Neurochirurgie 60 (2014) 48–50
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Clinical case
Chronic subdural haematoma associated with pre-eclampsia: Case report and review of the literature Hématome sous-dural chronique associé à la pré-éclampsie : cas clinique et revue de la littérature B.O. Djoubairou ∗ , J. Onen , A.K. Doleagbenou , N. El Fatemi , M.R. Maaqili Department of Neurosurgery, hôpital Ibn Sina, Mohammed V University–Souissi, Rabat-Sale, Morocco
a r t i c l e
i n f o
Article history: Received 5 October 2013 Received in revised form 8 November 2013 Accepted 20 November 2013 Available online 26 February 2014 Keywords: Pre-eclampsia Subdural haematoma
a b s t r a c t Pre-eclampsia complicates approximately 5–8% of all pregnancies and may have adverse long-term effects on both mother and child. Chronic atraumatic subdural haematoma as a complication of severe pre-eclampsia, in the absence of clotting factor abnormalities, is a very rare condition. We present the case of a 30-year-old Moroccan woman who had a pregnancy 10 years previously, with an uneventful delivery. She presented with pre-eclampsia complicating a 29-week-old pregnancy. A few days preceding maternity unit admission the patient complained of headaches and malaise. Her blood pressure at admission was 150/120 mmHg and subsequently was treated with doses of methyldopa and magnesium sulphate. Her condition worsened with a loss of consciousness 24 hours later and was transferred to the neurosurgical unit. A brain computerized tomography (CT) scan revealed a left-sided subdural haematoma and the patient underwent surgery, with a good postoperative outcome. This article highlights the occurrence of neurological complications due to pre-eclampsia/eclampsia that require particular neurosurgical attention, its treatment and prognosis. We also review the literature regarding this pathology. © 2014 Elsevier Masson SAS. All rights reserved.
r é s u m é Mots clés : Pré-éclampsie Hématome sous-dural
La pré-éclampsie complique 5–8 % de toutes les grossesses et aggrave le pronostic maternofœtal. L’hématome sous-dural chronique est une complication rare de la pré-éclampsie surtout en l’absence de trouble de la coagulation sanguine. Nous rapportons ici le cas d’une patiente de 30 ans, arabe, dont la première grossesse remonte à 10 ans avec accouchement par voie basse qui présente une pré-éclampsie sévère à 29 semaines d’aménorrhées, elle est admise avec une tension artérielle (TA) = 150/120 mmHg rebelle à la bithérapie (méthyldopa, sulfate de magnésium) à dose adéquate. Vingt-quatre heures après son hospitalisation elle se plaint de céphalées se compliquant d’un trouble de la conscience, ce qui motive la réalisation d’un scanner cérébral ayant objectivé un hématome sous-dural chronique hémisphérique gauche nécessitant un transfert en neurochirurgie où elle fut opérée avec une bonne évolution postopératoire. Cet article rapporte une complication neurologique rare de la pré-éclampsie, le traitement et pronostic ainsi qu’une revue de la littérature des hématomes sous-duraux associés à la pré-éclampsie. © 2014 Elsevier Masson SAS. Tous droits réservés.
1. Introduction Pregnancy is a transient condition, but when it is complicated by pre-eclampsia it has lasting effects on both mother and child. Pre-eclampsia complicates 5–8% of pregnancies. It is responsible for considerable morbidity and mortality. Deaths are due to
∗ Corresponding author. E-mail address: [email protected] (B.O. Djoubairou). 0028-3770/$ – see front matter © 2014 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.neuchi.2013.11.002
intracranial haemorrhage and cerebral infarction, acute pulmonary oedema, respiratory failure and liver failure or rupture. Intracranial haemorrhage in pregnancy is uncommon and a life-threatening complication which contributes significantly to maternal mortality. The aetiology of intracranial haemorrhage in pregnancy includes rupture of a cerebral aneurysm, arteriovenous malformation and pregnancy-related hypertension. The intracranial haemorrhage associated with pre-eclampsia is typically intraparenchymal [4]. The present article describes an uncommon case of atraumatic chronic subdural haematoma as a complication of severe
B.O. Djoubairou et al. / Neurochirurgie 60 (2014) 48–50
Fig. 1. Preoperative brain computerized tomography (CT) scan showing the left hemispheric chronic subdural haematoma with evidence of rebleeding. Scanner cérébral préopératoire objectivant un hématome sous-dural chronique hémisphérique gauche avec des signes de ressaignements.
pre-eclampsia, its treatment, outcome and a systematic review of the literature of brain complications in pre-eclampsia. 2. Case report We present the case of a 30-year-old Moroccan woman, second gravida, one para (G2P1), with no prior history of hypertension. Her first pregnancy occurred 10 years previously and the patient had a normal at term vaginal delivery. There was no prior medical history of head trauma or prolonged intake of non-steroidal anti-inflammatory drugs. The patient was admitted to the maternity unit of Mohammed V Souissi–Rabat University Hospital for pre-eclampsia complicating a 29-week-old pregnancy, with a neurological condition suggested by a brief history of headaches and malaise. She was initially admitted to the maternity unit with a blood pressure (BP) of 150/120 mmHg, pulse rate 94/min, respiratory rate 18 breaths/min, uterine height = 28 cm, no uterine contractions, with the presence of fetal heart sounds. Laboratory tests results: AST = 22 IU/l, ALT = 24 UI/l, total bilirubin = 3 mg/l, direct bilirubin = 1 mg/l, free bilirubin = 2 mg/l, K = 4 meq/l, glycaemia = 0.5 g/l, proteinNa = 140 meq/l, uria = 4 + fetal ultrasound estimated fetal weight at 725 g, with an adequate amount of amniotic fluid. She was then immediately put on methyldopa and magnesium sulphate with adequate doses. However, 24 hours later, her condition worsened (loss of consciousness), and she was transferred to the neurosurgical unit for further evaluation and treatment. Clinical examination on admission to the neurosurgical unit revealed a Glasgow Coma Scale (GCS) of 12, equal pupil size with both pupils reactive to light, no neck rigidity or neurological motor deficits, although a bilateral pedal oedema was observed. A computerized tomography (CT) scan showed a left cerebral convexity chronic subdural haematoma with signs of rebleeding and a midline shift of the brain (Fig. 1). The complementary laboratory tests, haemoglobin = 15 g/dl, platelets = 166,000, PT = 100%, ACT = 30, fibrinogen = 4.5, were all normal. The patient was immediately admitted to the operating room under general anaesthesia and the haematoma was drained through two burr holes and a siphonage drain which was left in-dwelling for 24 hours. Perioperatively, no problem with haemostasis was encountered. Twenty-four hours after surgery the patient’s level of consciousness gradually improved. CT scan one week after surgery showed reversal of midline shift (Fig. 2), while the CT angiogram was normal. Three days following surgery, the patient returned to the maternity unit with a GCS of 15 with no motor deficits and a
49
Fig. 2. Postoperative brain computerized tomography (CT) scan showing the reestablishment of near normal anatomy, with reversal of the midline shift. Scanner cérébral postopératoire objectivant un rétablissement de l’anatomie normale, avec les structures de la ligne médiane en place.
blood pressure of 130/90, with protein +1 in the urine. Continued monitoring of this patient was carried-out to optimize long-term outcome. Two weeks after the neurosurgical procedure, fetal cardiac monitoring suggested fetal distress and an emergency caesarean section was performed, unfortunately the newborn died 24 hours later, due to respiratory distress. The patient remains clinically well and follow-up is ongoing. 3. Discussion The American College of Obstetricians and Gynecologists defines pre-eclampsia as hypertension with a systolic blood pressure of 140 mmHg or higher or a diastolic blood pressure level of 90 mmHg or higher that occurs after 20 weeks of gestation in a woman with previously normal blood pressure. The hypertension must have associated proteinuria, defined as urinary excretion of 0.3 g of protein or higher in a 24-hour urine collection [7]. Pre-eclampsia and eclampsia, physiological changes peculiar to pregnancy, are major causes of intracerebral haemorrhage during pregnancy and in the puerperium [1,13]. As a specific form of pre-eclampsia, HELLP syndrome, coined by Weinstein based on the combination of haemolysis (H), elevated liver enzymes (EL), and low platelet count (LP). The syndrome tends to develop during antepartum, particularly during the third trimester, after 27 weeks of gestation [14]. Cases of spontaneous peripartum subdural haematoma and intracerebral haemorrhage have been reported in the literature, but in association with the HELLP syndrome, thrombotic microangiopathy or thrombocytopenia [3,11,12,17,19]. An intracranial haemorrhage associated with HELLP syndrome tends to occur during the antepartum period, although it may also appear after delivery [12,17,19]. Haemorrhage has been reported in the brainstem, basal ganglia, and subcortical parenchyma with or without intraventricular extension [5,6], and patients with an intracranial haemorrhage often have a poor outcome [12,17,19]. However, non-specific symptoms often lead to a delayed diagnosis until a severe disturbance of consciousness occurs following an intracranial haemorrhage. An unknown traumatic event in this patient is unlikely to have occurred because she had no evidence of trauma on physical examination. It is not uncommon for subdural haematomas to be chronic with subtle neurological findings. Since the neurological signs and symptoms evolved rapidly over several hours in our patient, it is unlikely that head trauma prior to admission contributed to development of the haematoma. Brain injury has been clearly linked to haemostatic abnormalities which may affect multiple organs. The frequency of haemostatic aberrations associated with brain injury is directly related to the severity of the neurological deficits [10].
50
B.O. Djoubairou et al. / Neurochirurgie 60 (2014) 48–50
Table 1 Review of the literature of published cases of subdural haematoma with pre-eclampsia. Revue de la littérature publiée sur les hématomes sous-duraux associés à la pré-éclampsie. Author
Year
Age
BP
Giannina et al. [3]
1997
19
150/100
Hashiguchi et al. [5]
2001
37
160/100
Yokota et al. [17]
2009
32
172/108
Pandey et al. [11]
2010
25
Normal
Sâmia et al. [12]
2013
36
HT crisis
Our case
2013
30
150/120
Gestation
G1P0 32 weeks G1P0 37 weeks G1P0 41 weeks G2P1 Full-term G2P0 35 weeks G2P1 29 weeks
Clinical signs
HELLP Syndr
Thrombo
CT scan
Prognosis M
F
Agitation Anisocoria Unconscious
Yes
No
ASH
D
A
Yes
No
ICH
A
A
Anisocoria
Yes
No
A
A
Unconscious
No
Yes
ASH ICH ASH
A
A
Anisocoria Sedated Unconscious
Yes
Yes
D
D
No
No
A
D
ASH ICH CSH
BP: blood pressure; HELLP syndr: HELLP syndrome; thrombo: thrombocytopenia; M: maternal; F: fetal; D: death; A: alive; ASH: acute subdural haematoma; CSH: chronic subdural haematoma; ICH: intraparenchymal haematoma. BP : tension artérielle ; HELLP syndr : syndrome de HELLP ; thrombo : thrombocytopénie ; M : maternel ; F : fœtal ; D : décès ; A : vivant ; ASH : hématome sous-dural aigu ; CSH : hématome sous-dural chronique ; ICH : hématome intraparenchymateux.
The coagulation studies were normal in this patient (i.e., prothrombin time, partial prothrombin time, and fibrinogen). Hypertension acts as an independent cause of stroke because the loss of the self-regulatory mechanisms of blood flow of the brain leads to vasodilation and brain oedema, particularly in the case of individuals without chronic hypertension. Brain ischaemia and haemorrhage are, in most cases, accompanied by a blood pressure increase of at least 10% due to an alteration of the self-regulatory mechanisms induced by a vasoactive substance release at the injury site [15]. Pre-eclampsia predisposes the patient to eclamptic seizures and cerebral haemorrhage with major cerebral damage. The pathology behind eclamptic seizures and cerebral oedema is incompletely understood with two prevailing hypotheses. One consists of cerebral vasospasm leading to cerebral ischaemia, cytotoxic oedema and infarction, the other attributes cerebral oedema to loss of cerebral auto-regulation with consequent hyperperfusion. MRI studies support the view that most cerebral oedemas are due to hyperperfusion [2,18]. Uncontrolled cerebral perfusion pressure may lead to cerebral barotrauma and vessel damage with perfusion injury. The most recent report on enquiries into maternal death from the United Kingdom showed that the majority of women with pre-eclampsia died from intracranial haemorrhage [8]. Although cerebral haemorrhage was previously linked to diastolic blood pressures above 110 mmHg, it is now recognized that systolic hypertension may be a better predictor [9]. It is, therefore, recommended that systolic blood pressures above 160 mmHg must be treated [16]. The main causes of subdural haematoma with preeclampsia reported in the literature are presented in the Table 1. In our clinical case hypertension (BP = 150/120 mmHg) is the most plausible explanation for the spontaneous subdural haematoma in this patient. 4. Conclusion Early stage diagnosis of cerebral disorders due to pre-eclampsia improves maternal prognosis. An excellent working relationship amongst obstetricians, anaesthesiologists, neurologists, neurointensivists, and neurosurgeons is essential to ensure prompt and appropriate management. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Bateman B, Schumacher H, Bushnell C, Pile-Spellman J, Simpson L, Sacco R, Berman M. Intracerebral hemorrhage in pregnancy: frequency, risk factors, and outcome. Neurology 2006;67:424–9. [2] Belfort MA, Varner MW, Dizon-Townson DS. Cerebral perfusion pressure, and not cerebral blood flow, may be the critical determinant of intracranial injury in preeclampsia: a new hypothesis. Am J Obstet Gynecol 2002;187: 626–34. [3] Giannina G, Smith D, Belfort MA, Kenneth J, et al. Atraumatic subdural hematoma associated with pre-eclampsia. J Matern Fetal Med 1997;6: 93–5. [4] Gonik B, Giezentanner A, Daily WH, Allen SJ. Intracranial hemorrhage in pregnancy. In: Clark SL, Cotton DB, Hankins GDV, Phelan JP, editors. Critical care obstetrics. 2nd ed Boston: Blackwell Scientific Publications; 1991. p. 521–33. [5] Hashiguchi K, Inamura T, Irita K, Abe M, Noda E, Yanai S, Takahashi S, Fukui M. Late occurrence of diffuse cerebral swelling after intracerebral hemorrhage in a patient with the HELLP syndrome – Case report. Neurol Med Chir (Tokyo) 2001;41:144–8. [6] Knopp U, Kehler U, Rickmann H, Gliemroth J. Cerebral haemodynamic pathologies in HELLP syndrome. Clin Neurol Neurosurg 2003;105:256–61. [7] Leeman L, Fontaine P. Hypertensive disorders of pregnancy. Am Fam Physician 2008;78(1):93–100. [8] The Confidential Enquiry into Maternal and Child Health (CEMACH). In: Lewis G, editor. Saving mothers’ lives: reviewing maternal deaths to make motherhood safer – 2003–2005. The seventh report on confidential enquiries into maternal deaths in the United Kingdom. London: CEMACH; 2007. [9] Martin JN, Thigpen BD, Moore RC, et al. Stroke and severe preeclampsia and eclampsia: a paradigm shift focusing on systolic blood pressure. Obstet Gynecol 2005;105:246–54. [10] Miner ME. Delayed and recurrent intracranial hematomas and posttraumatic coagulopathies. In: Wilkins RH, Setti SR, editors. Neurosurgery. 2nd ed New York: McGraw-Hill; 1996. p. 2809–11. [11] Pandey MP, Namita S, et al. Subdural hematoma in pregnancy induced idiopathic thrombocytopenia: conservative management. Indian J Anaesth 2010;54(5):470–1. [12] Sâmia Y, Wottrich J, Uggeri D, et al. Spontaneous acute subdural hematoma and intracerebral hemorrhage in a patient with thrombotic microangiopathy during pregnancy. Rev Bras Ter Intensiva 2013;25(2):175–80. [13] Sharshar T, Lamy C, Mas JL, Stroke in Pregnancy Study Group. Incidence and causes of strokes associated with pregnancy and puerperium. A study in public hospitals of Île de France. Stroke 1995;26:930–6. [14] Sibai BM, Ramadan MK, Usta I, Salama M, et al. Maternal morbidity and mortality in 442 pregnancies with hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome). Am J Obstet Gynecol 1993;169:1000–6. [15] Watson KV, Moldow CF, Ogburn PL, et al. Magnesium sulfate: rationale for its use in preeclampsia. Proc Natl Acad Sci U S A 1986;83:1075–8. [16] Wiebke G. Preeclampsia and anaesthesia. Curr Opin Anaesthesiol 2009;22:347–51. [17] Yokota H, Miyamoto K, Yokoyama K, et al. Spontaneous acute subdural haematoma and intracerebral haemorrhage in patient with HELLP syndrome: case report. Acta Neurochir 2009;151:1689–92. [18] Zeeman GG, Fleckenstein JL, Twickler DM, Cunningham FG. Cerebral infarction in eclampsia. Am J Obstet Gynecol 2004;190:714–20. [19] Zeidman LA, Videnovic A, Bernstein LP, Pellar CA. Lethal pontine hemorrhage in postpartum syndrome of hemolysis, elevated liver enzyme levels, and low platelet count. Arch Neurol 2005;62:1150–3.
Disponible en ligne sur
ScienceDirect www.sciencedirect.com
Clinical case
Chronic subdural haematoma associated with pre-eclampsia: Case report and review of the literature Hématome sous-dural chronique associé à la pré-éclampsie : cas clinique et revue de la littérature B.O. Djoubairou ∗ , J. Onen , A.K. Doleagbenou , N. El Fatemi , M.R. Maaqili Department of Neurosurgery, hôpital Ibn Sina, Mohammed V University–Souissi, Rabat-Sale, Morocco
a r t i c l e
i n f o
Article history: Received 5 October 2013 Received in revised form 8 November 2013 Accepted 20 November 2013 Available online 26 February 2014 Keywords: Pre-eclampsia Subdural haematoma
a b s t r a c t Pre-eclampsia complicates approximately 5–8% of all pregnancies and may have adverse long-term effects on both mother and child. Chronic atraumatic subdural haematoma as a complication of severe pre-eclampsia, in the absence of clotting factor abnormalities, is a very rare condition. We present the case of a 30-year-old Moroccan woman who had a pregnancy 10 years previously, with an uneventful delivery. She presented with pre-eclampsia complicating a 29-week-old pregnancy. A few days preceding maternity unit admission the patient complained of headaches and malaise. Her blood pressure at admission was 150/120 mmHg and subsequently was treated with doses of methyldopa and magnesium sulphate. Her condition worsened with a loss of consciousness 24 hours later and was transferred to the neurosurgical unit. A brain computerized tomography (CT) scan revealed a left-sided subdural haematoma and the patient underwent surgery, with a good postoperative outcome. This article highlights the occurrence of neurological complications due to pre-eclampsia/eclampsia that require particular neurosurgical attention, its treatment and prognosis. We also review the literature regarding this pathology. © 2014 Elsevier Masson SAS. All rights reserved.
r é s u m é Mots clés : Pré-éclampsie Hématome sous-dural
La pré-éclampsie complique 5–8 % de toutes les grossesses et aggrave le pronostic maternofœtal. L’hématome sous-dural chronique est une complication rare de la pré-éclampsie surtout en l’absence de trouble de la coagulation sanguine. Nous rapportons ici le cas d’une patiente de 30 ans, arabe, dont la première grossesse remonte à 10 ans avec accouchement par voie basse qui présente une pré-éclampsie sévère à 29 semaines d’aménorrhées, elle est admise avec une tension artérielle (TA) = 150/120 mmHg rebelle à la bithérapie (méthyldopa, sulfate de magnésium) à dose adéquate. Vingt-quatre heures après son hospitalisation elle se plaint de céphalées se compliquant d’un trouble de la conscience, ce qui motive la réalisation d’un scanner cérébral ayant objectivé un hématome sous-dural chronique hémisphérique gauche nécessitant un transfert en neurochirurgie où elle fut opérée avec une bonne évolution postopératoire. Cet article rapporte une complication neurologique rare de la pré-éclampsie, le traitement et pronostic ainsi qu’une revue de la littérature des hématomes sous-duraux associés à la pré-éclampsie. © 2014 Elsevier Masson SAS. Tous droits réservés.
1. Introduction Pregnancy is a transient condition, but when it is complicated by pre-eclampsia it has lasting effects on both mother and child. Pre-eclampsia complicates 5–8% of pregnancies. It is responsible for considerable morbidity and mortality. Deaths are due to
∗ Corresponding author. E-mail address: [email protected] (B.O. Djoubairou). 0028-3770/$ – see front matter © 2014 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.neuchi.2013.11.002
intracranial haemorrhage and cerebral infarction, acute pulmonary oedema, respiratory failure and liver failure or rupture. Intracranial haemorrhage in pregnancy is uncommon and a life-threatening complication which contributes significantly to maternal mortality. The aetiology of intracranial haemorrhage in pregnancy includes rupture of a cerebral aneurysm, arteriovenous malformation and pregnancy-related hypertension. The intracranial haemorrhage associated with pre-eclampsia is typically intraparenchymal [4]. The present article describes an uncommon case of atraumatic chronic subdural haematoma as a complication of severe
B.O. Djoubairou et al. / Neurochirurgie 60 (2014) 48–50
Fig. 1. Preoperative brain computerized tomography (CT) scan showing the left hemispheric chronic subdural haematoma with evidence of rebleeding. Scanner cérébral préopératoire objectivant un hématome sous-dural chronique hémisphérique gauche avec des signes de ressaignements.
pre-eclampsia, its treatment, outcome and a systematic review of the literature of brain complications in pre-eclampsia. 2. Case report We present the case of a 30-year-old Moroccan woman, second gravida, one para (G2P1), with no prior history of hypertension. Her first pregnancy occurred 10 years previously and the patient had a normal at term vaginal delivery. There was no prior medical history of head trauma or prolonged intake of non-steroidal anti-inflammatory drugs. The patient was admitted to the maternity unit of Mohammed V Souissi–Rabat University Hospital for pre-eclampsia complicating a 29-week-old pregnancy, with a neurological condition suggested by a brief history of headaches and malaise. She was initially admitted to the maternity unit with a blood pressure (BP) of 150/120 mmHg, pulse rate 94/min, respiratory rate 18 breaths/min, uterine height = 28 cm, no uterine contractions, with the presence of fetal heart sounds. Laboratory tests results: AST = 22 IU/l, ALT = 24 UI/l, total bilirubin = 3 mg/l, direct bilirubin = 1 mg/l, free bilirubin = 2 mg/l, K = 4 meq/l, glycaemia = 0.5 g/l, proteinNa = 140 meq/l, uria = 4 + fetal ultrasound estimated fetal weight at 725 g, with an adequate amount of amniotic fluid. She was then immediately put on methyldopa and magnesium sulphate with adequate doses. However, 24 hours later, her condition worsened (loss of consciousness), and she was transferred to the neurosurgical unit for further evaluation and treatment. Clinical examination on admission to the neurosurgical unit revealed a Glasgow Coma Scale (GCS) of 12, equal pupil size with both pupils reactive to light, no neck rigidity or neurological motor deficits, although a bilateral pedal oedema was observed. A computerized tomography (CT) scan showed a left cerebral convexity chronic subdural haematoma with signs of rebleeding and a midline shift of the brain (Fig. 1). The complementary laboratory tests, haemoglobin = 15 g/dl, platelets = 166,000, PT = 100%, ACT = 30, fibrinogen = 4.5, were all normal. The patient was immediately admitted to the operating room under general anaesthesia and the haematoma was drained through two burr holes and a siphonage drain which was left in-dwelling for 24 hours. Perioperatively, no problem with haemostasis was encountered. Twenty-four hours after surgery the patient’s level of consciousness gradually improved. CT scan one week after surgery showed reversal of midline shift (Fig. 2), while the CT angiogram was normal. Three days following surgery, the patient returned to the maternity unit with a GCS of 15 with no motor deficits and a
49
Fig. 2. Postoperative brain computerized tomography (CT) scan showing the reestablishment of near normal anatomy, with reversal of the midline shift. Scanner cérébral postopératoire objectivant un rétablissement de l’anatomie normale, avec les structures de la ligne médiane en place.
blood pressure of 130/90, with protein +1 in the urine. Continued monitoring of this patient was carried-out to optimize long-term outcome. Two weeks after the neurosurgical procedure, fetal cardiac monitoring suggested fetal distress and an emergency caesarean section was performed, unfortunately the newborn died 24 hours later, due to respiratory distress. The patient remains clinically well and follow-up is ongoing. 3. Discussion The American College of Obstetricians and Gynecologists defines pre-eclampsia as hypertension with a systolic blood pressure of 140 mmHg or higher or a diastolic blood pressure level of 90 mmHg or higher that occurs after 20 weeks of gestation in a woman with previously normal blood pressure. The hypertension must have associated proteinuria, defined as urinary excretion of 0.3 g of protein or higher in a 24-hour urine collection [7]. Pre-eclampsia and eclampsia, physiological changes peculiar to pregnancy, are major causes of intracerebral haemorrhage during pregnancy and in the puerperium [1,13]. As a specific form of pre-eclampsia, HELLP syndrome, coined by Weinstein based on the combination of haemolysis (H), elevated liver enzymes (EL), and low platelet count (LP). The syndrome tends to develop during antepartum, particularly during the third trimester, after 27 weeks of gestation [14]. Cases of spontaneous peripartum subdural haematoma and intracerebral haemorrhage have been reported in the literature, but in association with the HELLP syndrome, thrombotic microangiopathy or thrombocytopenia [3,11,12,17,19]. An intracranial haemorrhage associated with HELLP syndrome tends to occur during the antepartum period, although it may also appear after delivery [12,17,19]. Haemorrhage has been reported in the brainstem, basal ganglia, and subcortical parenchyma with or without intraventricular extension [5,6], and patients with an intracranial haemorrhage often have a poor outcome [12,17,19]. However, non-specific symptoms often lead to a delayed diagnosis until a severe disturbance of consciousness occurs following an intracranial haemorrhage. An unknown traumatic event in this patient is unlikely to have occurred because she had no evidence of trauma on physical examination. It is not uncommon for subdural haematomas to be chronic with subtle neurological findings. Since the neurological signs and symptoms evolved rapidly over several hours in our patient, it is unlikely that head trauma prior to admission contributed to development of the haematoma. Brain injury has been clearly linked to haemostatic abnormalities which may affect multiple organs. The frequency of haemostatic aberrations associated with brain injury is directly related to the severity of the neurological deficits [10].
50
B.O. Djoubairou et al. / Neurochirurgie 60 (2014) 48–50
Table 1 Review of the literature of published cases of subdural haematoma with pre-eclampsia. Revue de la littérature publiée sur les hématomes sous-duraux associés à la pré-éclampsie. Author
Year
Age
BP
Giannina et al. [3]
1997
19
150/100
Hashiguchi et al. [5]
2001
37
160/100
Yokota et al. [17]
2009
32
172/108
Pandey et al. [11]
2010
25
Normal
Sâmia et al. [12]
2013
36
HT crisis
Our case
2013
30
150/120
Gestation
G1P0 32 weeks G1P0 37 weeks G1P0 41 weeks G2P1 Full-term G2P0 35 weeks G2P1 29 weeks
Clinical signs
HELLP Syndr
Thrombo
CT scan
Prognosis M
F
Agitation Anisocoria Unconscious
Yes
No
ASH
D
A
Yes
No
ICH
A
A
Anisocoria
Yes
No
A
A
Unconscious
No
Yes
ASH ICH ASH
A
A
Anisocoria Sedated Unconscious
Yes
Yes
D
D
No
No
A
D
ASH ICH CSH
BP: blood pressure; HELLP syndr: HELLP syndrome; thrombo: thrombocytopenia; M: maternal; F: fetal; D: death; A: alive; ASH: acute subdural haematoma; CSH: chronic subdural haematoma; ICH: intraparenchymal haematoma. BP : tension artérielle ; HELLP syndr : syndrome de HELLP ; thrombo : thrombocytopénie ; M : maternel ; F : fœtal ; D : décès ; A : vivant ; ASH : hématome sous-dural aigu ; CSH : hématome sous-dural chronique ; ICH : hématome intraparenchymateux.
The coagulation studies were normal in this patient (i.e., prothrombin time, partial prothrombin time, and fibrinogen). Hypertension acts as an independent cause of stroke because the loss of the self-regulatory mechanisms of blood flow of the brain leads to vasodilation and brain oedema, particularly in the case of individuals without chronic hypertension. Brain ischaemia and haemorrhage are, in most cases, accompanied by a blood pressure increase of at least 10% due to an alteration of the self-regulatory mechanisms induced by a vasoactive substance release at the injury site [15]. Pre-eclampsia predisposes the patient to eclamptic seizures and cerebral haemorrhage with major cerebral damage. The pathology behind eclamptic seizures and cerebral oedema is incompletely understood with two prevailing hypotheses. One consists of cerebral vasospasm leading to cerebral ischaemia, cytotoxic oedema and infarction, the other attributes cerebral oedema to loss of cerebral auto-regulation with consequent hyperperfusion. MRI studies support the view that most cerebral oedemas are due to hyperperfusion [2,18]. Uncontrolled cerebral perfusion pressure may lead to cerebral barotrauma and vessel damage with perfusion injury. The most recent report on enquiries into maternal death from the United Kingdom showed that the majority of women with pre-eclampsia died from intracranial haemorrhage [8]. Although cerebral haemorrhage was previously linked to diastolic blood pressures above 110 mmHg, it is now recognized that systolic hypertension may be a better predictor [9]. It is, therefore, recommended that systolic blood pressures above 160 mmHg must be treated [16]. The main causes of subdural haematoma with preeclampsia reported in the literature are presented in the Table 1. In our clinical case hypertension (BP = 150/120 mmHg) is the most plausible explanation for the spontaneous subdural haematoma in this patient. 4. Conclusion Early stage diagnosis of cerebral disorders due to pre-eclampsia improves maternal prognosis. An excellent working relationship amongst obstetricians, anaesthesiologists, neurologists, neurointensivists, and neurosurgeons is essential to ensure prompt and appropriate management. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
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