Pregnancy-Induced Acute Neurologic Emergencies and Neurologic Conditions Encountered in Pregnancy

doi:10.1053/j.sult.2011.09.002

Seminars in Ultrasound, CT and MRI

Volume 33, Issue 1, February 2012, Pages 46-54

https://doi.org/10.1053/j.sult.2011.09.002 Get rights and content

Neurologic complications and conditions associated with pregnancy are rare. Frequently, presenting symptoms of neurologic conditions are nonspecific and can overlap with normal symptoms of pregnancy. As a result, clinical assessment can be insufficient to differentiate symptoms of a normal pregnancy from a neurologic disorder. It is imperative that the radiologist have a basic familiarity with the most common neurologic conditions encountered in pregnancy. The most commonly imaged acute and nonemergent disorders will be described, including eclampsia, cerebrovascular disease including cerebral venous thrombosis, postpartum cerebral angiopathy, multiple sclerosis, tumors, Bell palsy, Guillain-Barré syndrome, and pituitary disorders.

Section snippets

Pre-Eclampsia, Eclampsia, and Posterior Reversible Encephalopathy Syndrome

Pre-eclampsia (toxemia of pregnancy) is traditionally defined as the new onset of hypertension and proteinuria after the 20th week of gestation, but there can be atypical presentations including rare cases with normal blood pressure. Additional features can include headache, dizziness, tinnitus, drowsiness, visual disturbances, HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count), hyperreflexia, and clonus.¹ Pre-eclampsia is estimated to occur in 2%-8% of all pregnancies.¹

Multiple Sclerosis

Many studies have endeavored to further elucidate the relationship of pregnancy in patients with multiple sclerosis (MS). To this end, a host of conflicting data has accumulated over the years. Most studies have shown that pregnancy brings a protective effect from MS exacerbations, which is most pronounced during the third trimester.¹⁰ The postpartum period, however, sees an increased risk up to 50%-100%.⁵ Although some studies suggest that there is overall no net increased risk of MS

Indications for Neuroimaging

The decision to pursue imaging in pregnant patients should balance the considerations of answering the clinical question with the risk to the fetus and mother. Whenever possible, avoiding the use of ionizing radiation is preferred. There is a paucity of evidence defining the risk of MRI and CT for the developing child, and most data available are from observational, theoretical, and animal studies.⁶ Contrast administration should only occur when absolutely necessary. Elective procedures should

References (29)

R. Dineen et al.
Imaging of acute neurological conditions in pregnancy and the puerperium
Clin Radiol
(2005)
G.G. Zeeman et al.
Cerebral infarction in eclampsia
Am J Obstet Gynecol
(2004)
J.O. Donaldson
Neurologic emergencies in pregnancy
Obstet Gynecol Clin North Am
(1991)
P. Verdru et al.
Pregnancy and multiple sclerosis: The influence on long term disability
Clin Neurol Neurosurg
(1994)
J.T. Vrabec et al.
Bell's palsy and pregnancy
Otolaryngol Head Neck Surg
(2007)
I.T. Zak et al.
Imaging of neurologic disorders associated with pregnancy and the postpartum period
Radiographics
(2007)
R.B. Schwartz et al.
Preeclampsia-eclampsia: Clinical and neuroradiographic correlates and insights into the pathogenesis of hypertensive encephalopathy
Radiology
(2000)
S.D. Brass et al.
Neurological disorders in pregnancy from a neuroimaging perspective
Semin Neurol
(2007)
M.T. Mantello et al.
Imaging of neurologic complications associated with pregnancy
AJR Am J Roentgenol
(1993)
S. Waddy et al.
Cerebrovascular disease in pregnancy

M.R. Ursell et al.

Recurrent intracranial hemorrhage due to postpartum cerebral angiopathy: Implications for management

Stroke

(1998)

C. Confavreux et al.

Rate of pregnancy-related relapse in multiple sclerosis

N Engl J Med

(1998)

J. Kutcher et al.

Neurologic disorders complicating pregnancy: UpToDate (online)

S.D. Cook et al.

Multiple sclerosis and pregnancy

Cited by (12)

Intracranial emergencies during pregnancy requiring urgent neurosurgical treatment
2020, Clinical Neurology and Neurosurgery
Citation Excerpt :
From an ethical point of view, the first concern in this scenario should be the child-bearing woman’s health and safety. If the woman’s health condition is critical, saving the woman’s life while taking measures to preserve the fetus need to be in the focus of attention [15,30]. A particularly difficult situation emerges in the case of maternal brain death.
Despite contemporary diagnostic and therapeutic techniques intracranial emergencies in the obstetric setting pose still a major challenge for the clinicians. There are limited guidelines and differing ethical views. Multidisciplinary teams are needed to support the pregnant woman in a way that she can deliver a viable and healthy child. The aim of the present study was to scrutinize the management of intracranial emergencies during pregnancy which needed urgent neurosurgical treatment.
Data of all pregnant women who presented with newly diagnosed intracranial pathologies and neurological symptoms caused by these pathologies in an emergency setting were collected over a 10-year period (2008–2018). Patient characteristics including maternal age, gestational age, and preoperative work-up of both mother and fetus were recorded. Furthermore, the surgical treatment, mode of delivery, and neonatal and maternal outcomes were analysed.
The mean maternal age was 32.7 years and most patients were in their third trimester. There was one twin pregnancy (total of 12 fetuses). Five out of eleven pregnant women suffered from intracerebral haemorrhage (epidural haematoma (1), arteriovenous malformation (1), subarachnoid haemorrhage (2) and intracerebral haemorrhage (1)) and the other six patients had intracranial neoplasms (primary meningeal sarcoma (1), trigeminal schwannoma (1), anaplastic astrocytoma (2), glioblastoma (1) and sphenoid wing meningioma (1)).Neurosurgical procedures were performed via craniotomies in eight patients. A stereotactic biopsy via a frontal burr hole was achieved one patient. The two other patients with subarachnoid haemorrhage due to rupture of PICA aneurysms were treated with coil embolization. Depending on the gestational age and the clinical condition of the pregnant women it was decided to perform an emergency Caesarean section prior to further therapeutic measures in seven patients. Two out of 12 fetuses were unviable. Six women survived, while five women succumbed to the intracranial pathology.
The individualized treatment approach in this peculiar obstetric scenario needs to consider various issues such as the clinical condition of the pregnant woman, prognosis of the disease, gestational age and the status of the pregnancy. The primary concern in this context must be the mother`s health and safety. Caesarean section is the primary mode of delivery in most cases. While contemporary care can insure survival for the majority of infants, maternal mortality still poses an extraordinary challenge. Interdisciplinary consulting of the patient and/or her family is necessary to develop a treatment strategy for both the expectant woman and her offspring.
Sonographic evaluation of peripheral nerves in subtypes of Guillain-Barré syndrome
2016, Journal of the Neurological Sciences
Citation Excerpt :
However, such distinction is not straightforward because traumatic neurotomesis, axon damage due to compression, and vasculitic neuritis may develop enlargement of peripheral nerves [12–14]. Although many groups reported enlargement of nerve sizes in GBS, most of the reports have been from western countries where AIDP predominates [15–30]. To date, we are aware of only a few reports on sonographic evaluation of axonal subtype of GBS which studies relatively small number of patients [16,31].
Sonography of peripheral nerves can depict alteration of nerve sizes that could reflect inflammation and edema in inflammatory and demyelinating neuropathies. Guillain-Barré syndrome (GBS). Information on sonographic comparison of an axonal subtype (acute motor [and sensory] axonal neuropathy [AMAN and AMSAN]) and a demyelinating subtype (acute inflammatory demyelinating polyneuropathy [AIDP]) has been sparse.
Sonography of peripheral nerves and cervical nerve roots were prospectively recorded in patients with GBS who were within three weeks of disease onset.
Five patients with AIDP and nine with AMAN (n = 6)/AMSAN (n = 3) were enrolled. The patients with AIDP showed evidence of greater degrees of demyelination (e.g., slower conduction velocities and increased distal latencies) than those with AMAN/AMSAN. The patients with AIDP tended to show enlarged nerves in the proximal segments and in the cervical roots, whereas the patients with AMAN/AMSAN had greater enlargement in the distal neve segment, especially in the median nerve (P = 0.03; Wrist-axilla cross-sectional ratio).
In this small study, two subtypes of GBS showed different patterns of involvement that might reflect different pathomechanisms.
Neurologic disease with pregnancy and considerations for the obstetric anesthesiologist
2014, Seminars in Perinatology
Citation Excerpt :
If possible, consultation with the anesthesiology team should occur early enough in pregnancy to allow these communications to occur. Primary intracranial neoplasms occur in pregnancy at the same rate as in the general population.36 However, the behavior of brain tumor in pregnancy is likely to be quite different.
Women with neurologic conditions present a challenge during pregnancy and in the peripartum period. Given the low prevalence of these diseases during pregnancy, most management decisions are guided by retrospective reviews and case reports. This article reviews current literature for some of the more common or complex neurologic conditions affecting pregnancy with special consideration for anesthetic management. In particular, epilepsy; multiple sclerosis; primary intracranial hypertension; secondary intracranial hypertension—Arnold–Chiari malformations and intracranial neoplasms; spinal cord injury; neuromuscular junction disorders—myasthenia gravis; and hereditary neuromuscular disorders—myotonic dystrophy and spinal muscular atrophy will be discussed. By increasing understanding of anesthetic issues for parturients with neurologic disease, providers may more effectively anticipate anesthetic considerations, thereby optimizing care plans.
Pituitary apoplexy in a teenager - Case report
2014, Pediatric Neurology
Citation Excerpt :
A recent hemorrhage can appear as a single or multiple hyperdense lesions with little or no contrast enhancement on CT. Lesion detection is better with MRI than with CT in the subacute and chronic stages.5 T1-weighted MRI images are also more useful than CT both for tumoral volume determination and detection of intratumoral hemorrhage.11
Pituitary apoplexy is a rare clinical emergency which results from hemorrhage or infarction in the pituitary gland.
We present a 14-year-old girl with pituitary apoplexy and review the literature.
Our patient experienced blurred vision, nausea, and headache. Her best-corrected visual acuity was 20/200 and 20/20. Confrontation test visual field testing revealed bitemporal hemianopsia. Brain imaging demonstrated a suprasellar mass. The microscopic endonasal transsphenoidal approach only found 5-10 mL brownish fluid-like material. Pathology confirmed no malignancy. Pituitary apoplexy was diagnosed. Her nausea and headache gradually improved. Six months after operation, her best-corrected visual acuity had improved to 20/30 and 20/20.
Although pituitary apoplexy is rare in pediatric patients, prompt evaluation including detailed ophthalmic examination, biochemical evaluation, endocrine workup, and image study are very important.
Cranial neuroimaging in pregnancy and the post-partum period
2013, Clinical Radiology
Citation Excerpt :
Sheehan syndrome is clinical panhypopituitarism due to pituitary infarction after an obstetric-related hypotensive episode around the time of delivery. If hypotension and tachycardia persist after adequate initial treatment of obstetric haemorrhage, this condition should be suspected.52 Lymphocytic hypophysitis is a non-infectious inflammatory process in which the pituitary is infiltrated by lymphocytes and plasma cells accompanied by various degrees of pituitary dysfunction.
Several diverse neurological conditions may be seen during pregnancy and the post partum period. These usually require neuroimaging for definitive diagnosis and range from a predisposition to neurovascular abnormalities, such as acute ischaemic stroke and cerebral venous sinus thrombosis, through to more specific pregnancy-related conditions, such as eclampsia/posterior reversible leukoencephalopathy and post-partum angiopathy. Additionally, the pregnant patient is predisposed to pituitary disease. It is necessary that the radiologist has an awareness of these conditions to allow swift specific diagnoses or suggest the most appropriate diagnosis when imaging findings are non-specific. We describe epidemiological and radiological features to allow the radiologist to guide the clinician in management, and review guidelines for safe cranial imaging of the pregnant patient.
Neurosurgical emergencies during pregnancy – Management dilemmas
2023, Surgical Neurology International

View all citing articles on Scopus

View full text

Published by Elsevier Inc.

Pregnancy-Induced Acute Neurologic Emergencies and Neurologic Conditions Encountered in Pregnancy

Section snippets

Pre-Eclampsia, Eclampsia, and Posterior Reversible Encephalopathy Syndrome

Multiple Sclerosis

Indications for Neuroimaging

Clin Radiol

Am J Obstet Gynecol

Obstet Gynecol Clin North Am

Clin Neurol Neurosurg

Otolaryngol Head Neck Surg

Imaging of neurologic disorders associated with pregnancy and the postpartum period

Radiographics

Preeclampsia-eclampsia: Clinical and neuroradiographic correlates and insights into the pathogenesis of hypertensive encephalopathy

Radiology

Neurological disorders in pregnancy from a neuroimaging perspective

Semin Neurol

Imaging of neurologic complications associated with pregnancy

AJR Am J Roentgenol