhemorrhagic strokes in women who delivered in public maternities of Ile de France was 4.3 per 100,000 deliveries (95% confidence interval, 2.4 to 7.1) and that of intraparenchymal hemorrhage was 4.6 per 100,000 deliveries (95% confidence interval, 2.6 to 7.5). Eclampsia accounted for 47% of cases of nonhemorrhagic strokes. The other causes were extracranial vertebral artery dissection, postpartum cerebral angiopathy, inherited protein S deficiency, and disseminated intravascular coagulation associated with amniotic fluid embolism. The cause remained undetermined in four cases despite extensive investigations. Eclampsia accounted for 44% of intraparenchymal hemorrhages. Another 37% were due to rupture of a vascular malformation. The cause remained undetermined in three cases. There were four maternal deaths (all associated with intraparenchymal hemorrhage), three of them in eclamptic women. Fetal mortality and prematurity were associated with eclampsia.

CONCLUSIONS

The incidence of nonhemorrhagic stroke does not seem to be much increased during pregnancy and early puerperium. In contrast to that in the nonpregnant state, the frequency of intraparenchymal hemorrhage in pregnancy appears to be similar to that of nonhemorrhagic strokes, suggesting that pregnancy may increase the risk of cerebral hemorrhage. Eclampsia is the main cause of both nonhemorrhagic stroke and intraparenchymal hemorrhage. Intraparenchymal hemorrhage associated with eclampsia carries a poor prognosis.

Computed tomographic changes of the brain in toxaemia of pregnancy

Four cases of toxaemia of pregnancy examined with computed tomography scans of the brain are reported. A review of the literature reveals 19 other cases with previously reported CT brain scans. The review shows intracerebral oedema as the main finding. Haemorrhage, massive or punctate was noted in four cases. The pathogenesis of the CT changes and the clinico-radiological correlation of the visual disturbances are discussed.

Repeated cranial computed tomographic and magnetic resonance imaging scans in two cases of eclampsia

In two cases of eclampsia with consumptive thrombocytopenia, the maximum increase in blood pressure and the lowest platelet count coincided with the maximum degree of neurologic and neuroradiologic abnormality. Computed tomograms showed decreased attenuation, and T2-weighted magnetic resonance images showed increased signal intensity focally in the cerebral cortex and the deep gray and white matter. Blood pressure, platelet count, clinical status, and roentgenograms normalized completely in both cases. Severe arterial hypertension and disseminated transitory microvascular occlusions presumably caused multiple small foci of brain edema that resolved without remaining detectable ischemic brain damage.

Eclampsia: a pediatric neurologic problem

Eclampsia is a syndrome of hypertension, proteinuria, edema, and neurologic manifestations such as seizures, focal deficits, or blindness occurring during pregnancy, mainly in primigravidas. Although it is not seen often in the pediatric population, it occurs with greater frequency among pregnant patients under the age of 15 than in the general population. Serious sequelae can be prevented with prompt and adequate treatment, including termination of pregnancy.

Balint's syndrome following eclampsia

A young female patient sustained bilateral parieto-occipital infarcts and presented with Balint's syndrome following treatment of eclampsia and caesarean section. Altered cerebral blood flow autoregulation and raised intracranial pressure due to eclampsia probably resulted in impaired cerebral perfusion and borderzone cerebral ischaemia in this patient. Careful reduction of blood pressure in patients with eclampsia is emphasized.

Head computed tomographic scans in women with eclampsia

From 1980 to 1986, head computed tomographic scans were performed in 49 women with eclampsia managed according to the standardized regimen used at Parkland Memorial Hospital. Abnormal radiographic findings were seen in 14 (29%). Although this incidence may have been affected by the temporal relationship of the scan to the seizure, it was greatly impacted by technical resolution obtained with succeeding improved equipment. In the last 3 years of the study more than a third of these scans showed some abnormality, and in 1986, using "fourth-generation" equipment, half were abnormal. These areas of radiographic hypodensity correspond to those with petechial hemorrhages and local edema that have been described at autopsy in women who died after eclamptic episodes. All women recovered fully despite ominous findings in some. We conclude that the clinical utility of tomography in women with otherwise "uncomplicated eclampsia" is limited because these findings seldom alter management.

CT and angiographic correlation of severe neurological disease in toxemia of pregnancy

Two patients with severe cerebral symptoms of toxemia of pregnancy were examined using computed tomography (CT) and angiography. CT disclosed extensive areas of low attenuation within the cerebral hemispheres. Angiography revealed constriction and narrowing of proximal and peripheral vessels suggesting vasculitis with extensive areas of impaired regional cerebral blood flow. A review of the known pathology and the theories regarding the pathophysiology of the cerebral effects of toxemia is presented.

Cortical blindness in toxaemia of pregnancy: findings on computed tomography

Two patients with toxaemia of pregnancy presented with cortical blindness. Immediate cranial computed tomography (CT) demonstrated bilateral hypodense areas in the occipital lobes. Both patients underwent Caesarean section for delivery. There was gradual and complete recovery of vision, together with CT documentation of resolution of the cerebral changes, indicative of the reversible nature of the ischaemic lesion.