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01-12-2018 | Review Article

Imaging neurological emergencies in pregnancy and puerperium

Authors: Matthew A. Haber, Diego Nunez

Published in: Emergency Radiology | Issue 6/2018

Abstract

The altered physiologic state of female patients during and just after pregnancy places them at an increased risk for several potentially life-threatening neurologic disorders. Swift diagnosis of such pathology and related complications is critical in order to reduce risk of morbidity and mortality to both the mother and the fetus. Neuroimaging plays an important role in the emergent diagnosis of pathology associated with pregnancy and puerperium, and it is critical for the radiologist to be cognizant of correlative imaging findings. Furthermore, given concerns regarding risks of neuroimaging to the fetus, it is important for the radiologist to act as an informed consultant regarding balancing fetal risks and the mother’s health. The purpose of this review is to elucidate the underlying pathophysiology and neuroimaging findings associated with diagnoses that are unique to or highly associated with pregnancy and puerperium, as well as to understand the role that CT and MR play in diagnosis during and just after pregnancy, and their respective risks to the fetus.

Razmara A, Bakhadirov K, Batra A, Feske SK (2014) Cerebrovascular complications of pregnancy and the postpartum period. Curr Cardiol Rep 16(10):532CrossRef

Moatti Z, Gupta M, Yadava R, Thamban S (2014) A review of stroke and pregnancy: incidence, management and prevention. Eur J Obstet Gynecol Reprod Biol 181:20–27CrossRef

Grear KE, Bushnell CD (2013) Stroke and pregnancy: clinical presentation, evaluation, treatment, and epidemiology. Clin Obstet Gynecol 56(2):350–359CrossRef

Frontera JA, Ahmed W (2014) Neurocritical care complications of pregnancy and puerperum. J Crit Care 29(6):1069–1081CrossRef

Swartz RH, Cayley ML, Foley N, Ladhani NNN, Leffert L, Bushnell C, McClure J, Lindsay MP (2017) The incidence of pregnancy-related stroke: a systematic review and meta-analysis. Int J Stroke 12(7):687–697CrossRef

Hacein-bey L, Varelas PN, Ulmer JL, Mark LP, Raghavan K, Provenzale JM (2016) Imaging of cerebrovascular disease in pregnancy and the puerperium. AJR Am J Roentgenol 206(1):26–38CrossRef

Mas JL, Lamy C (1998) Stroke in pregnancy and the puerperium. J Neurol 245(6–7):305–313CrossRef

Feske SK (2007) Stroke in pregnancy. Semin Neurol 27(5):442–452CrossRef

Kittner SJ, Stern BJ, Feeser BR, Hebel JR, Nagey DA, Buchholz DW, Earley CJ, Johnson CJ, Macko RF, Sloan MA, Wityk RJ, Wozniak MA (1996) Pregnancy and the risk of stroke. N Engl J Med 335(11):768–774CrossRef

10.

Brass SD, Copen WA (2007) Neurological disorders in pregnancy from a neuroimaging perspective. Semin Neurol 27(5):411–424CrossRef

11.

Klein JP, Hsu L (2011) Neuroimaging during pregnancy. Semin Neurol 31(4):361–373CrossRef

12.

Shainker SA, Edlow JA, O'brien K (2015) Cerebrovascular emergencies in pregnancy. Best Pract Res Clin Obstet Gynaecol 29(5):721–731CrossRef

13.

O'neal MA (2017) Headaches complicating pregnancy and the postpartum period. Pract Neurol 17(3):191–202CrossRef

14.

Ascanio LC, Maragkos GA, Young BC, Boone MD, Kasper EM (2018) Spontaneous intracranial hemorrhage in pregnancy: a systematic review of the literature. Neurocrit Care

15.

Zak IT, Dulai HS, Kish KK (2007) Imaging of neurologic disorders associated with pregnancy and the postpartum period. Radiographics 27(1):95–108CrossRef

16.

Mcdermott M, Miller EC, Rundek T, Hurn PD, Bushnell CD (2018) Preeclampsia: association with posterior reversible encephalopathy syndrome and stroke. Stroke 49(3):524–530CrossRef

17.

Edlow JA, Caplan LR, O'brien K, Tibbles CD (2013) Diagnosis of acute neurological emergencies in pregnant and post-partum women. Lancet Neurol 12(2):175–185CrossRef

18.

Hiremath R, Mundaganur P, Sonwalkar P, Vishal NS, Narendra GS, Sanjay P (2014) Cross sectional imaging of post partum headache and seizures. J Clin Diagn Res 8(12):RC01–RC05PubMedPubMedCentral

19.

Alvis JS, Hicks RJ (2012) Pregnancy-induced acute neurologic emergencies and neurologic conditions encountered in pregnancy. Semin Ultrasound CT MR 33(1):46–54CrossRef

20.

Moffett-king A (2002) Natural killer cells and pregnancy. Nat Rev Immunol 2(9):656–663CrossRef

21.

Brewer J, Owens MY, Wallace K, Reeves AA, Morris R, Khan M, LaMarca B, Martin JN Jr (2013) Posterior reversible encephalopathy syndrome in 46 of 47 patients with eclampsia. Am J Obstet Gynecol 208(6):468.e1–468.e6CrossRef

22.

Kanekar S, Bennett S (2016) Imaging of neurologic conditions in pregnant patients. Radiographics 236(7):2102–2122CrossRef

23.

Schwartz RB, Feske SK, Polak JF, DeGirolami U, Iaia A, Beckner KM, Bravo SM, Klufas RA, Chai RYC, Repke JT (2000) Preeclampsia-eclampsia: clinical and neuroradiographic correlates and insights into the pathogenesis of hypertensive encephalopathy. Radiology 217(2):371–376CrossRef

24.

Zeeman GG (2009) Neurologic complications of pre-eclampsia. Semin Perinatol 33(3):166–172CrossRef

25.

Loureiro R, Leite CC, Kahhale S, Freire S, Sousa B, Cardoso EF, Alves EA, Borba P, Cerri GG, Zugaib M (2003) Diffusion imaging may predict reversible brain lesions in eclampsia and severe preeclampsia: initial experience. Am J Obstet Gynecol 189(5):1350–1355CrossRef

26.

Schaefer PW, Buonanno FS, Gonzalez RG, Schwamm LH (1997) Diffusion-weighted imaging discriminates between cytotoxic and vasogenic edema in a patient with eclampsia. Stroke 128(5):1082–1085CrossRef

27.

Ferro JM, Canhão P (2014) Cerebral venous sinus thrombosis: update on diagnosis and management. Curr Cardiol Rep 16(9):523CrossRef

28.

Savage H, Harrison M (2008) Central venous sinus [added] thrombosis misdiagnosed as eclampsia in an emergency department. Emerg Med J 25(1):49–50CrossRef

29.

Plowman RS, Javidan-nejad C, Raptis CA et al (2017) Imaging of pregnancy-related vascular complications. Radiographics 37(4):1270–1289CrossRef

30.

Fraum TJ, Ludwig DR, Bashir MR, Fowler KJ (2017) Gadolinium-based contrast agents: a comprehensive risk assessment. J Magn Reson Imaging 46(2):338–353CrossRef

31.

Puac P, Rodríguez A, Vallejo C, Zamora CA, Castillo M (2017) Safety of contrast material use during pregnancy and lactation. Magn Reson Imaging Clin N Am 25(4):787–797CrossRef

32.

Ray JG, Vermeulen MJ, Bharatha A, Montanera WJ, Park AL (2016) Association between MRI exposure during pregnancy and fetal and childhood outcomes. JAMA 316(9):952–961CrossRef

33.

Chen SP, Fuh JL, Wang SJ (2010) Reversible cerebral vasoconstriction syndrome: an under-recognized clinical emergency. Ther Adv Neurol Disord 3(3):161–171CrossRef

34.

Ducros A (2012) Reversible cerebral vasoconstriction syndrome. Lancet Neurol 11(10):906–917CrossRef

35.

Ghia D, Cuganesan R, Cappelen-smith C (2011) Delayed angiographic changes in postpartum cerebral angiopathy. J Clin Neurosci 18(3):435–436CrossRef

36.

Fugate JE, Ameriso SF, Ortiz G, Schottlaender LV, Wijdicks EFM, Flemming KD, Rabinstein AA (2012) Variable presentations of postpartum angiopathy. Stroke 43(3):670–676CrossRef

37.

Singhal AB (2004) Postpartum angiopathy with reversible posterior leukoencephalopathy. Arch Neurol 61(3):411–416CrossRef

38.

Ollivier M, Bertrand A, Clarençon F, Gerber S, Deltour S, Domont F, Trunet S, Dormont D, Leclercq D (2017) Neuroimaging features in posterior reversible encephalopathy syndrome: a pictorial review. J Neurol Sci 373:188–200CrossRef

39.

Achar SK, Shetty N, Joseph TT (2011) Posterior reversible encephalopathy syndrome at term pregnancy. Indian J Anesth 55(4):399–401CrossRef

40.

Vandenbossche G, Maquet J, Vroonen P, Lambert G, Nisolle M, Kridelka F, Emonts E (2016) A reversible posterior leucoencephalopathy syndrome including blindness caused by preeclampsia. Facts Views Vis Obgyn 8(3):173–177PubMedPubMedCentral

41.

Mueller-mang C, Mang T, Pirker A, Klein K, Prchla C, Prayer D (2009) Posterior reversible encephalopathy syndrome: do predisposing risk factors make a difference in MRI appearance? Neuroradiology 51(6):373–383CrossRef

42.

Bartynski WS (2008) Posterior reversible encephalopathy syndrome, part 1: fundamental imaging and clinical features. AJNR Am J Neuroradiol 29(6):1036–1042CrossRef

43.

Bartynski WS (2008) Posterior reversible encephalopathy syndrome, part 2: controversies surrounding pathophysiology of vasogenic edema. AJNR Am J Neuroradiol 29(6):1043–1049CrossRef

44.

Lamy C, Oppenheim C, Méder JF, Mas JL (2004) Neuroimaging in posterior reversible encephalopathy syndrome. J Neuroimaging 14(2):89–96CrossRef

45.

Casey SO, Sampaio RC, Michel E, Truwit CL (2000) Posterior reversible encephalopathy syndrome: utility of fluid-attenuated inversion recovery MR imaging in the detection of cortical and subcortical lesions. AJNR Am J Neuroradiol 21(7):1199–1206PubMed

46.

Doelken M, Lanz S, Rennert J, Alibek S, Richter G, Doerfler A (2007) Differentiation of cytotoxic and vasogenic edema in a patient with reversible posterior leukoencephalopathy syndrome using diffusion-weighted MRI. Diagn Interv Radiol 13(3):125–128PubMed

47.

Junewar V, Verma R, Sankhwar PL, Garg RK, Singh MK, Malhotra HS, Sharma PK, Parihar A (2014) Neuroimaging features and predictors of outcome in eclamptic encephalopathy: a prospective observational study. AJNR Am J Neuroradiol 35(9):1728–1734CrossRef

48.

Bartynski WS, Boardman JF (2008) Catheter angiography, MR angiography, and MR perfusion in posterior reversible encephalopathy syndrome. AJNR Am J Neuroradiol 29(3):447–455CrossRef

49.

Abraham RR, Pollitzer RE, Gokden M, Goulden PA (2016) Spontaneous pituitary apoplexy during the second trimester of pregnancy, with sensory loss. BMJ Case Rep https://doi.org/10.1136/bcr-2015-212405

50.

Briet C, Salenave S, Bonneville JF, Laws ER, Chanson P (2015) Pituitary apoplexy. Endocr Rev 36(6):622–645CrossRef

51.

Mathur D, Lim LF, Mathur M, Sng BL (2014) Pituitary apoplexy with reversible cerebral vasoconstrictive syndrome after spinal anaesthesia for emergency caesarean section: an uncommon cause for postpartum headache. Anaesth Intensive Care 42(1):99–105PubMed

52.

Watson V (2015) An unexpected headache: pituitary apoplexy in a pregnant woman on anticoagulation. BMJ Case Rep 2015

53.

Gutenberg A, Larsen J, Lupi I, Rohde V, Caturegli P (2009) A radiologic score to distinguish autoimmune hypophysitis from nonsecreting pituitary adenoma preoperatively. AJNR Am J Neuroradiol 30(9):1766–1772CrossRef

54.

Landek-salgado MA, Gutenberg A, Lupi I et al (2010) Pregnancy, postpartum autoimmune thyroiditis, and autoimmune hypophysitis: intimate relationships. Autoimmun Rev 9(3):153–157CrossRef

55.

Molitch ME (1998) Pituitary diseases in pregnancy. Semin Perinatol 22(6):457–470CrossRef

56.

Kerrison JB, Lee AG, Weinstein JM (1997) Acute loss of vision during pregnancy due to a suprasellar mass. Surv Ophthalmol 41(5):402–408CrossRef

57.

Tonda C, Rizvi AA (2011) Headache, pituitary lesion and panhypopituitarism in a pregnant woman: tumor, apoplexy or hypophysitis? Am J Med Sci 342(3):247–249CrossRef

58.

Mcgrath E, Monaghan TS, Alexander M, Hennessy MJ (2010) Recurrent spontaneous intracranial hypotension in early pregnancy. BMJ Case Rep 2010

59.

Bakir B, Aydin K, Talu G, Ozyalcin S (2008) Cranial magnetic resonance imaging in spontaneous intracranial hypotension after epidural blood patch. Pain Pract 8(3):206–209CrossRef

60.

Grange J, Lorre G, Ducarme G (2016) Iterative epidural blood patch for recurrent spontaneous intracranial hypotension during pregnancy. J Clin Anesth 34:239–243CrossRef

61.

Fairhall JM, Stoodley MA (2009) Intracranial haemorrhage in pregnancy. Obstet Med 2(4):142–148CrossRef

62.

Atwell TD, Lteif AN, Brown DL, Mccann M, Townsend JE, Leroy AJ (2008) Neonatal thyroid function after administration of IV iodinated contrast agent to 21 pregnant patients. AJR Am J Roentgenol 191(1):268–271CrossRef

63.

Bourjeily G, Chalhoub M, Phornphutkul C, Alleyne TC, Woodfield CA, Chen KK (2010) Neonatal thyroid function: effect of a single exposure to iodinated contrast medium in utero. Radiology 256(3):744–750CrossRef

Title: Imaging neurological emergencies in pregnancy and puerperium
Authors: Matthew A. Haber
Diego Nunez
Publication date: 01-12-2018
Publisher: Springer Berlin Heidelberg
Published in: Emergency Radiology / Issue 6/2018
Print ISSN: 1070-3004
Electronic ISSN: 1438-1435
DOI: https://doi.org/10.1007/s10140-018-1625-8

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Imaging neurological emergencies in pregnancy and puerperium

Abstract

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Springer Medicine

Abstract

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