Posterior leukoencephalopathy syndrome: Postpartum focal neurologic deficits: A report of three cases and review of the literature
A 45-year-old woman, G1 P0, at the 39th week of gestation, was admitted to the emergency department after a generalized seizure at home without prodromal symptoms. After seizure, she presented drowsiness. According to the patient's husband, the patient was presenting progressive and widespread edema in the prior weeks but she did not suffer any hypertensive episode or neurologic symptom. Cesarean section was indicated due to eclampsia 1 h from the admission. General anesthesia was performed with rapid intubation sequence using 100 mg of succinylcholine and 200 mg of propofol and 150 ug of fentanyl after the umbilical cord was clamped, without any complications. She maintained systolic blood pressure between 110 mmHg and 80 mmHg during anesthesia. An intravenous administration of magnesium sulfate first bolus of 4 gr followed by a infusion of 1 g/24 h was started. A live male infant with significant clinical deterioration was delivered. The newborn umbilical cord pH was 6.75 and he was transferred to the pediatric ICU for appropriate resuscitation. Emerge from anesthesia in the operating room was delayed for no apparent reason, and once the patient was awake, she was stirred and confused without apparent focal neurological deficit. The patient was admitted extubated to the PACU, conscious, with agitation, disorientation, incoherent speech, exaltation of the patellar reflexes and blurred vision. No neurological focal deficit at that time of clinical assessment was found. The patient presented obesity and foveal edema. The administration of magnesium sulfate was continued and an intravenous infusion of labetalol was added. Despite this treatment, her blood pressure remained high. Dexamethasone 4 mg was added to the treatment. The laboratory test at admission was altered with creatinine 2.12 mg/dL, potassium 5.1 mEq/L, magnesium 5.88 mg/dL and sodium 130 mEq/L, pH 7.26 and HCO3 13 mEq/L, elevated LDH and 3 + proteinuria.\nSix hours after surgery, a cranial CT, brain MRI, electroencephalogram and angioresonance were performed. The cranial CT scan was normal. The brain MRI showed subcortical hyperintense lesions, on T2-weighted sequences, with different characteristics []. The electroencephalogram showed signs of brain involvement lateralized in the right hemisphere and the angioresonance was normal. In the PACU, her blood pressure remained high. Creatinine values increased to 3.2 mg/dL; however, these values normalized within 2 days and the creatinine clearance at discharge was 155 mL/min, with persistence of proteinuria 305 mg/mL and albumin 1.4 g/dL. Intravenous infusion of antihypertensive drugs was removed and she was treated orally with amlodipine 10 mg/day, labetalol 200 mg tid, irbesartan 300 mg/day and enalapril 10 mg bid. Because of persistent high blood pressure and renal impairment, a renal Doppler ultrasound was also performed, which showed good bilateral arterial and venous supply. The resistance indices and acceleration, as well as the morphology of the wave, were normal. Due to the patient's improvement, she was transferred to the gynecology ward. The patient was discharged without any neurological deficits.