Critical Care Medicine-Neurologic Disorders>>>>>Encephalopathy and Delirium
Question 1#

A 34-year-old previously healthy female was admitted to the hospital in labor. She was hypertensive on admission and complained of right upper quadrant pain. Fifteen minutes after delivery she developed a generalized onset motor seizure and was intubated and admitted to the ICU.

Her seizure is MOST likely:

A. A late initial manifestation of a preexisting epilepsy
B. A complication of delivery before normalization of blood pressure
C. Associated with subcortical vasogenic cerebral edema on imaging
D. A complication of high dermatomal level of epidural analgesia/anesthesia
E. Associated with thrombocytosis and cerebral vascular occlusion

Correct Answer is C

Comment:

Correct Answer: C

Brain imaging obtained in this patient is likely to demonstrate posterior reversible encephalopathy syndrome (PRES), which is found in most (over 90%) patients with eclampsia. Typical features of PRES on brain imaging include subcortical vasogenic cerebral edema, most commonly in parietal and occipital regions. This patient has developed severe preeclampsia antepartum. Although her blood pressure is not specified, right upper quadrant pain is a severe feature of preeclampsia. Such pain is thought to result from distension of liver capsule and may coexist with HELLP syndrome—Hemolysis, Elevated Liver enzymes, Low Platelets. A combination of hypertension and right upper quadrant pain in a parturient should prompt laboratory testing for HELLP syndrome and consideration of expedient delivery. Rapid delivery of the fetus is the definitive treatment in preeclampsia, eclampsia, and HELLP syndrome and is prioritized over blood pressure control (Answer B). 

New-onset generalized motor seizure in a patient with preeclampsia suggests eclampsia. Although the majority of cases of eclampsia occur ante- or intrapartum, eclampsia may also occur postpartum. Given the clinical presentation consistent with eclampsia, it is less likely that seizures in this patient are a manifestation of epilepsy (answer A). High dermatomal level of epidural anesthesia typically presents with upper extremity weakness, respiratory failure, and circulatory shock; seizures due to cerebral hypoxia in the setting of shock and hypoventilation are possible but less likely due to absence of other indications of high level of epidural anesthesia (answer D). Thrombocytopenia, not thrombocytosis, is a component of HELLP syndrome.

References:

1. Brewer J, Owens MY, Wallace K, et al. Posterior reversible encephalopathy syndrome in 46 of 47 patients with eclampsia. Am J Obstet Gynecol. 2013;208:468.e1-468.e6.
2.  Aagaard-Tillery KM, Belfort MA. Eclampsia: Morbidity, mortality, and management. Clin Obstet Gynecol. 2005;48:12-23.
3. McDermott M, Miller EC, Rundek T, et al. Preeclampsia: association with posterior reversible encephalopathy syndrome and stroke. Stroke. 2018;49:524-530.