Tuesday, October 01, 2013

Dx of neurologic emergencies in pregnancy/postpartum

Edlow JA, Caplan LR, Obrien K, Tibbles CD. Diagnosis of acute neurological emergencies in pregnant and post-partum women.  Lancet Neurology 2013; 12: 175-185

This is a review article that is nicely written.  I am blogging some of the minutiae of the article, not necessarily the major points, that might escape otherwise.  Here are a few pearls from the article:

1.  There is 8-39 % overlap between PRES and RCVS of patients with both conditions.

2.  Suspicious for preeclampsia:  bilateral throbbing headaches with blurring and scintillating scotomata. Before ecampsia occurs with seizures, preceding symptoms may include frontal or occipital headache, blurring, photophobia, RUQ or epigastric pain, and altered mental status.  90 % occur at or after 28 weeks, and a third after delivery. 

3.  Differential of thunderclap headaches:  subarachnoid hemorrhage, PRES, RCVS, and extracranial arterial dissections. 

4.  HELLP syndrome stands for hemolysis, elevated liver function tests, low platelets.  However, TTP also can present with low platelets.  TTP is treated with plasma exchange, HELLP with magnesium and delivery of fetus. 

5.  In PRES seizures occur at onset, in CVT they occur somewhat later in course, usually after headache is established.

6.  More than 75 % of CVT cases in this group are postpartun, not during pregnancy.

7.  RCVS is associated also (in addition to postpartum state) with "vasoactive substances" including SSRIs, cocaine, phenylpropanolamine, blood products, catechol secreting tumors, and dissections.  RECURRING DAILY THUNDERCLAP HEADACHES AFTER A SINGLE THUNDERCLAP HEADACHE OVER SEVERAL WEEKS ARE NEARLY PATHOGNOMONIC.  Vomiting, confusion photophobia, and blurring are common.  Seizures almost always follow the headache. 

8.  Rare:  Air embolism: with PFO.  Associated agitation, confusion, seizures and encephalopathy in context of CV or respiratory collapse during or after labor.  Nearly any focal neurologic or generalized neuro symptoms can occur.  Two signs that are pathognomonic include air in retinal veins and mill wheel cardiac murmur. 

9.  Choriocarcinoma metastasizes to the brain in 20 percent of cases. 

10. Wernicke's encephalopathy can complicate hyperemesis gravidarum.  Eye movement problems are almost always present and is frequently a metablolic acidosis.

11.  TTP pentad is:  thrombocytopenia, microangiopathic hemolytic anemia,  fever, neurologic and renal dysfunction. 

12.  There are three differtiable pituitary disorders:  adenoma with apoplexy-- hemorrhage or infarct into the gland (headache, visual loss, opthalmoplegia and decreased consciousness);  Sheehan's syndrome ( hypopituitarism indolently presenting weeks to months after severe postpartum hemorrhage), and lymphocytic hypophysitis (headache and visual symptoms that present acutely).