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Postpartum Pre-Eclampsia Complicated by Atypical Positional Headache
Abstract Number: T-50
Abstract Type: Case Report/Case Series
A 39-year old female patient, Gravida 2, Para 0, with a twin pregnancy at 36 weeks gestation, presented for cesarean section. An uneventful cesarean section was performed under spinal anesthesia. A few hours post-partum, the patient developed hypertension with blood pressures (BP) in the 170-180/80-90 mmHg. A diagnosis of severe pre-eclampsia was made and magnesium sulfate therapy was started.
On postpartum day (POD) 3, the patient complained of a severe, atypical, positional headache, described as pulsating at the front and the back of the head, worse when lying down and improved when sitting in the upright position. Magnetic resonance imaging (MRI) demonstrated multifocal areas of cortical and subcortical T2 hyperintensity involving the bilateral parasagittal frontoparietal lobes, compatible with Posterior Reversible Encephalopathy Syndrome (PRES). Magnetic resonance angiography (MRA) demonstrated multifocal areas of stenosis involving the anterior and posterior cerebral circulation, compatible with Reversible Cerebral Vasoconstriction Syndrome (RCVS).
The patient was admitted to the neurosurgical intensive care unit (ICU), managed with labetalol, nicardipine, verapamil and magnesium sulfate. On POD 7, MRI showed resolving PRES and improvement of the headache but MRA showed little improvement in the cerebral vasoconstriction. On POD 11, the headache and the BP were under control and the patient was discharged home. The patient was followed in the neurology outpatient clinic with transcranial doppler and resolution of the cerebral vasoconstriction by the POD 52.
PRES is a clinicoradiological diagnosis characterized by reversible brain edema secondary to cerebrovascular auto-regulatory dysfunction. Clinically, the patient may present with seizures, headache, altered consciousness and visual disturbances. PRES is associated with pre-eclampsia, eclampsia and hypertensive disorders.
RCVS is characterized by severe headache with reversible cerebral vasoconstriction usually within 12 weeks after diagnosis. Ten percent of RCVS cases are complicated by PRES.
PRES and RCVS are reversible with early recognition and treatment of hypertension in ICU setting. Delayed diagnosis may result in cerebral ischemia and infarction.
1. SK Feske. Posterior Reversible Encephalopathy Syndrome: A Review. Semin. Neurol 2011; 31:202-215.
2. A Ducros, M GBousser. Reversible Vasoconstriction Syndrome. Pract. Neurol. 2009; 9:256-269.