Posterior Reversible Encephalopathy Syndrome After a Cesarean Delivery

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.Figure 1.: MRI on the fifth day after ICU admission.Figure 2.: MRI control on the 14th day after ICU admission.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. Xavier Onrubia, MD Aitana Lluch-Oltra, MD Rocío Armero, PhD Raquel Higueras, MD Cristina Sifre, PhD Manuel Barberá, PhD Department of Anesthesia and Critical Care Hospital Universitari Dr. Peset València, Spain [email protected]