Anesth Analg 2007;104:746-747
© 2007 International Anesthesia Research Society
doi: 10.1213/01.ane.0000255966.11300.b3
LETTER TO THE EDITOR
Section Editor:
Lawrence Saidman
Posterior Reversible Encephalopathy Syndrome After a Cesarean Delivery
Xavier Onrubia, MD,
Aitana Lluch-Oltra, MD,
Rocío Armero, PhD,
Raquel Higueras, MD,
Cristina Sifre, PhD, and
Manuel Barberá, PhD
Department of Anesthesia and Critical Care; Hospital Universitari Dr. Peset; València, Spain; onrubia_xav{at}gva.es
To the Editor:
We present a clinical case of a 23-year-old woman, at the 38th week of her first gestation, who presented with hypertension (arterial blood pressure (BP) 175/120 mm Hg). After an unremarkable cesarean delivery, the patient developed a headache and confusion without any focal neurological deficit. Cranial computed tomography showed no pathological findings. She was transferred to the intensive care unit (ICU). At the time of transfer her BP was 210/140 mm Hg. The hypertension was treated with urapidil, labetalol, and magnesium sulfate, with improvement within 4 h to a BP of 155/90 mm Hg. However, her mental state continued to be abnormal, with confusion, restlessness, and uncoordinated movements. These gradually improved over the following 4 days. Her magnesium was, therefore, weaned while she was maintained on urapidil and labetalol.
On the fifth day the patient became confused and disorientated, with visual and auditory hallucinations, blurred vision, hyperreflexia, and sluggish mentation. Her BP increased acutely to 220/120 mm Hg. Repeat magnetic resonance imaging scan established a diagnosis of posterior reversible encephalopathy syndrome. The patient was started on IV nimodipine, which helped restore normal BP (135/70 mm Hg.). Over the next few days her neurologic symptoms disappeared. She was discharged from the ICU on day 14, and was discharged from the hospital 9 days later. Figures 1 and 2 show the evolution of neuroradiological injury.
Posterior reversible leukoencephalopathy syndrome was initially associated with eclampsia, immunosuppressive treatment, and uremia (1,2), but more recently it has been related to a wide variety of conditions, particularly pregnancy (3–6). In most cases of posterior reversible encephalopathy syndrome, neurological symptoms and cerebral lesions disappear with aggressive control of BP. Cerebral vasospasm likely contributes to the clinical and radiological findings, which is why nimodipine is a mainstay of therapy (3,5,6). Posterior reversible encephalopathy syndrome is reversible when adequate treatment is promptly instituted, but delayed diagnosis and treatment can result in permanent neurological sequelae.
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