A Vital Role of Magnetic Resonance Imaging in Pregnancy-Related Neurological Complications

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1 Originl Article Print ISSN: Online ISSN: X DOI: /ijss/2017/125 A Vitl Role of Mgnetic Resonnce Imging in Pregnncy-Relted Neurologicl Complictions Prveen Kumr Mgudeeswrn 1, Aucker Sulimn Frook 2, Preethi Gnesn 1, Vsudve Ntrj 1, Annd Rjmni 3 1 PostGrdute, Deprtment of Rdiology nd Imging Sciences, Chettind Hospitl nd Reserch Institute, Kelmkkm, Knchipurm, Tmil Ndu, Indi, 2 Professor, Deprtment of Rdiology nd Imging Sciences, Chettind Hospitl nd Reserch Institute, Kelmkkm, Knchipurm, Tmil Ndu, Indi, 3 Assistnt Professor, Deprtment of Rdiology nd Imging Sciences, Chettind Hospitl nd Reserch Institute, Kelmkkm, Knchipurm, Tmil Ndu, Indi Astrct Introduction: Any neurologicl prolem occurring during pregnncy hs serious complictions for oth mother nd child. Hedche remins the most common symptom of intrcrnil disese, encountered y most of the women during pregnncy nd puerperium. Aim: To evlute nd chrcterize the vrious neurologicl conditions of the centrl nervous system nd pituitry glnd tht occurs during pregnncy nd postprtum period with the help of 1.5 tesl mgnetic resonnce imging (MRI). Plce nd Durtion of Study: The study ws conducted in the Deprtment of Rdiology, Chettind Hospitl nd Reserch Institute, Chenni from My 2014 to My Mterils nd Methods: A retrospective nlysis of ll pregnnt nd postprtum ptients presenting with neurologicl mnifesttions of the centrl nervous system nd pituitry glnd were included in this study. Ptients imged in GE sign1.5hdxt MRI. The imges otined were sujected for rdiologicl interprettion. Results: The cses included cererl venous thromosis (CVT), posterior reversile encephlopthy syndrome (PRES), eclmptic encephlopthy, ischemic stroke, nd less common entities like pituitry poplexy. Conclusion: MRI plys very crucil role in erly dignosis of neurologicl nd pituitry-ssocited complictions in pregnncy nd postprtum period. The most common neurologicl complictions which cuse incresed mternl mortlity re eclmptic encephlopthy nd CVT. Hence, erly imging cn help in erly nd pproprite mngement of serious pregnncy-relted neurologicl complictions. Key words: Mgnetic resonnce imging, Mternl helth, Mternl mortlity, Neurologicl disorder, Pregnncy disorder, Puerperium INTRODUCTION Adequte mternl cre in the ntentl period nd lso fter delivery cn resolve mny pregnncy relted complictions nd fetl prolems. 1 During this time, physiologicl nd physicl chnges tke plce in the womn, Access this rticle online Month of Sumission : Month of Peer Review : Month of Acceptnce : Month of Pulishing : to prepre her ody for delivery. These chnges include cogultion, hemodynmic, nd hormonl chnges s well s chnges in mechnicl pressure due to n enlrged uterus. Usully, these chnges re not pthologic, ut sometimes it leds to vrious dverse effects. A series of neurologicl disorders my e encountered during pregnncy nd puerperium. 2 Hedche remins the most common symptom encountered due to intrcrnil disese during the course of pregnncy nd the puerperium. 3 Thus, the development of cute hedche should e tken seriously. Epilepsy, migrine nd stroke re the most common neurologicl diseses which complicte pregnncy. Other nonspecific ut occur more often in pregnnt women (e.g.: Cererl infrction, durl venous Corresponding Author: Dr. Aucker Sulimn Frook, Professor, Deprtment of Rdiology nd Imging Sciences, Chettind Hospitl nd Reserch Institute, Kelmkkm, Knchipurm , Tmil Ndu, Indi. Phone: E-mil: fsulimn@hotmil.com Interntionl Journl of Scientific Study Mrch 2017 Vol 4 Issue

2 thromosis, nd pituitry poplexy). Series symptoms of cererl venous thromosis (CVT) usully ppered in the first 3 weeks fter delivery, women who hd home deliveries nd poor prentl cre were more often ffected. 4 Even when imging chnges re nonspecific, knowledge of those entities ssocited with pregnncy nd wreness of the incresed likelihood of certin diseses in pregnncy will llow more informed differentil dignosis. Mgnetic resonnce imging (MRI) hs proved to e oon in the erly nd ccurte dignosis of pregnncy-relted neurologic complictions. By knowing the prevlence nd spectrum of neurologic complictions in pregnncy, pproprite tretment cn e initited in erly, thus improving mternl nd fetl outcomes. 5 MATERIALS AND METHODS The study ws hospitl sed cross-sectionl study, conducted in the Deprtment of Rdiology, Chettind Hospitl nd Reserch Institute, Chenni from My 2014 to My Cliniclly suspected cses of neurologicl disorders of the centrl nervous system nd pituitry glnd ssocited with pregnncy, who were referred to the Deprtment for Rdiologicl evlution nd who hd positive imging findings were tken up for the study. Most common presenting symptoms were hedche, vomiting, seizures, ltered sensorium, neurologicl deficits, visul disturnces, nd symptoms of pituitry hypofunction. MR sequences long with time of flight (TOF), mgnetic resonnce ngiogrphy (MRA), nd mgnetic resonnce venogrphy (MRV) were done. Smple Selection Inclusion criteri Neurologicl mnifesttions of the centrl nervous system nd pituitry glnd re precipitted ecuse of the pregnncy nd postprtum stte were included. Ptients of second, third trimester nd postprtum were included ecuse most of the disorders occur in this period. Exclusion criteri Clustrophoic ptients. Neurologicl disorders not directly relted to pregnncy were excluded from the study. Ptients presenting in the first trimester were not included. Consent All uthors declre tht written informed consent ws otined from the ptient (or other pproved prties) for puliction of this cse report nd ccompnying imges. RESULTS A totl numer of deliveries in the hospitl during the study period ws A totl numer of ntentl nd puerperl ptients who presented with neurologicl symptoms during tht period ws 150. The cses included eclmptic encephlopthy, CVT, posterior reversile encephlopthy syndrome (PRES), ischemic stroke, surchnoid hemorrhge (SAH), pituitry poplexy, nd pituitry denom (Tle 1). DISCUSSION In oth pregnncy nd puerperium, numer of pthologic mnifesttions involves the centrl nervous system nd pituitry glnd. The most common presenting complint of ptients in oth pregnncy nd periprtum phse is hedche. History of seizures for the first time in periprtum period cuses iggest dignostic muss. Periprtum seizures contriute significnt prolems to oth mternl moridity nd mortlity including their unorn children. 6 The incidence of eclmpsi hs een drmticlly incresing in the worldwide nd reported s 2 in 100 to 18 in 1700 pregnncies. Usully, eclmpsi my result in PRES. Some neurologic conditions re relted to the physiologic modifictions in pregnncy, such s: Eclmpsi Reversile cererl vsoconstriction syndrome Sheehn syndrome. Some of the cererovsculr diseses occur more frequently in pregnncy nd postprtum women, prticulrly: Cererl infrction Durl venous thromosis Pituitry poplexy. Neoplstic Disorders Primry intrcrnil tumors Intrcrnil metstsis. Few of these conditions my remin sutle nd go unnoticed during the pregnncy nd postprtum. MRI plys Tle 1: Pregnncy ptients ffected with Neurologicl complictions Dignosis Numer of cses (%) Eclmptic encephlopthy 21 (33.33) Cererl venous thromosis 15 (23.80) PRES 11 (17.45) Ischemic stroke 8 (12.70) Surchnoid hemorrhge 4 (6.34) Pituitry poplexy 3 (4.79) Pituitry denom 1 (1.59) PRES: Posterior reversile encephlopthy syndrome 193 Interntionl Journl of Scientific Study Mrch 2017 Vol 4 Issue 12

3 n importnt role in recognition nd chrcteriztion of these lesions nd helps in future mngement. Additionl dignostic merit of MRI cn e performed with the help of MRV with contrst or without contrst using time of flight sequences. 8 MRI is the preferred imging option in pregnncy. There is no documenttion of hzrdous fetl effects in humns due to the mgnetic field exposure. Ischemic stroke The most importnt leding cuse of mternl mortlity is stroke. It usully mimic other complictions such s eclmpsi, so it should e tken into serious considertion whenever neurologicl deteriortion is oserved. In pregnnt women, the incidence of ischemic stroke is grdully incresed y 3 times when compred to nonpregnnt women. 1 The risk of stroke in most of the ptients is reported in 2 dys efore delivery nd 1 dy fter delivery. The most commonly reported etiology is crdio emolism. Other risk fctors include lupus, lood trnsfusion, nd migrine. Mjor enefits of MRI re cquired through diffusion-weighted imging (DWI), with the use of this sequence rdition exposure is eliminted. The risk of ischemic stroke increses with ge, prticulrly fter ge 35 yers. Blck women re t higher risk. The risk of oth ischemic infrction, which ccounts for 60% of ll strokes. There re two types of infrcts: Thromotic infrcts Emolic infrcts. Thromotic infrcts Results from hypercogulle sttes nd thromosis on top of existing therosclerotic plques. Fctors leding to hypercogulility of lood include low levels of inhiitors of the cogulnt protein S; elevted levels of inhiitors of protein C; incresed levels of firinogen, fctor VII, fctor VIII, nd fctor X; nd n enhnced ility to neutrlize heprin. 2 Infrctions typiclly occur in the mjor rteril distriutions. Emoli infrcts Results from dissections due to prolonged difficult lor, crdic vlvulr disese, nd the rre dilted periprtum crdiomyopthy. 5 Wtershed infrcts cn result from dissections nd significnt ostetric hemorrhge. Frontl nd prietl regions were the most common site of infrcts (Figures 1 nd 2). Eclmptic encephlopthy The most serious compliction tht occurs in pregnncies is eclmpsi, nd it ccounts for out 10% of the deths relted to pregnncy. 9 Cliniclly, eclmpsi is defined s seizure or com ssocited with pregnncy-induced hypertension, nd more thn 30% of cses re dignosed postprtum. Antentl women present with tonic clonic Figure 1: Mgnetic resonnce imging scn of womn presenting motor wekness in the right rm nd leg t 26 gesttionl weeks on diffusion-weighted imges shows left thlmic infrction (rrow) Figure 2: Complete (irreversile) cererl infrctions in 24-yer-old womn who developed corticl lindness fter difficult lor. () Axil diffusion-weighted mgnetic resonnce imging (MRI) shows restricted diffusion in oth occipitl loes, primrily in the rteril wtershed zones. () Axil fluid-ttenuted inversion recovery MRI shows corresponding edem nd mss effect seizures or com who hve developed pregnncy-induced hypertension. The exct dignosis is mde y the presence of hypertension, proteinuri, nd edem long with seizures occurring fter 20 weeks of pregnncy. 9 Aout 70% of ptients were dignosed in nteprtum, nd more thn 90% mde fter 27 weeks of gesttionl ge. More then 50-75% of ptients presents with occipitl or frontl hedches tht usully precede the ttck of seizures, nd 20-30% hve visul lurring or corticl lindness. 10 The most commonly involved rin regions in eclmptic encephlopthy re prieto-occipitl, frontl, temporl, nd sometimes even cereellr hemispheres. In typicl cses even sl gngli, thlmus nd rinstem re involved. The exct mechnism remins unknown. It is likely to e multifctoril, nd it cuses cytotoxic effects on the vsculr endothelium Interntionl Journl of Scientific Study Mrch 2017 Vol 4 Issue

4 leding to incresed permeility nd vsogenic edem. Cererl uto regultion impirment eventully leds to disruption of the lood-rin rrier in the posterior circultion. The predilection for the posterior circultion nd wtershed zones is elieved to e relted to its sprse vsomotor sympthetic innervtion. The most importnt compliction ssocited with eclmpsi is PRES. 11 Lesions typiclly show no diffusion restriction. DWI is prticulrly useful in distinguishing the reversile vsogenic edem from the cytotoxic edem of complete infrction. Ctheter ngiogrphy typiclly shows vsospsm in the medium nd lrge cererl rteries, prticulrly of the silr rtery. Tretment of eclmpsi is supportive, with controlling of seizures nd hypertension, s well s mintining stle hemodynmic stte. Mgnesium sulfte is the drug of choice to prevent recurrent convulsions in eclmpsi. PRES Eclmpsi is one of the most importnt cuses of PRES. 11 This condition is likely induced y endothelil dysfunction leding to incresed permeility. Clinicl fetures re hedche, ltered consciousness, visul normlities, nd seizures in conjunction with the neuroimging findings of vsogenic edem, typiclly involving the posterior circultion. Four mjor types of rdiologicl presenttion of PRES re holohemispheric wtershed pttern, superior frontl sulcus involvement pttern, predominnt prietooccipitl involvement, nd symmetric presenttion of primry pttern. 11 A typicl MRI finding on T2-weighted imge nd fluid-ttenuted inversion recovery (FLAIR) ssocited with PRES is hyperintensity of the prieto-occipitl cortices nd sucorticl white mtter, usully indicting vsogenic edem. Usully, the regions of clcrine nd prmedin occipitl loe structures re spred. It should e differentited from infrction in the ilterl posterior cererl rtery territory, where the clcrine, thlmic, nd midrin regions re usully ffected. The most importnt complictions of PRES re cererl ischemi, cererl hernition, nd cererl hemorrhge. Cliniclly, PRES resolves fter 3-8 dys. The most idel time to repet MRI in PRES ptients is 7-10 dys. In follow-up MRI, more frequent complete resolutions of edem were oserved (Figure 3). CVT CVT my occur nytime during the course of pregnncy nd the puerperium, ut the risk of developing of CVT is incresed twice during the first 2 weeks of the puerperium. 12 There is high risk of developing CVT in young mothers nd fter cesren section. Aout 6% of mternl deths is due to CVT. Hypercogulle stte provokes CVT during Figure 3: A 36-week pregnnt womn presented with history of eclmpsi. () Axil fluid-ttenuted inversion recovery (FLAIR) mgnetic resonnce imging (MRI) shows symmetric edem in the thlmi nd sl gngli. () Axil FLAIR MRI shows diffuse edem in the pons. Follow-up MRI otined 2 months lter ws norml posterior reversile encephlopthy syndrome pregnncy nd puerperium. The condition tht provokes hypercogulle sttes re clotting fctors, fctors II, VII, nd X re incresed during the pregnncy, the level of protein S is decresed, ut the level of protein C remins unchnged. 12 The hypercogulle stte, long with dehydrtion during lor nd puerperium, is responsile for thromotic complictions such s CVT in pregnncy. The most common symptom of CVT tht occurs in 95% of ptients is hedche. Other mnifesttions re focl seizures, presis, ppilledem, ltered consciousness, nd isolted intrcrnil hypertension. The ssocited risk fctors with pregnncy-relted cererl venous sinus thromosis re incresed mternl ge, hyperemesis, delivery y cesren section, mternl infection, nd mternl hypertension. The most commonly involved sinus in nonseptic ptients is superior sgittl sinus, nd in sepsis ptients most commonly involved sinus is cvernous nd lterl sinus thromosis. On MRI, usully, it shows the high signl intensity of the venous sinuses with ll routine sequences (usully on T1-weighted, T2-weighted, nd FLAIR). On contrst enhnced T1W, it usully shows high signl intensity with corresponding filling defect fter gdolinium enhncement my develop within the first week fter clinicl onset. Erly detection cn e done with MRI within 7 dys of clinicl onset. Other prenchyml signs of CVT include diffuse mss effect, loclized sulcl effcement, nd venous infrcts. Venous infrcts re often ssocited with hemorrhge t the gry-white mtter interfce. MRV helps us to understnd involvement of the mjor cererl veins triutries, durl venous sinuses, nd ntomic vrints 12 ctheter ngiogrphy hs more significnce in the tretment of CVT rther thn dignostic purpose (Figures 4 nd 5) Interntionl Journl of Scientific Study Mrch 2017 Vol 4 Issue 12

5 SAH The occurrence of SAH during pregnncy is drmticlly incresed, 85% of SAHs occur in the second or third trimester. The risk of developing SAH is 5 times higher thn in non-pregnnt women. 1 Most commonly occurs in young primigrvids during the third trimester. Strining during the time of delivery usully increses the leeding during the puerperl period. 12 The most common cuse of SAH during pregnncy is rupture of n intrcrnil neurysm. Other cuses include pregnncy-induced hypertension, filure of cererl utoregultion with propgtion of the incresed rteril pressure wves to the reltively thin-wlled pil veins, ruptured erry neurysm, rteriovenous mlformtion, nticogulnt toxicity, leeding disorders, nd cocine use. Tretment of ruptured neurysms is sme s in the cse of non-pregnnt women. Unruptured neurysms should e left s such, they should e treted only if they re symptomtic or enlrging. Ptients undergoing endovsculr tretment for ruptured neurysms in the first trimester should e dvised to terminte the pregnncy ecuse of high risk to fetus. Figure 4: Thromosis of the superior sgittl sinus nd venous infrction in 25-yer-old womn who ws 34 weeks pregnnt nd developed hedches nd lurring of vision. Sgittl T1-weighted, xil T2-weighted mgnetic resonnce imges show high signl intensity in the superior sgittl sinus (rrow) Figure 5: Axil fluid-ttenuted inversion recover mgnetic resonnce imging (MRI) show high signl intensity in the superior sgittl sinus (rrow). Axil gdolinium-enhnced T1-weighted MRI shows filling defect (empty delt sign) (rrow) in the superior sgittl sinus. On three-dimensionl time of flight MR venogrm, the superior sgittl sinus is not visulized ecuse of extensive thromosis During second nd third trimester successful endovsculr coil tretment of ruptured neurysms hs een reported. An erly nd precise dignosis is criticl, nd it is highly recommended to perform MRI on these ptients. In few cses, FLAIR is useful in the detection of SAH. MRA plys very crucil role in identifying the cuses of hemorrhge, e.g., neurysm, moymoy disese, or rteriovenous mlformtion, without the use of contrst mteril. Pituitry disorders The rising levels of estrogen during pregnncy results in enlrgement of the denohypophysis. This is compensted y the rising levels of prolctin in the circultion. Prolctin levels my rech 35 ng/ml during the first trimester, 175 ng/ml during the second trimester, nd up to 210 ng/ml during the third trimester. 13 There is chnce of pituitry hemorrhge, infrction, nd ccelerted prolctinom growth during the course of pregnncy nd the puerperium. Pituitry poplexy Pituitry poplexy is n cute syndrome. It is usully chrcterized y cute hemorrhgic infrction in n existing pituitry denom or physiologiclly enlrging pituitry glnd. The ptients my present with severe hedche, vomiting, nd visul disturnces including visul field defects nd restricted eye movements. Incidence of pituitry poplexy increses during pregnncy, nd postprtum period, due to incresed pituitry stimultion from plcentl estrogens, the enlrgement of the denohypophysis, rpid growth of tumors, nd my lso result from ischemi. On MRI, the pituitry glnd is enlrged with vrile T1 nd T2 signl intensities, depending on the ge of the hemorrhge. On DWI, n poplexy secondry to infrction my lso e detected erlier. All ptients with poplexy do not show intrsellr hemorrhge. Tretment of pituitry poplexy is supportive, usully hormonl replcement is done. Trnssphenoidl surgery lthough sfe is rrely needed (Figure 6). Neoplstic disorders During pregnncy, there will e chnge in the hormonl level which usully enhnces the rte of growth of prolctinoms. Usully, symptoms of these tumors re msked y other existing pthologic processes such s migrine or pre-eclmpsi. During pregnncy, there is grdul increse in the size of the tumor. The most common symptoms of primry rin tumors re hedche, vomiting, visul symptoms, focl neurologic deficits, nd seizures. MRI plys very crucil role in dignosis. Usully, MRI is preferred ecuse of proper tissue resolution nd the use of mgnetic field is sfe nd does not ffect the fetus. 14 The contrst mteril used for MRI in pregnncy is gdolinium, nd it is sfe in pregnncy. Interntionl Journl of Scientific Study Mrch 2017 Vol 4 Issue

6 Pituitry denom Prolctinoms re the most common pituitry tumors occurring during pregnncy. The elevted level of prolctin is recognized during pregnncy. During pregnncy evlution of pituitry mss poses n interesting chllenge, ecuse of continuously rising level of prolctin. In the presence of prolctinom, prolctin levels my vry. Hence, periodic mesurements of prolctin give us little clue in dignosis. Evlution of pituitry tumor is further hindered y dministrtion of gdolinium during pregnncy. The optic chism nd optic nerves symptomticlly compressed y pituitry mcrodenom. 12 Cliniclly pituitry denom is defined s the height of the pituitry glnd exceeds y 12 mm. If imging ecomes necessry, high-resolution MRI sequences without contrst mteril cn e performed. Medictions such s romocriptine dopmine gonist re considered the tretment of choice for prolctin-secreting microdenom nd denoms confined to the sell nd it cn decrese the size of the tumor y up to 50% in pregnncy. Trnssphenoidl resection is considered in pregnnt ptients in whom the tumor continues to grow, cusing worsening visul symptoms. Adrenocorticotropic hormone secreting denoms should lwys e surgiclly removed. In growth hormone secreting denoms nd nonfunctioning denoms surgery nd mediction re not indicted. In thyroid-stimulting hormone secreting tumors should receive only ntithyroid medictions to control hyperthyroidism (Figure 7). 13 CONCLUSION Pregnncy is nturl phenomenon, vrious centrl nervous system, nd pituitry disorders cn occur during the course of pregnncy nd postprtum period. Good prentl cre, sfety of drugs, nd use of proper dignostic modlities during pregnncy cn prevent mny of these neurologic complictions. 13 Accurte dignosis is crucil, in cute neurologic disorders nd pituitry disorders during pregnncy nd postprtum period ecuse pproprite nd timely tretment cn reverse the disese process nd it plys crucil role in reducing the risk of cute complictions nd long-term sequele. These disorders when filure to dignose t the erliest cn led to life-thretening complictions, such s ischemi, mssive infrction, nd deth. Common complictions to occur in this period re eclmptic encephlopthy, followed y CVT, PRES, nd ischemic stroke. Superior sgittl nd sigmoid sinuses re more frequently involved in CVT. The most common pttern of PRES is prieto-occipitl. Use of pproprite imging modlity potentilly helps to dignose serious neurologicl illnesses erly thus helping the ostetricin to institute pproprite tretment strtegies. MRI plys very importnt role in depicting these disorders nd Figure 6: Mgnetic resonnce imging scn of pituitry hemorrhgic poplexy in womn presenting prolctinom t 34 gesttionl weeks. The ptient lso presented symptoms of hedche nd vomiting. An enlrged pituitry glnd ws oserved with focl hemorrhge, high signl intensity on sgittl T1-weighted imge (: Arrow), nd low signl intensity on sgittl T2-weighted imge (: Arrow) complictions rise due to these disorders t erliest. 14 The rdiologist my e the first person to propose the correct dignosis on the sis of the imging findings. Therefore, it is importnt tht rdiologists working in the emergency deprtment setting e fmilir with these entities to minimize the time to dignosis. REFERENCES Figure 7: Prolctinom in 27-yer-old womn who ws 32 weeks pregnnt nd presented with hedches, visul disturnces, nd prolctin level of 290 ng/ml. Unenhnced coronl () nd sgittl () T1-weighted mgnetic resonnce imging show lrge sellr nd suprsellr tumor tht cuses mild compression of the optic chism (rrow) 1. Welch KM. Migrine nd pregnncy. Adv Neurol 1994;64: Comeglio P, Fedi S, Liott AA, Celli AP, Chirntini E, Prisco D, et l. Blood clotting ctivtion during norml pregnncy. Throm Res 1996;84: Jmes AH, Bushnell CD, Jmison MG, Myers ER. Incidence nd risk fctors for stroke in pregnncy nd the puerperium. Ostet Gynecol 2005;106: Gupt S, Rohtgi A, Shrm SK, Gurtoo A. A study of neurologicl disorders during pregnncy nd puerperium. Ann Indin Acd Neurol 2006;9: Zk IT, Duli HS, Kish KK. Imging of neurologic disorders ssocited with pregnncy nd the postprtum period. Rdiogrphics 2007;27: Munnur U, Krnd DR, Bndi VD, Lpsi V, Suresh MS, Rmshesh P, et l. 197 Interntionl Journl of Scientific Study Mrch 2017 Vol 4 Issue 12

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