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LETTERS TO EDITOR
Year : 2018  |  Volume : 17  |  Issue : 2  |  Page : 94-95  

Coexisting cerebral venous sinus thrombosis and posterior reversible encephalopathy syndrome in a preeclamptic female


1 Department of Radiology, Subharti Medical College, Meerut, Uttar Pradesh, India
2 Department of Medicine, Subharti Medical College, Meerut, Uttar Pradesh, India

Date of Web Publication13-Mar-2018

Correspondence Address:
Dr. Sonal Saran
Flat No 1, Ramdas Bhawan, R-Enclave, Subhartipuram, Subharti Medical College, Meerut - 250 005, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aam.aam_41_17

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How to cite this article:
Saran S, Bansal P, Singhal S, Malik A. Coexisting cerebral venous sinus thrombosis and posterior reversible encephalopathy syndrome in a preeclamptic female. Ann Afr Med 2018;17:94-5

How to cite this URL:
Saran S, Bansal P, Singhal S, Malik A. Coexisting cerebral venous sinus thrombosis and posterior reversible encephalopathy syndrome in a preeclamptic female. Ann Afr Med [serial online] 2018 [cited 2019 Oct 21];17:94-5. Available from: http://www.annalsafrmed.org/text.asp?2018/17/2/94/227178



Sir,

Posterior reversible encephalopathy (PRES) is clinical entity with characteristic radiological changes. It is clinically characterized by altered mental status, headache, seizers, and loss of vision. Radiological features include white matter vasogenic edema predominantly affecting posterior parietal and occipital lobes of the brain. Causes include sudden hypertensive episode, immunosuppression, and pregnancy.[1]

Cerebral venous sinus thrombosis (CVST), on the other hand, is predisposed by hypercoagulable disorders, pregnancy, postpartum period, long-term oral contraceptive use, malignancies, and infective causes. However, the disease is most commonly encountered during pregnancy.[2]

A 25-year-old woman, G1 P0, at 35 weeks and 3 days of pregnancy, presented with headache for 2-day duration. She had no history of the use of oral contraceptives. At presentation, her blood pressure and heart rate were 180/120 mmHg and 85 beats/min, respectively. She was hospitalized at our institute for the evaluation of severe preeclampsia. Ultrasonographic examination detected a growth restricted fetus corresponding to 30 weeks 0 day gestational age. Fetal heart rate monitoring showed the absence of fetal heart rate variability. Two doses of betamethasone 6 mg was administered intramuscularly for fetal lung maturation. Antihypertensive treatment with nifedipine 10 mg was started. Single live male baby was delivered by cesarean section. Her complete blood counts and renal and liver function tests were within normal limits.

Prophylactic intravenous MgSO4 (1 g/h) treatment was started due to prodromal symptoms of headache and visual disturbance and continued 24 h after delivery. On postoperative day 2, the patient was consulted with neurology clinic since patient's headache worsened and she had blurring of vision. On neurologic examination, papilledema was detected.

Magnetic resonance imaging (MRI) brain with venography was performed which were consistent with PRES and CVST [Figure 1].
Figure 1: (a-c) Axial T2-weighted magnetic resonance imaging sequence shows hyperintense signal changes at cortical-subcortical areas of bilateral posterior superior and parasagittal areas of parietal and occipital lobes which appear hypointense on T1-weighted sequence(e). (d) Apparent diffusion coefficient map shows no evidence of any restriction of diffusion compatible with vasogenic edema. (f) Magnetic resonance venogram shows poor visualization of the right transverse and sigmoid sinus suggestive of venous sinus thrombosis

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All laboratory tests to detect coagulation abnormalities were within normal range.

She was admitted to neurology intensive care unit. Anticoagulation with low-molecular-weight heparin (LMWH) was started, and the patient was discharged from hospital on postoperative day 6. LMWH was continued for 1 month. After treatment period, MRI brain with venogram was performed, which came out to be normal [Figure 2].
Figure 2: Follow-up magnetic resonance imaging brain with venography was performed 1 month later which shows (a) and (b) no obvious signal alteration in parietal and occipital lobes on T1- and T2-weighted images which suggest almost complete resolution of the abnormality. (c) Magnetic resonance venogram also shows recanalization of previously thrombosed right transverse and sigmoid sinuses

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CVST and PRES are two different diseases with almost similar clinical presentation but different treatment protocols. Both have pregnancy and preeclampsia as common predisposing factors. MRI brain with venogram should be performed to confirm the diagnosis.[3],[4]

It is important for both radiologist and treating physician to recognize the conditions and treat accordingly.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Hinchey J, Chaves C, Appignani B, Breen J, Pao L, Wang A, et al. Areversible posterior leukoencephalopathy syndrome. N Engl J Med 1996;334:494-500.  Back to cited text no. 1
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2.
Saadatnia M, Fatehi F, Basiri K, Mousavi SA, Mehr GK. Cerebral venous sinus thrombosis risk factors. Int J Stroke 2009;4:111-23.  Back to cited text no. 2
    
3.
Coutinho JM, Ferro JM, Canhão P, Barinagarrementeria F, Cantú C, Bousser MG, et al. Cerebral venous and sinus thrombosis in women. Stroke 2009;40:2356-61.  Back to cited text no. 3
    
4.
Fugate JE, Claassen DO, Cloft HJ, Kallmes DF, Kozak OS, Rabinstein AA, et al. Posterior reversible encephalopathy syndrome: Associated clinical and radiologic findings. Mayo Clin Proc 2010;85:427-32.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2]



 

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