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Delayed and Complicated Postpartum Diagnosis of Posterior Reversible Encephalopathy Syndrome
Abstract Number: F-23
Abstract Type: Case Report/Case Series
Introduction: Though postpartum headaches (PPH) are common and usually benign, rare and serious causes must be considered when evaluating each patient. We report a complicated PPH case in which a number of serious causes were considered before the patient eventually suffered multiple seizures and MRI revealed a diagnosis of posterior reversible encephalopathy syndrome (PRES).
Case: A 30 year old G9P3 with a history of postpartum subarachnoid hemorrhage underwent a scheduled caesarean under epidural anesthesia. On PPD 4, she developed a headache with associated neck stiffness and hypertension. Over the course of 3-4 days and two hospital admissions, CTs, MRIs and CSF analysis were all unremarkable. Treatment with two separate courses of magnesium (Mg) for possible preeclampsia improved symptoms, but therapy was discontinued after each workup did not support the diagnosis. On PPD 9, worsening headache preceded multiple seizures and subsequent onset of blurry vision and photophobia. MR venogram was negative for thrombosis, but repeat MRI showed cerebral edema in right occipital and posterior temporal areas, supporting a diagnosis of PRES. Her headache, hypertension and vision changes resolved over the next 3 days after which she was discharged on phenytoin and beta blocker therapy.
Discussion: PRES is a rare neurologic disorder characterized by headache, confusion, vision changes, seizures and classic MRI findings of cerebral edema of the parietal and occipital lobes.1 Altered cerebrovascular autoregulation is thought to cause loss of blood brain barrier integrity and vasogenic edema. Usually PRES is self-resolving with supportive therapy, though irreversible neurological injury can occur with delayed recognition and treatment.
In our case, symptom presentation was atypical with delayed seizures and unchanged mental status. Furthermore, features of the patient’s history and presentation were suggestive of other diagnoses that needed to be excluded; preeclampsia, intracranial hemorrhage, brain tumor, meningitis, venous thrombosis and PDPH were all considered. Ultimately, the presence of seizures, vision changes and supportive MRI findings confirmed diagnosis of PRES. Whilst unilateral MRI findings are atypical, varied imaging has been reported.2
Associated with various disease states, PRES is known to be precipitated by preeclampsia. 3 Though preeclampsia was not diagnosed in our case, the symptomatic improvement on Mg may be due to calcium channel blocking properties relieving vasospasm reported to contribute to PRES.4
PRES has also being reported following dural puncture,4 and authors hypothesize CSF loss may cause traction on posterior cerebral structures and induce vasospasm that results in PRES. Our patient did have a lumbar puncture and could have suffered unrecognized dural puncture during her epidural placement.
1. N Engl J Med. 1996; 334:494-500
2. Radiat Med. 2006; 24:659-68
3. Can J Anaesth. 1998;45:452-9
4. Anesth Analg. 2007; 105:77