Posterior reversible encephalopathy syndrome in post-lumbar puncture headache in normotensive pregnancy

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  • MAEDA Yuto
    Department of Obstetrics and Gynecology, Kobe City Medical Center General Hospital
  • NAKAKITA Baku
    Department of Obstetrics and Gynecology, Kobe City Medical Center General Hospital
  • OH Noriko
    Department of Obstetrics and Gynecology, Kobe City Medical Center General Hospital
  • TOMITA Hiroyuki
    Department of Obstetrics and Gynecology, Kobe City Medical Center General Hospital
  • UEMATSU Kazuhiko
    Department of Obstetrics and Gynecology, Kobe City Medical Center General Hospital
  • AOKI Takuya
    Department of Obstetrics and Gynecology, Kobe City Medical Center General Hospital
  • YOSHIOKA Shinya
    Department of Obstetrics and Gynecology, Kobe City Medical Center General Hospital

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Other Title
  • 表腰椎穿刺後頭痛に引き続いて発症し，診断に苦慮した可逆性後白質脳症症候群（PRES）の1例
  • 症例報告 表腰椎穿刺後頭痛に引き続いて発症し,診断に苦慮した可逆性後白質脳症症候群(PRES)の1例
  • ショウレイ ホウコク ヒョウ ヨウツイ センシ コウトウツウ ニ ヒキツズイテ ハッショウ シ,シンダン ニ クリョ シタ カギャクセイ ゴ ハクシツ ノウショウ ショウコウグン(PRES)ノ 1レイ

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<p>Posterior reversible encephalopathy syndrome (PRES) is an encephalopathy with headache and seizures as the main symptoms. The pathogenesis of PRES remains unclear, but it appears to be related to endothelial dysfunction and breakdown of the blood-brain barrier leading to angiogenic brain edema. PRES seems to have some predisposing factors such as hypertension and immunosuppressant use. Reportedly, patients with preeclampsia are likely to have PRES. Here we report a case of PRES with challenging differential diagnosis in post-lumbar puncture headache (PLPHA) after cesarean section in a normotensive pregnancy. A 41-year-old multiparous woman underwent cesarean section using spinal and epidural anesthesia. She was normotensive during pregnancy. Although she had uncomplicated postoperative course until postoperative day 2, she developed frontal lobe headache on day 3. Her blood pressure and neurological examination were normal, and her pain was relieved in a lying position; hence, we diagnosed her with PLPHA. Conservative therapy was initiated, and the headache was resolved. However, her headache relapsed on day 5, accompanied with mild hypertension. Blood and urine tests did not reveal signs of preeclampsia, and oral caffeine was administered for PLPHA. However, she developed a tonic-clonic seizure on day 7. Head computed tomography scan post seizures did not reveal intracranial hemorrhage, and brain magnetic resonance (MR) imaging revealed edema of the bilateral posterior occipital lobes and cerebellum with hyperintense signal on T2-weighted signal. PRES was diagnosed, and infusions of magnesium sulfate and nifedipine were started. Subsequently, her blood pressure reduced to her baseline, and her headache was relieved. MR angiography revealed cerebral vasospasm on postoperative day 15; hence, lomerizine was started. Repeat MR angiography showed resolution of vasospasm, and she was discharged on postoperative day 25 without further seizure activity. The clinical course in this case was initially consistent with PLPHA. However, her headache from postoperative day 5 was atypical as in PLPHA; in some aspect, response to conservative treatment was weak and was accompanied by hypertension, suggesting that the headache was due to PRES. In other cases of PRES that occurred after PLPHA, blood pressure was initially normal and slightly elevated to the limit of mild hypertension, even when the patients had seizures. In conclusion, our case suggests that PRES should be considered when patients receive epidural or spinal anesthesia and develop headache atypical for PLPHA, such as headache with hypertension or refractory to conservative therapy, even if the blood pressure was normal during pregnancy. [Adv Obstet Gynecol, 70 (3) : 311-316, 2018 (H30.8)]</p>

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