Posterior reversible encephalopathy syndrome and eclampsia: pressing the case for more aggressive blood pressure control

Abstract

Objective: To assess the prevalence, clinical presentations, and neuroimaging abnormalities in a series of patients treated for eclampsia at Mayo Clinic in Rochester, MN.

Patients and methods: We reviewed the records of all pregnant patients diagnosed as having eclampsia at Mayo Clinic in Rochester, MN, between January 1, 2001, and December 31, 2008. All patients who underwent neuroimaging were identified, and all studies were reviewed by an independent neuroradiologist. Comparisons were made between groups who did and did not undergo imaging to identify differentiating clinical or laboratory variables.

Results: Thirteen cases of eclampsia were found, with neuroimaging studies available for 7: magnetic resonance imaging (n=6) and computed tomography (n=1). All 7 patients developed eclamptic seizures, and 2 of 7 patients had severe hypertension, with recorded systolic blood pressures exceeding 180 mm Hg. Neuroimaging showed characteristic changes of posterior reversible encephalopathy syndrome (PRES) in all patients. Follow-up imaging showed resolution in 2 of 3 patients; 1 patient had residual neuroimaging abnormalities.

Conclusion: Our results suggest that the clinical syndrome of eclampsia is associated with an anatomical substrate that is recognizable by neuroimaging as PRES. The levels of blood pressure elevation are lower than those reported in cases of PRES because of hypertensive encephalopathy. Further studies are needed to determine whether more aggressive blood pressure control and early neuroimaging may have a role in the management of these patients.

FIGURE.

Magnetic resonance imaging of the head for a 23-year-old woman (gravida 3, para 1) who delivered at 40 weeks gestation after an uneventful pregnancy. Four days after delivery, she developed a dull headache, followed 5 days later by blurred vision and clumsiness. She had a seizure at home, and on admission, was found to be hypertensive, with a blood pressure of 158/86 mm Hg and an estimated urine protein of 349 mg/24 h. Findings on magnetic resonance imaging of the head (A) were consistent with posterior reversible encephalopathy syndrome (PRES). Blood pressure was controlled, and the patient was discharged. Two weeks after initial imaging, follow-up magnetic resonance imaging (B) revealed near-complete resolution of the changes of PRES, with a residual punctate abnormality in the right superior frontal lobe. She continued to have a dull headache. Her systolic blood pressure returned to the low 100s, and her headache subsequently resolved.