Posterior Leukoencephalopathy Syndrome: Blindness in 2 Peripartum Patients

Presentation of Case 1:

A healthy 20‐year‐old primagravid woman was admitted to the hospital for delivery. Her prenatal course was unremarkable with no evidence of hypertension. On admission her blood pressure was elevated up to 167/99. Treatment was begun with nifedipine for pregnancy‐induced hypertension, and she delivered a healthy male infant. Her blood pressure in the hospital immediately postpartum ranged from 120/60 to 165/90 mm Hg. On postpartum day 2, the patient complained of bilateral frontal headache and blurred vision which progressed over 24 hours to acute bilateral blindness. Examination demonstrated a blood pressure of 133/79 mm Hg and was remarkable for the patient having a profound decrease in visual acuity with mere light perception. Laboratory test results revealed mild proteinuria. An MRI of the brain showed hyperintense T2 areas affecting both white and gray matter in the bilateral occipital, parietal, and frontal lobes. Eclampsia‐induced cortical blindness was diagnosed, and treatment with magnesium and hydralazine was initiated. Within 48 hours, the patient's vision returned to 20/20 acuity.

Presentation of Case 2:

A 23‐year‐old primagravid woman at 32 weeks of pregnancy presented with a 1‐day history of nausea, bilateral frontal headache, and blurred vision. She had no significant medical history. Her blood pressure was 150/90. Her physical exam was remarkable for profoundly decreased visual acuity bilaterally. Laboratory investigation showed mild renal insufficiency and proteinuria. A brain MRI demonstrated hyperintense T2 signal affecting both the gray and white matter in the bilateral occipital lobes as well the right posterior parietal and the left frontal lobes. Adiagnosis of cortical blindness secondary to severe preeclampsia was made, and she underwent an emergent cesarean section. Within 24 hours of delivery, her vision was totally restored.

Discussion:

Preeclampsia is defined as new‐onset elevated blood pressure (>140/90 mm Hg) with proteinuria after 20 weeks of gestation. It affects between 5% and 8% of pregnant women and may be associated with visual disturbances, headache, edema, and epigastric pain. One third of cases develop postpartum, with 80% of these occurring 3‐14 days after delivery. Transient cortical blindness is a rare but dramatic consequence of severe eclampsia. It is characterized predominantly by white matter vasogenic edema of the occipital lobe and posterior parietal lobes. Its mechanism is unclear but may result from cerebral vasospasm and ischemic insult or augmented capillary permeability‐induced vasogenic edema. Treatment requires normalization of blood pressure to values before the preeclampsia. With prompt recognition and treatment the prognosis is excellent.

Conclusions:

Physician who assist in the care of pregnant and postpartum patients should have a high index of suspicion for eclampsia‐induced central nervous system complications, so there is timely recognition, and treatment is initiated in order to avoid irreversible vision loss.

Author Disclosure:

K. Kobaidze, None.