Keywords: Gravidic Eclampsia; HELLP Sindrome; Posterior...
Transcript of Keywords: Gravidic Eclampsia; HELLP Sindrome; Posterior...
REVERSIBLE POSTERIOR ENCEPHALOPATHY SYNDROME IN
GRAVIDIC ECLAMPSIAG. Mancini (1), L. Sparvoli (2), F. Muzzi (1), A. Pisani (1), A. Genovese (2)
(1) UOC Neurologia e (2) UOC Radiologia - Ospedale G.B. Grassi – Roma (Ostia) - ASL ROMA D
Keywords: Gravidic Eclampsia; HELLP Sindrome; Posterior Reversible Encephalopathy Syndrome (PRES);
CT-Scan Brain Imaging; Magnetic Resonance Imaging
INTRODUCTIONPosterior reversible encephalopathy syndrome (PRES) is a clinico-
radiological entity characterized by headache, seizures,
disturbance of consciousness and visual symptoms associated
with potentially reversible neuroradiological abnormalities. This
radiological picture is more often found in the parieto-occipital
lobes.
The Pre-eclamptic Syndrome is characterized by oedema,
proteinuria, arterial hypertension arising after the twentieth week of
pregnancy. The Eclampsia is made up by the pre-eclamptic triad
associated with epileptic seizures. The pathogenesis of these
disorders is not yet completely clear.
We report a case of a 27th week pregnant woman who presented
recurrent epileptic seizures, preceeded by visual deficits; her
neuroradiological findings were suggestive of PRES.
CASE REPORT
On April 12th 2014, a 23-years-old pregnant woman, affected by
Type II diabetes, obesity and arterial hypertension, underwent
medical care in our ER Department for three recurrent seizures,
preceeded by bilateral visual disorder and confusion. Her basic
therapy was metildopa, ASA, calcic nadroparin and metformin. She
was pregnant at the 27th week. She suddenly developed high blood
pressure, slight normocitic anemia (from 13 to 10.9 g/dl), lowered
platelets (from 109000 to 79000/mm3), nausea, vomiting, and
proteinuria with elevated cytolytic enzymes (ALT 110 U/L, AST 92
U/L, LDH 607 U/L) and elevated D-Dimer (9116 ng/ml), and other
coagulative parameters, glicemia and serum electrolites in the
normal range. The symptoms rapidly improved after intravenous
diazepam, magnesium sulphate and midazolam, followed by
intramuscular phenobarbital, given because of persistent status
epilepticus. A urgent caesarean section was made 2 hours after the
admission, after which the patient rapidly recovered .
DIAGNOSTIC EXAMS
A CT-scan at the admission showed two bilateral hypodense areas
in the parieto-occipital boundary (Fig. 1)
DISCUSSION
Associated gravidic eclampsia, HELLP syndrome and bilateral
posterior parietal hypodensities at CT-scan or T2
hyperintensities at MRI are suggestive of a condition of PRES.
This condition is supposed to represent a particular kind of brain
oedema correlated with a reversible damage to the Blood-Brain
Barrier. The damage is selectively located in the posterior
watershed zone whose cerebral arterioles have a poorer
sympathetic innervation, resulting in reduced vasoconstriction
and increased local vulnerability.
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Fig. 2: EEG in the 3rd day
Fig. 4: EEG in the 7th day
The EEG on the 3rd day showed a
bilateral fronto-central isolated
sharp waves and mildly irregular
posterior alpha rhythm (Fig.2). Four
days later these lesions were
confirmed by brain magnetic
resonance imaging (MRI), that
showed hyperintense gyriform
lesions on T2-weighted and FLAIR
images and some hypo- to
isointense symmetric lesions on T1-
weighted images in the bilateral
posterior parietal lobes (Fig.3).
Fig. 3: RM in the 4° day
A new EEG at the 7th day showed normal findings (Fig. 4). After
two months, a second MRI showed the complete disappearance
of the bilateral posterior parietal lesions, according with the
condition of PRES (Fig. 5).
T1-weighted FLAIR
Fig. 1: Brain CT-scan
Fig. 5: RM at 2 months
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