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.

REFERENCES

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3. Xuechuan H, Yang F, Yan Y: Two Cases of Severe Preeclampsia Were

Diagnosed with HELLP Postpartum after Caesarian Section. Case

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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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