Postpartum Woman With Seizures

Abstract

A 27-year-old woman, postpartum day 9, presented with sudden onset of headache, vomiting, visual blurring, and 3 episodes of generalized tonic-clonic seizures. She had had an uneventful cesarean delivery 9 days previously and was discharged home. Her antenatal period was uneventful, and she did not have gestational hypertension. On examination, she was alert, oriented, and afebrile. Her blood pressure was 150/100 mm Hg, which had increased from her mean antenatal recording of 130/80 mm Hg. Fundus examination result was normal, and there were no focal neurologic deficits. Magnetic resonance imaging (MRI) of the brain showed T2 and T2 fluid-attenuated inversion recovery (FLAIR) hyperintense signals in bilateral parietooccipital lobes (Figures 1 and 2) and bilateral cerebellar hemispheres (Figure 3), without any diffusion restriction. She was treated with intravenous labetalol, nifedipine, and fosphenytoin. Her blood pressure normalized and her symptoms subsided, and she was later discharged.Figure 2Axial MRI showing T2 FLAIR hyperintensity of bilateral parietal lobes (arrows).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Axial MRI showing T2 FLAIR hyperintensity of bilateral cerebellar hemispheres (arrows).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Posterior reversible encephalopathy syndrome. Posterior reversible encephalopathy syndrome is a clinicoradiologic entity, characterized by the clinical triad of headache, visual blurring, and seizures. The classic neuroimaging feature is parietooccipital lobe edema, observed as T2 hyperintense lesions in the MRI.1Bartynski W.S. Posterior reversible encephalopathy syndrome, part 1: fundamental imaging and clinical features.AJNR Am J Neuroradiol. 2008; 29: 1036-1042Crossref PubMed Scopus (796) Google Scholar Cerebellar involvement as observed in this case is much rarer, and such atypical presentations are also possible.2McKinney A.M. Short J. Truwit C.L. et al.Posterior reversible encephalopathy syndrome: incidence of atypical regions of involvement and imaging findings.AJR Am J Roentgenol. 2007; 189: 904-912Crossref PubMed Scopus (519) Google Scholar Posterior reversible encephalopathy syndrome is usually accompanied by hypertension. Other causes include chronic kidney disease and immunosuppressive therapy.3Garg R.K. Posterior leukoencephalopathy syndrome.Postgrad Med J. 2001; 77: 24-28Crossref PubMed Scopus (236) Google Scholar Patients with blood pressure fluctuations in the antepartum and postpartum period are particularly vulnerable for the syndrome. In the setting of postpartum seizures, the differential diagnosis includes postpartum eclampsia, cerebral venous thrombosis, and intracerebral hemorrhage.