Neuroimaging features and predictors of outcome in eclamptic encephalopathy: a prospective observational study

Abstract

Background and purpose: Posterior reversible encephalopathy syndrome is associated with eclampsia. We assessed the distribution and nature of typical and atypical cranial MR imaging findings in these patients and their correlation with clinical and laboratory data and predictors of outcome.

Materials and methods: Forty-five clinically confirmed cases of eclampsia were included in this prospective observational study. Subjects with hemolysis, elevated liver enzymes, and low platelets syndrome (n = 9) and pre-existing neurologic conditions (1 with cerebral solitary cysticercus granuloma) were excluded. Patients underwent blood investigations and cranial MR imaging.

Results: Twenty-seven patients had abnormal while 8 had normal MR imaging findings. Involvement of brain regions was as follows: frontal, 88.89%; temporal, 44.44%; parietal, 100%; occipital, 100%; deep gray matter, 29.63%; cerebellum, 22.22%; brain stem, 14.81%. Cytotoxic edema was present in 33.33% of cases; 66.67% of patients had mild posterior reversible encephalopathy syndrome; 25.92% had moderate posterior reversible encephalopathy syndrome; and 7.41% had severe posterior reversible encephalopathy syndrome. Abnormal neuroimaging findings were significantly associated with altered sensorium; visual disturbances; status epilepticus; and elevated serum creatinine, uric acid, and lactate dehydrogenase (P=.006, P=.018, P=.015, P=.019, P=.003, and P=.001, respectively). Serum creatinine, uric acid, and lactate dehydrogenase values and the presence of moderate or severe posterior reversible encephalopathy syndrome were significantly associated with mortality (P<.001, P<.001, P=.009, and P=.027, respectively).

Conclusions: Neuroimaging in eclampsia demonstrates a higher incidence of atypical distributions and cytotoxic edema than previously thought. Altered sensorium; visual disturbances; status epilepticus; and elevated serum uric acid, lactate dehydrogenase, and creatinine are associated with abnormal neuroimaging findings. Higher serum creatinine, uric acid, and lactate dehydrogenase levels and moderate and severe forms of posterior reversible encephalopathy syndrome are possible predictors of poor outcome.

Fig 1.

Distribution of lesions in MR imaging–positive cases.

Fig 2.

MR images of the brain of a 25-year-old woman with antepartum eclampsia. A, FLAIR MR image shows edema involving the cortex and subcortical white matter of the bilateral occipital and parietal regions and the splenium of the corpus callosum. B, DWI shows hyperintensity in corresponding areas. C, ADC image shows hyperintensity in the bilateral occipital and parietal regions but hypointensity in the splenium of the corpus callosum.

Fig 3.

FLAIR MR images of the brain of a 19-year-old woman with antepartum eclampsia showing involvement of bilateral frontal, parietal (A), and cerebellar (B) regions.

Fig 4.

Brain MR images of a 20-year-old woman with early postpartum eclampsia. A, FLAIR MR image shows edema involving the bilateral frontal and parietal regions. FLAIR (B), DWI (C), and ADC (D) show involvement of the right thalamus with cytotoxic edema.