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Posterior reversible encephalopathy syndrome in 46 of 47 patients with eclampsia
Accepted Manuscript Posterior reversible encephalopathy syndrome in 46 of 47 patients with eclampsia Gerda G. Zeeman, MD PhD F. Gary Cunningham, MD PII:
S0002-9378(13)02037-1
DOI:
10.1016/j.ajog.2013.11.025
Reference:
YMOB 9558
To appear in:
American Journal of Obstetrics and Gynecology
Received Date: 13 August 2013 Accepted Date: 14 November 2013
Please cite this article as: Zeeman GG, Cunningham FG, Posterior reversible encephalopathy syndrome in 46 of 47 patients with eclampsia, American Journal of Obstetrics and Gynecology (2013), doi: 10.1016/j.ajog.2013.11.025. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Posterior reversible encephalopathy syndrome in 46 of 47 patients with eclampsia
1. Department of Obstetrics and Gynecology
M AN U
Division of Obstetrics and Prenatal Medicine
SC
RI PT
Gerda G. Zeeman MD PhD1 and F. Gary Cunningham MD2
Erasmus Medical Center- Sophia, SK4130 PO Box 2040 3000 CA Rotterdam The Netherlands
TE D
[email protected]
2. Department of Obstetrics and Gynecology
EP
UT Southwestern Medical Center 5323 Harry Hines Blvd.
AC C
Dallas, TX 75390-9032
United States of America [email protected]
Conflict of interest statement: Both authors decline any potential conflict of interest
ACCEPTED MANUSCRIPT
With interest we read the article by Brewer et al who describe the use of various neuroimaging modalities such as magnetic resonance imaging (MRI) and computed tomography (CT) in
RI PT
women with eclamptic seizures (1). The posterior reversible encephalopathy syndrome (PRES) was found in all but one patient. In 2003 Loureiro et al published a series of 14 women with eclampsia and 3 women with severe preeclampsia and neurological symptoms who all
SC
underwent cranial MRI (2). In 2004 we published a similar series of 27 nulliparous eclamptic women who had cranial MRI following their eclamptic seizure (3). In both series, as also
M AN U
described by Brewer et al, PRES was found to be a core component of the pathogenesis of eclampsia. While FLAIR MRI and CT, as described by Brewer et al, can only identify the presence of cerebral edema per se, it does not distinguish between reversible areas of vasogenic edema and areas of cytotoxic edema, that may progress to tissue loss. The study by
TE D
Loureiro in 2003 and our study in 2004 specifically reported the use of Diffusion weighted MRI (DW-MRI) and Apparent Diffusion Coefficient (ADC) mapping to distinguish between these two forms of cerebral edema. While in our study all but two had reversible vasogenic edema six
EP
eclamptic women were also found to have areas of cytotoxic edema consistent with cerebral infarction. Five of these 6 women had persistent imaging findings of brain tissue loss (gliosis)
AC C
when studied 6-8 weeks postpartum. Our study as well as that of Loureiro et al. documented a transition between reversible vasogenic edema to irreversible cerebral ischemia and infarction in a fourth of eclamptic women. While long-term clinical consequences of eclampsia, such as subtle brain dysfunction, need to be determined the presence of cytotoxic edema and tissue loss on follow up seems ominous. There is a predictive role for diffusion-weighted MRI in the evaluation of the course of cerebral edema in the acute phase in women with eclampsia and
ACCEPTED MANUSCRIPT
women with severe preeclampsia who have neurological symptoms. Therefore, we recommend adding this modality, including ADC MRI modalities, to the standard neuroimaging protocol for
RI PT
women with eclampsia and those women with preeclampsia and concomitant neurological symptoms.
AC C
EP
TE D
M AN U
SC
1. Brewer J, Owens MY, Wallace K, Reeves AA, Morris R, Khan M, Lamarca B, Martin JN. Posterior Reversible Encephalopathy Syndrome in 46 of 47 patients with eclampsia. Am J Obstet Gynecol 2013;208:468.e1-6. 2. Loureiro R, Leite CC, Kahhale S, Freire S, Sousa B, Cardoso EF, Alves EA, Borba P, Cerri GG, Zugaib M. Diffusion imaging may predict reversible brain lesions in eclampsia and severe preeclampsia: Initial experience. Am J Obstet Gynecol 2003;189:1350-5 3. Zeeman GG, Fleckenstein JL, Twickler DM, Cunningham FG. Cerebral infarction in eclampsia. Am J Obstet Gynecol 2004;190:714-20
S0002-9378(13)02037-1
DOI:
10.1016/j.ajog.2013.11.025
Reference:
YMOB 9558
To appear in:
American Journal of Obstetrics and Gynecology
Received Date: 13 August 2013 Accepted Date: 14 November 2013
Please cite this article as: Zeeman GG, Cunningham FG, Posterior reversible encephalopathy syndrome in 46 of 47 patients with eclampsia, American Journal of Obstetrics and Gynecology (2013), doi: 10.1016/j.ajog.2013.11.025. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Posterior reversible encephalopathy syndrome in 46 of 47 patients with eclampsia
1. Department of Obstetrics and Gynecology
M AN U
Division of Obstetrics and Prenatal Medicine
SC
RI PT
Gerda G. Zeeman MD PhD1 and F. Gary Cunningham MD2
Erasmus Medical Center- Sophia, SK4130 PO Box 2040 3000 CA Rotterdam The Netherlands
TE D
[email protected]
2. Department of Obstetrics and Gynecology
EP
UT Southwestern Medical Center 5323 Harry Hines Blvd.
AC C
Dallas, TX 75390-9032
United States of America [email protected]
Conflict of interest statement: Both authors decline any potential conflict of interest
ACCEPTED MANUSCRIPT
With interest we read the article by Brewer et al who describe the use of various neuroimaging modalities such as magnetic resonance imaging (MRI) and computed tomography (CT) in
RI PT
women with eclamptic seizures (1). The posterior reversible encephalopathy syndrome (PRES) was found in all but one patient. In 2003 Loureiro et al published a series of 14 women with eclampsia and 3 women with severe preeclampsia and neurological symptoms who all
SC
underwent cranial MRI (2). In 2004 we published a similar series of 27 nulliparous eclamptic women who had cranial MRI following their eclamptic seizure (3). In both series, as also
M AN U
described by Brewer et al, PRES was found to be a core component of the pathogenesis of eclampsia. While FLAIR MRI and CT, as described by Brewer et al, can only identify the presence of cerebral edema per se, it does not distinguish between reversible areas of vasogenic edema and areas of cytotoxic edema, that may progress to tissue loss. The study by
TE D
Loureiro in 2003 and our study in 2004 specifically reported the use of Diffusion weighted MRI (DW-MRI) and Apparent Diffusion Coefficient (ADC) mapping to distinguish between these two forms of cerebral edema. While in our study all but two had reversible vasogenic edema six
EP
eclamptic women were also found to have areas of cytotoxic edema consistent with cerebral infarction. Five of these 6 women had persistent imaging findings of brain tissue loss (gliosis)
AC C
when studied 6-8 weeks postpartum. Our study as well as that of Loureiro et al. documented a transition between reversible vasogenic edema to irreversible cerebral ischemia and infarction in a fourth of eclamptic women. While long-term clinical consequences of eclampsia, such as subtle brain dysfunction, need to be determined the presence of cytotoxic edema and tissue loss on follow up seems ominous. There is a predictive role for diffusion-weighted MRI in the evaluation of the course of cerebral edema in the acute phase in women with eclampsia and
ACCEPTED MANUSCRIPT
women with severe preeclampsia who have neurological symptoms. Therefore, we recommend adding this modality, including ADC MRI modalities, to the standard neuroimaging protocol for
RI PT
women with eclampsia and those women with preeclampsia and concomitant neurological symptoms.
AC C
EP
TE D
M AN U
SC
1. Brewer J, Owens MY, Wallace K, Reeves AA, Morris R, Khan M, Lamarca B, Martin JN. Posterior Reversible Encephalopathy Syndrome in 46 of 47 patients with eclampsia. Am J Obstet Gynecol 2013;208:468.e1-6. 2. Loureiro R, Leite CC, Kahhale S, Freire S, Sousa B, Cardoso EF, Alves EA, Borba P, Cerri GG, Zugaib M. Diffusion imaging may predict reversible brain lesions in eclampsia and severe preeclampsia: Initial experience. Am J Obstet Gynecol 2003;189:1350-5 3. Zeeman GG, Fleckenstein JL, Twickler DM, Cunningham FG. Cerebral infarction in eclampsia. Am J Obstet Gynecol 2004;190:714-20