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.

MRI characteristics of brain edema in preeclampsia/eclampsia patients with posterior reversible encephalopathy syndrome

BACKGROUND

The neuroimaging manifestations of eclampsia and preeclampsia often overlap, mainly presenting as posterior reversible encephalopathy syndrome (PRES). The purpose of this retrospective study was to compare the extent and nature of brain edema in eclampsia and preeclampsia patients with PRES based on MRI characteristics.

METHODS

One hundred fifty women diagnosed with preeclampsia-eclampsia and undergoing cranial MRI were enrolled; 24 of these were diagnosed as having eclampsia. According to clinicoradiologic diagnosis of PRES, eligible patients were classified as having eclampsia with PRES (group E-PRES) and preeclampsia with PRES (group P-PRES). A scale on T2W FLAIR-SPIR images was established to evaluate the extent of brain edema, and the score of brain edema (SBE) of both groups was compared. In patients of the two groups who also underwent DWI sequence, the presence or absence of hyperintensity on DWI and hypointensity on ADC maps were determined to compare the nature of brain edema. Furthermore, clinical and biochemical data of the two groups were compared.

RESULTS

The incidence of PRES in eclampsia patients was significantly higher than that in preeclampsia patients (87.50% vs. 46.03%, P<0.001). The SBE of all regions and typical regions in group E-PRES patients were significantly higher than those in group P-PRES patients (15.88±8.72 vs. 10.90±10.21, P=0.021; 8.52±3.87 vs. 5.01±4.19, P=0.002; respectively). The presence of hyperintensity on DWI was determined more frequently in group E-PRES patients than group P-PRES patients (71.43% vs. 32.00%, P=0.024). Age, systolic blood pressure, white blood cell count, neutrophil count and percentage of neutrophils were significantly different between the two groups (P<0.05).

CONCLUSIONS

Certain MRI characteristics that reflect the extent and nature of brain edema were different between eclampsia and preeclampsia patients with PRES. Additional prospective studies are still required to explore whether these MRI characteristics of brain edema may further become a potential predictor for eclamptic seizures in preeclampsia patients with PRES.

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.

Clinical and imaging profile of patients with new-onset seizures & a presumptive diagnosis of eclampsia - A prospective observational study

OBJECTIVE

To study the clinical and imaging profile of patients with new-onset seizures with a presumptive diagnosis of eclampsia.

METHODS

This was a cross-sectional study, conducted in a tertiary teaching hospital, on pregnant women presenting with new onset seizures with presumptive diagnosis of eclampsia excluding those with pre-existing neurological conditions. Demographic details, medical and obstetric examination findings were noted. All women underwent neuroimaging within 5 days of onset seizures.

RESULTS

Presumptive diagnosis of eclampsia was made in 0.7% (n = 186) of women delivering during the time period. Most women (55.4%) presented with seizures in the antenatal period. Neuroimaging is performed in 130 cases and it was found to be abnormal in 45.4% of women (59/130). Most common associated neurological condition was Posterior Reversible Encephalopathy Syndrome in 20% (n = 26) followed by Cerebral Venosus Sinus Thrombosis in 10% (n = 14). All six women with primary intracerebral haemorrhage succumbed to the disease.

CONCLUSION

New-onset seizures may be the initial presentation of uncommon and unpredictable complication of pregnancy with serious maternal/ fetal morbidity and mortality. Neuroimaging will help in these patients to avoid the delay or misdiagnosis, resulting in early initiation of specific treatment which will help to improve and optimize outcomes.

Incidence of posterior reversible encephalopathy syndrome in eclamptic and patients with preeclampsia with neurologic symptoms

BACKGROUND

Posterior reversible encephalopathy syndrome is observed frequently in patients with eclampsia; however, it has also been reported in some patients with preeclampsia.

OBJECTIVES

The aim of this study was to determine the incidence of posterior reversible encephalopathy syndrome in patients with preeclampsia and eclampsia and to assess whether these 2 patient groups share similar pathophysiologic backgrounds by comparing clinical and radiologic characteristics.

STUDY DESIGN

This was a retrospective cohort study of 4849 pregnant patients. A total of 49 patients with eclampsia and preeclampsia and with neurologic symptoms underwent magnetic resonance imaging and magnetic resonance angiography; 10 patients were excluded from further analysis because of a history of epilepsy or dissociative disorder. The age, parity, blood pressure, and routine laboratory data at the onset of symptoms were also recorded.

RESULTS

Among 39 patients with neurologic symptoms, 12 of 13 patients with eclampsia (92.3%) and 5 of 26 patients with preeclampsia (19.2%) experienced the development of posterior reversible encephalopathy syndrome. Whereas age and blood pressure at onset were not significantly different between patients with and without encephalopathy, hematocrit, serum creatinine, aspartate transaminase, alanine transaminase, and lactate dehydrogenase values were significantly higher in patients with posterior reversible encephalopathy syndrome than in those without magnetic resonance imaging abnormalities. In contrast, patients with eclampsia with posterior reversible encephalopathy syndrome did not show any significant differences in clinical and laboratory data compared with patients with preeclampsia with posterior reversible encephalopathy syndrome. In addition to the parietooccipital regions, atypical regions (such as the frontal and temporal lobes), and basal ganglia were also involved in patients with eclampsia and patients with preeclampsia with posterior reversible encephalopathy syndrome. Finally, intraparenchymal hemorrhage was detected in 1 patient with eclampsia, and subarachnoid hemorrhage was observed in 1 patient with preeclampsia.

CONCLUSIONS

Although the incidence of posterior reversible encephalopathy syndrome was high in patients with eclampsia, nearly 20% of the patients with preeclampsia with neurologic symptoms also experienced posterior reversible encephalopathy syndrome. The similarities in clinical and radiologic findings of posterior reversible encephalopathy syndrome between the 2 groups support the hypothesis that these 2 patient groups have a shared pathophysiologic background. Thus, magnetic resonance imaging studies should be considered for patients with the recent onset of neurologic symptoms, regardless of the development of eclampsia.

Study on Neurological Manifestations of Eclampsia & Findings of CT scan of Brain

This cross sectional study was carried out in the Department of Obstetrics & Gynaecology in Mymensingh Medical College Hospital during the period of January 2011 to December 2012 to evaluate neurological manifestations in eclampsia by CT scan of brain. A total 35 patients with eclampsia were studied, who underwent CT scan of brain in Radiology & Imaging Department of Mymensingh Medical College Hospital. The study patients were divided into two groups, those who had changes in brain on CT scan (Group A) & those who had no changes in brain on CT scan (Group B). Finally the study variables were compared between these two groups. Each selected patient fulfilling the criteria was sent to the department of Radiology & Imaging for CT scanning of brain. In antepartum cases of eclampsia CT scan of brain were done after delivery/ termination of pregnancy. In all cases, CT scan of brain was done within 72 hours of admission. Out of 35 patients total 85.72% had changes in brain on CT scan & 14.28% had no changes in brain on CT scan. Among them 45.72% patients had cerebral oedema, 37.14% had cerebral infarct & 2.86% patients had intracerebral haemorrhage. Comparison of neurological parameters were done & showed that there were statistically significant difference between the two groups regarding headache, visual disturbance, hypereflexia & depression of consciousness. There was no statistically significant difference regarding aphasia & hemiplegia between the two groups. So the CT scan of brain has been useful in demonstrating the lesion of brain in patients with eclampsia & also helpful to evaluate the neurological manifestations in eclampsia.

Posterior reversible encephalopathy syndrome: a case series in patients with eclampsia

Posterior Reversible Encephalopathy Syndrome (PRES) refers to a clinicoradiologic entity with characteristic features on neuro-imaging and non-specific symptoms comprising headache, confusion, visual disturbances and seizures. The lesions in PRES are thought to be due to vasogenic oedema, predominantly in the posterior cerebral hemispheres, and are reversible with appropriate management. We report 3 cases of acute PRES who had eclampsia and presented with recurrent episodes of seizures and hypertension. Their MRI scan showed diffuse abnormal signal intensities involving predominantly deep white matter of the occipital lobes. Based on the findings the most probable diagnosis of PRES was suggested. They were started on antihypertensive drugs. On follow-up examination after 5-7 weeks, the patients showed marked improvement clinically and on neuro-imaging following which they were discharged in stable condition.

Hydrocephalus after Intraventricular Hemorrhage in Eclamptic Woman with HELLP Syndrome

We report the first case of an obstructive hydrocephalus after intraventricular hemorrhage in a woman with HELLP syndrome and eclampsia. A 25-year-old primiparaous woman had severe preeclampsia at 36 weeks of gestation. She complained of epigastric pain and nausea. The levels of AST, ALT, and LDH were 539, 560, and 1051 IU/L, respectively; the platelet count was 101 x 109/L. Cesarean section was promptly performed. Intraoperatively, she had a first convulsion. The CT scan revealed only mild brain edema. The platelet count deteriorated to 30 x 109/L at 5 hour after the operation, and she had a second convulsion with an intraventricular hemorrhage. On the 6th post-cesarean day, she complained severe headache followed by coma. The CT scan revealed the enlargement of both lateral ventricles, indicating the occurrence of obstructive hydrocephalus. Drainage into cerebral ventricle was performed, resulting in the recovery of consciousness to a normal level.

The visually-evoked cerebral blood flow response in women with a recent history of preeclampsia and/or eclampsia

Several studies provide evidence for altered cerebral hemodynamics during (pre)eclampsia. Whether (pre)eclampsia has a persistent negative impact on cerebral hemodynamics, possibly contributing to an elevated risk of premature stroke, is unknown. The aims of this study were (i) to refine and apply a control system-based method previously introduced by Rosengarten to quantify the visually-evoked blood flow response of the posterior cerebral artery (PCA); and (ii) to test the hypothesis with this method that cerebral hemodynamics in women with a recent history of (pre)eclampsia is abnormal relative to that in parous controls. Hereto, we recorded cerebral blood flow velocity (CBFV) in the PCA by transcranial Doppler (TCD) sonography during cyclic visual stimulation in 15 former preeclamptics, 13 former eclamptics and 13 controls. The typical CBFV response was fitted with the step response of a second-order-linear model enabling quantification by parameters K (gain), zeta (damping), omega (natural frequency), T(v) (rate time) and T(d) (time delay). The method refinement introduced here consisted of response filtering before quantification and of considering the individual instead of group-averaged response patterns. Application of this refinement reduced the fitting errors (1.4 +/- 1.2 vs. 3.2 +/- 1.8, p < 0.01). Intergroup differences in model parameters were not found. Although statistically not significant, a trend was observed that critical damping (zeta>1) occurred more frequently in the combined group of former patients than in the controls (7 of 28 vs.1 of 13, p = 0.16). Critical damping (zeta>1) reflects an abnormal response, which is either compensated for by a rise in rate time ("intermediate"; zeta>1; T(v) > 20) or remains uncompensated ("sluggish"; zeta>1; T(v) < 20). Critical damping increased significantly (p = 0.039) with (pre-)eclampsia-to-test-interval in the PE+E patients with abnormal responses (zeta>1), suggesting that (pre)eclampsia might induce diminishing cerebral hemodynamic function over time. Based on a system-analytical classification approach, the data of this study provide evidence for individual CBFV responses to be abnormal in former (pre)eclamptics compared with controls. Further study is needed to reveal how the abnormal CBFV response classification reflects cerebrovascular dysfunction.

Use of uterine Doppler in an Australian level II maternity hospital

OBJECTIVE

To evaluate the clinical usefulness of uterine Doppler.

DESIGN

Retrospective study between March 2001 and March 2003.

SETTING

A high-risk population of pregnant women in a busy level II Maternity unit.

METHODS

Resistance index (RI) measurements of the right and left uterine artery were obtained by using pulsed wave Colour Doppler. The presence of a unilateral or bilateral early diastolic notch was noted. An abnormal result was defined as a mean RI >or= 0.58 with no, one or two notches or a mean RI < 0.58 in the presence of bilateral notches.

RESULTS

Pre-eclampsia was found in 45 (24.7%) women, gestational hypertension (GH) in 22 (12.1%) and intrauterine growth restriction (IUGR) in 42 (23.1%) of women included (total 59.9%). In the overall group, 127 (69.8%) women were found to have abnormal uterine artery Doppler results and 55 (30.2%) of patients had a normal Doppler study. No significant differences were found between the group of women with abnormal uterine artery Doppler and the women with a normal velocity waveform in the prediction of pre-eclampsia, IUGR and GH, this was also true in the various high-risk-subgroups.

CONCLUSIONS

Uterine Doppler is not particularly useful to the obstetrician in the management of patients with an a priori very high risk to develop uteroplacental insufficiency.

[Clinical and neuroradiographic correlates in eclampsia]

Brain computed tomography, magnetic resonance imaging and magnetic resonance angiography were performed in five eclamptic patients. Three of them had HELLP syndrome. The findings on the imaging studies showed bilateral lesions affecting regions of the brain, such as cortico-subcortical either posterior and anterior circulation territories, white matter, talamic or mesencephalic-protuberancial areas. No vasospasm in middle size arteries were observed with magnetic resonance angiography. Although visual disturbance and occipital lobe involvement were correlated, no other mentioned lesions had clinical manifestations.

Maternal transcranial Doppler in pre-eclampsia and eclampsia

Pre-eclampsia affects 3-7% of women and is associated with significant maternal and perinatal morbidity and mortality. Transcranial Doppler (TCD) has been used in pre-eclampsia/eclampsia to evaluate non-invasively the cerebrovascular hemodynamics in the maternal middle cerebral artery. TCD has demonstrated in pre-eclamptic women maternal cerebral vasospasm, which does not correlate with mean arterial pressure assessed simultaneously. Estimated cerebral perfusion pressure, assessed using a modified formula, has been shown to be increased in women with severe and non-severe pre-eclampsia. However, in severe pre-eclampsia, elevated cerebral perfusion pressure is counterbalanced by increases in cerebrovascular resistance and cerebral blood flow is unaffected. In eclampsia a significant fall in cerebral vascular resistance occurs which, in the presence of increases in cerebral perfusion pressure, leads to hyperperfusion. Cerebral vascular changes to date have not been sensitive enough to predict the development of pre-eclampsia or eclampsia. Longitudinal studies with the aim of predicting the onset of pre-eclampsia and to assess the effects of various drugs on the maternal cerebral circulation need to be designed.

Impaired cerebral glucose metabolism in eclampsia: a new finding in two cases

The pathophysiology of the reversible neurological manifestation in eclamptic women remains unclear. We report on 2 women with eclampsia who were repetitively examined by (1) transcranial Doppler (TCD), (2) magnetic resonance imaging (MRI) including T1- and T2-weighted images, fluid attenuated inversion recovery sequence, dynamic susceptibility-weighted perfusion imaging and magnetic resonance angiography (MRA), and (3) (18)fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET). In both cases repetitive TCD revealed no signs of vasospasm; the same was true for MRA. MRI perfusion imaging showed completely homogenous cerebral blood flow in both cases. In the initial phase T2-weighted images revealed hyperintensities in both patients (predominantly bilateral frontal and parietal in 1 and in the temporo-occipital subcortex and the basal ganglia in the other). FDG-PET showed inhomogeneous glucose metabolism (GM) in both patients. Primary increased glucose utilization in the hyperintense T2-weighted areas as well as an attenuated GM parieto-occipital were observed in the 1st case; a high GM was found bilaterally in the basal ganglia and an attenuated one in the occipital cortex in the 2nd. In both cases MRI, and FDG-PET normalized within 3 weeks. These case reports document an altered cerebral GM in the presence of homogenous perfusion in eclamptic women. The high GM may be explained by a decoupling of cerebral perfusion and GM, possibly indicating an increased neuronal activity. The attenuation of the GM is most probably due to a deafferentation of cortical neurons.

Late onset postpartum eclampsia: a rare and difficult diagnosis

Late postpartum eclampsia without the classical pre-eclamptic signs oedema, proteinuria and hypertension is a rarely noticed complication of pregnancy. In three patients eclampsia started no earlier than 6, 8 and 11 days postpartum. Seizures were preceded by headache, vomiting, visual disturbance or impaired level of consciousness. One patient suffered a series of seizures making neurointensive care necessary. In another patient the clinical course was complicated by an additional Guillain-Barré syndrome. Aside from the typical parieto-occipital lesions brain MRI showed cerebellar hyperintensities on T2 weighted sequences as well as abnormalities on diffusion weighted images in one patient. In all patients neurological deficits and MRI findings were reversible.

Serial assessment in eclampsia of cerebrohemodynamics by combined transcranial Doppler and magnetic resonance angiography

We used two different noninvasive methods, i.e., transcranial Doppler velocimetry and magnetic resonance angiography to serially assess cerebrohemodynamics in a patient with postpartum eclampsia. Five hours after an eclamptic seizure, a decrease in mean velocity in both middle cerebral arteries and slight angiographical spasms indicated cerebral hypoperfusion. On hospital day 8, the patient showed an increase in the mean velocity of the middle cerebral artery, accompanied by significant vasospasms. Abnormal findings were not observed on hospital day 20. These combined methods are useful in assessing cerebrohemodynamics in eclampsia.

Maternal cerebral hemodynamics in pregnancy-related hypertension. A prospective transcranial Doppler study

AIM

To compare maternal cerebral hemodynamics, as assessed by transcranial Doppler studies, with the clinical and radiological findings in different types of pregnancy-related hypertension and to determine their pathophysiology.

METHODS

A prospective study of 66 consecutive pregnant women with hypertensive disorders (eclampsia, n = 3; pre-eclampsia, n = 41; isolated hemolysis, elevated liver enzymes, and low platelet count (HELLP)-syndrome, n = 12; pre-eclampsia superimposed on chronic hypertension, n = 5; chronic hypertension, n = 5) and 21 women with uncomplicated pregnancies. Mean blood flow velocities (Vmean) were assessed serially by means of transcranial Doppler in all basal arteries and correlated with changes in mean arterial blood pressure (MABP) and the clinical course.

RESULTS

Patients with the pre-eclampsia/eclampsia syndrome showed significantly elevated Vmean values as compared to controls. In the course of the illness Vmean over the whole length of all insonated basal arteries rose simultaneously. The three eclamptic patients showed the highest Vmean values (156, 182, 192 cm/s, respectively), of the middle cerebral artery (MCA) while MABP was 135, 135, and 150 mmHg, respectively. In pre-eclamptic patients the maximal Vmean MCA ranged from 80 (67, 93) to 145 (114, 151) cm/s [median (25th, 75th percentile)] depending on the severity of clinical presentation. In patients with isolated HELLP-syndrome changes in Vmean were either mild (5/12 cases) or absent (7/12 cases).

CONCLUSIONS

Considerable differences in cerebral hemodynamics were observed in the various types of pregnancy-related hypertensive disorders examined in this study. Our findings in patients with pre-eclampsia/eclampsia syndrome suggest a breakdown of autoregulation with hyperperfusion and vasogenic edema being the most probable pathophysiological mechanism.

Regional cerebral blood flow after status epilepticus

Two patients with status epilepticus due to specific conditions were examined using MRI and stable Xe/CT CBF. [Case 1] A 30-year-old woman developed a grand mal seizure during delivery. She was comatose, and MRI revealed abnormal high intensity areas bilateral basal ganglia, compatible with eclampsia. Regional CBF was decreased in bilateral occipital lobes and right basal ganglia. Six days after onset. Regional gray matter flow was increased, especially in the thalami and basal ganglia. [Case 2] The patient is a 31-year-old male diagnosed with temporal lobe epilepsy since 10 years. At the onset, he had a prolonged right hemiconvulsion followed by generalized tonic-clonic convulsion. MRI 13 days after onset showed left hemispheric edematous swelling of gray matter. Stable Xe/CT 3 weeks after onset demonstrated increased cortical CBF corresponding to edematous area. The results suggested that regional CBF decreased immediately after status epilepticus and then increased for 1-3 weeks in the interictal period. We speculate that the energy debt incurred during prolonged seizure causes relative ischemic condition in the neurons, with the increase in CBF resulting from accelerated energy production for a long period.

Persistence of cerebral hemodynamic changes in patients with eclampsia: A report of three cases

OBJECTIVE

This study was undertaken to compare the persistence of changes in estimated cerebral perfusion pressure and the resistance area product, an index of cerebrovascular resistance, in women with preeclampsia and women with eclampsia.

STUDY DESIGN

The maternal middle cerebral artery was evaluated by transcranial Doppler ultrasonography in 6 patients with severe preeclampsia and 3 women with eclampsia, and cerebral blood flow velocities were determined. Estimated cerebral perfusion pressure was calculated according to the following equation: Estimated cerebral perfusion pressure = Mean cerebral blood flow velocity/(Mean cerebral blood flow velocity - Diastolic cerebral blood flow velocity) x (Mean blood pressure - Diastolic blood pressure). Because the diameters of the vessels could not be measured directly, an index of resistance was calculated according to the following equation: Resistance area product = Mean blood pressure/Mean cerebral blood flow velocity. We calculated an index of cerebral blood flow according to the following equation: Index = Estimated cerebral perfusion pressure/Resistance area product. Patients were reassessed at 24 and 48 hours after delivery.

RESULTS

At the initial assessment the estimated cerebral perfusion pressure was higher in women with eclampsia than in those with severe preeclampsia. In addition, cerebrovascular resistance was significantly decreased in the eclampsia group, and it remained decreased as long as 4 days in 1 patient with eclampsia.

CONCLUSIONS

Preeclampsia is associated with increases in cerebral perfusion pressure counterbalanced by increases in cerebrovascular resistance, with no change in cerebral blood flow. In eclampsia a significant increase in cerebral perfusion pressure occurs, but a significant fall in cerebrovascular resistance also occurs and a loss of autoregulation results in cerebral overperfusion similar to that of hypertensive encephalopathy. This may persist for as long as 4 days.

[Brain stem involvement in eclampsia and HELLP syndrome]

INTRODUCTION

Nowadays, eclampsia is a rare complication of pregnancy and the puerperium. However, it is still one of the main causes of maternal morbi-mortality. Systemic findings in eclampsia may sometimes include association with microangiopathic hemolytic anaemia, raised liver enzymes and thrombocytopenia. This clinical combination constitutes the HELLP syndrome (Hemolysis Elevated Liver enzymes Low Platelets). The commonest neurological findings in eclampsia are headache, visual alterations, convulsions and stupor or coma. The presence of clinical symptoms and signs due to brainstem disorders is unusual.

CLINICAL CASE

We present the case of a thirty year old woman with eclampsia and associated HELLP syndrome, which briefly affected the brain stem. The patient showed progressive general and neurological improvement. Three months afterwards she still had paresia of the sixth right cranial nerve, due to what was presumed to be a right paramedian infarct of the pons.

CONCLUSION

We consider it important not to forget this exceptional association so that suitable treatment may be given to such patients since prognosis is not invariably bad.

Transcranial assessment of maternal cerebral blood flow velocity in patients with pre-eclampsia

BACKGROUND

To clarify the cerebral hemodynamics in pre-eclamptic pregnant women, we investigated the blood flow velocity of the cerebral arteries.

METHODS

The mean blood flow velocity and pulsatility index (PI) of the middle cerebral artery (MCA) and internal carotid artery (ICA) in normal pregnant women (n = 35) and pre-eclamptic patients (n = 18) were examined transcranially using pulsed-wave Doppler technique with a 2 MHz probe. In two pre-eclamptic women with post-partum visual disturbance, we examined the mean blood flow velocity and PI of the MCA and ICA every day.

RESULTS

The mean blood flow velocity of the MCA in the pre-eclamptic patients (89.7 +/- 20.5 cm/s) was significantly higher than that in the normal pregnant women (53.6 +/- 16.9 cm/s) (p < 0.05). PI of the MCA in the former group (0.67 +/- 0.13) was significantly lower than that in the latter (0.78 +/- 0.02) (p < 0.05). There was no significant difference between these two groups in these variables of the ICA. In the two patients with visual disturbance, the mean blood flow velocity of the MCA was increased before the onset of visual disturbance and decreased gradually following the disappearance of this symptom. In these patients, spasm of the MCA was confirmed by magnetic resonance angiography.

CONCLUSIONS

In pre-eclamptic patients, we found increased MCA mean velocity before the onset of visual disturbance. Transcranial Doppler may be useful for the evaluation of cerebral hemodynamics and the prediction of eclampsia.

Single photon emission and cerebral computerised tomographic scan and transcranial Doppler sonographic findings in eclampsia

OBJECTIVE

To define more clearly the neuropathophysiology of eclampsia utilising single-photon emission computed tomography (SPECT), cerebral computerised tomography (CT) and transcranial Doppler (TCD) ultrasonography.

DESIGN

A prospective study

SETTING

The obstetric unit in King Edward VIII Hospital, a large tertiary referral centre in Kwa-Zulu Natal, South Africa.

PARTICIPANTS

Sixty-five women with eclampsia.

INTERVENTIONS

Imaging and ultrasonographic investigations were performed within 48 hours postpartum. Unenhanced cerebral CT scans were performed in all the women and SPECT scans were performed on 63 women using Technetium-99m-hexamethylpropyleneamineoxime (99mTc-HMPAO) as a tracer of regional cerebral blood flow. Middle cerebral artery blood flow velocity waveforms were measured using 2 MHz pulsed Doppler ultrasound via the transtemporal approach.

MAIN OUTCOME MEASURES

Abnormalities in SPECT scan, CT scan and TCD ultrasound findings.

RESULTS

SPECT scanning revealed perfusion deficits in the watershed areas in all women, 75% of whom had concomitant deficits in the parieto-occipital areas of the brain. Hypodensities (cerebral oedema) were reported in 38 CT scans (58.5%), with parieto-occipital involvement in 97.4% of cases. Increased flow velocity measurements in the middle and posterior cerebral arteries were recorded in 36 (85.7%) women in whom TCD ultrasound was performed.

CONCLUSION

The pathophysiological mechanism of eclamptic seizures is primary cerebral vasospasm with resultant ischaemia and cerebral oedema involving mainly the watershed areas and parieto-occipital lobes of the brain. SPECT scanning has been shown to be superior to CT scanning and TCD ultrasonography in detecting neuropathophysiologic alterations in eclampsia. However, each of the three investigative tools provide its own unique information and all three are necessary research techniques to improve our understanding of the neuropathophysiological mechanism of eclamptic seizures.

Serial assessments of middle cerebral artery flow velocity with transcranial Doppler sonography in the recovery stage of eclampsia. A case report

The pathophysiologic changes of eclampsia and/or hypertensive encephalopathy are unclear. Changes of middle cerebral artery flow velocity during the recovery stage in a case of eclampsia are reported. After the disappearance of signs and symptoms, the flow velocity began to increase, owing probably to delayed vasospasm, which was confirmed by magnetic resonance angiography. The vasospasm may be a consequence of eclampsia and may be of small significance in the pathogenesis.

Maternal cerebral blood flow changes associated with eclampsia

To determine whether there is a difference in middle cerebral blood flow velocity in eclampsia compared to a match control of severe preeclamptic patients in the peripartum phase. Three eclamptic and six preeclamptic women had maternal middle cerebral blood flow velocity assessed antepartum and at 24 and 48 hours postpartum. We compared the effect of an eclamptic convulsion on cerebral blood flow velocity changes using analysis of variance. Cerebral blood flow velocity was significantly higher in eclamptic than in preeclamptic women (p < 0.01) and rose significantly in the post-convulsive phase. Cerebral blood flow velocity was significantly elevated in eclamptic women compared with preeclamptic women in a setting of minimal change in mean arterial pressure.

[Imaging techniques in the diagnosis of brain lesions in eclampsia. Apropos of a case]

Eclampsia is defined as the development of convulsion and/or coma during pregnancy. Physiopathology remains unclear. We report a case of eclampsia and review the literature. CT, MR and angiographic findings are described. Value of various techniques is discussed.

The diagnostic value of cranial computed tomography in complicated eclampsia

Cranial CT scanning was performed in twenty-two patients with severe neurological complications secondary to eclampsia. All patients had repetitive and/or prolonged convulsions. In addition, three patients were in prolonged coma, and three had cortical blindness. One of the patients had central facial paresis, and two had hemiparesis. In seventeen patients, abnormal CT findings were identified. Diffuse cerebral edema was determined in four patients. The most frequent finding was bilateral low-density areas in the parietal and/or occipital lobes (7 cases). In three patients, CT revealed bilateral low-density areas in the basal ganglia. All women but three recovered completely. Two of the three patients who died had intracranial massive hemorrhage. Follow-up CT examinations demonstrated complete resolution of the low-density areas and slight cortical atrophy in three of four patients. Complete recovery of the patients associated with complete resolution of the low-density lesions suggested that these lesions corresponded to edema. We concluded that CT is useful in patients with complicated eclampsia because it may orientate management.

The use of nimodipine in a patient with eclampsia: color flow Doppler demonstration of retinal artery relaxation

Color flow Doppler ultrasonography was used to demonstrate a significant and sustained reduction in the central retinal artery pulsatility index after administration of the calcium antagonist nimodipine to a patient with eclampsia. Nimodipine is an effective cerebral vasodilator and may be useful in the management of eclamptic patients with severe vasospasm.

Maternal cerebral vasospasm in eclampsia assessed by transcranial Doppler

We report a case of postpartum eclampsia in which the patient was assessed during delivery and postpartum by maternal cerebral transcranial Doppler ultrasound. We provide documentation of the changes in the cerebral blood flow velocity with the development of eclampsia.

[Cerebral lesions in the severe pregnancy induced hypertension: 61 cases of X-ray computed tomography of the brain]

Among 61 patients with severe pregnancy induced hypertension, cerebral lesions were detected on CT scans in 23 cases (37.7%). The positive rates were 5/25 cases in preeclampsia and 18/36 cases in eclampsia. The incidence rate of cerebral lesions in eclampsia was significantly higher than that in preeclampsia (chi 2 test, P < 0.05). Furthermore, it showed that patients with renal impairment and retinal changes were more susceptible to cerebral lesions (P < 0.05), through comparative study of the relationships between either the function of liver and kidney or retinal changes and cerebral lesions. Main manifestations of cerebral lesions were ischemia, edema and infarction. The represented the different pathological stage of cerebral lesions. The cerebral lesions were mainly involved at cortical or subcortical area of bilateral parietal or occipital lobe (60%), secondly at the deep basal ganglia and the superior sagittal sinus. The pathological process of cerebral lesions and the management of pregnancy induced hypertension were analysed.

Imaging of neurologic complications associated with pregnancy

The occurrence of a neurologic event during pregnancy or the puerperium may have devastating consequences for mother and child. It is imperative that the radiologist be familiar with the entities likely to be encountered in pregnancy so that these patients can be examined rapidly and efficiently. The importance of early and accurate diagnostic imaging is underscored by the fact that most patients are otherwise young and healthy, and prompt institution of appropriate therapy can result in complete recovery. In this report, we illustrate some of the more common neurologic complications that occur during pregnancy and the immediate postpartum period.

Cerebral imaging in eclampsia: magnetic resonance imaging versus computed tomography

OBJECTIVES

Our objectives were to study the cerebral pathophysiology of eclampsia with the noninvasive technique of magnetic resonance imaging to compare the ability of magnetic resonance imaging to detect cerebral abnormalities in eclampsia with that of computed tomography.

STUDY DESIGN

Twenty-four patients with eclampsia received both magnetic resonance imaging and computed tomographic scanning.

RESULTS

Forty-six percent of the magnetic resonance imaging was abnormal and 33% of the computed tomography was abnormal. This higher incidence of abnormal magnetic resonance imaging scans was present in spite of the fact that they were obtained significantly longer after the patient's seizure activity. The most common abnormalities were cortisol, subcortical, and white matter edema.

CONCLUSION

Magnetic resonance imaging and computed tomographic scan abnormalities in eclampsia are usually similar. Cerebral imaging is not necessary in patients with uncomplicated eclampsia.

Computed tomography of the brain in eclampsia

Computed tomography (CT) of the brain was performed on 44 women with eclampsia, 31 during pregnancy and 13 postpartum. All CT scans were done within 24 hours of eclampsia, including 12 within 1 hour of the convulsions and eight before the repetition of additional seizures, 2 minutes to 14 hours later. Control scans were performed on 15 hypertensive pregnant patients and on ten normotensive pregnant women after fetal death or just after delivery. Among the women with eclampsia, 26 CT scans were considered normal with no evidence of cerebral edema, three displayed signs of cerebral hemorrhage or thrombosis, six showed areas of focalized hypodensity located in the cortical lobes and the subcortical white matter, and nine were classified as cerebral atrophy with enlarged cerebral ventricles. We conclude that radiologic evidence of diffuse brain edema is probably not a common feature in eclampsia.

Pseudotumor cerebri following eclampsia

Pseudotumor cerebri, or increased intracranial pressure without a mass lesion, has been associated with hormonal activity but the exact causative relation is still obscure. We report a case of a 15-year-old girl who developed pseudotumor cerebri manifested by headache, visual symptoms and extraocular muscle palsies 3 weeks after recovering from eclampsia. Possible associations with eclampsia and postpartum changes in estrogen, progesterone and prolactin are discussed.

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.

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.

Evaluation by computerized axial tomography of eclamptic women with seizures refractory to magnesium sulfate therapy

Over a 1-year period, seven eclamptic patients with repetitive seizures while receiving therapeutic levels of intravenous magnesium sulfate were evaluated by computerized axial tomography. In five patients brain abnormalities were identified, which included diffuse cerebral edema (one), cerebral venous thrombosis (two), and low density white matter (two). Clinical management of eclamptic women on the basis of structural central nervous system abnormalities documented by computerized tomography appears to warrant further investigation.

CT findings in eclampsia

Cranial CT was performed in five patients with eclampsia: densitometric modifications were present in all cases. Only one patient, who later died, displayed multiple foci of cerebral haemorrhage; all others presented bilateral, symmetrical, nonenhancing hypodensities with mass effect interpreted as cerebral oedema. At CT performed 7-14 days after interruption of the pregnancy, these characteristic hypodense lesions were no longer present while neurological symptoms disappeared.

Eclampsia. IV. Neurological findings and future outcome

Sixty-five patients with eclampsia were longitudinally evaluated regarding neurological abnormalities and maternal outcome (6 to 42 months) after eclampsia. Electroencephalograms were obtained on all patients during the subsequent 6 months. Computerized axial tomographic scans (n = 20) and cerebral arteriograms (n = 3) were obtained on patients with neurological deficits and/or those with an atypical clinical course. The electroencephalogram was abnormal in 49 patients (75%) at initial assessment but gradually returned to normal in all observed patients within 6 months. Cerebral arteriograms and computerized axial tomographic scans were normal in each patient studied. None of the patients had neurological deficits or subsequent convulsions on follow-up examination. Thirty-eight patients had one or more subsequent pregnancies without recurrent eclampsia, but 14 (37%) had pregnancy-induced hypertension. The findings suggest that neurological events of eclampsia are acute and transient and that long-term neurological deficit is rare in the properly managed patient. Computerized axial tomography and electroencephalography are rarely indicated in the management of such patients.

Toxemia of pregnancy: cerebral CT findings

Four patients with pregnancy-induced hypertension (preeclampsia-eclampsia) and neurological dysfunction unrelated to intracranial hemorrhage, cerebral venous thrombosis, or preexisting neurological disorder had cranial CT performed during their hospitalization. Three patients had diffuse white matter hypodensities with associated mass effect. The fourth patient had bilateral, asymmetric hypodensities confined to the basal ganglia. Computed tomography is useful in establishing an early diagnosis of the complicating neurological disorder as well as in providing a better understanding of the physiopathological changes seen in the brain in this condition.