Semin Neurol 2007; 27(5): 411-424
DOI: 10.1055/s-2007-991123
© Thieme Medical Publishers

Neurological Disorders in Pregnancy from a Neuroimaging Perspective

Steven D. Brass1 , William A. Copen2
  • 1Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
  • 2Division of Neuroradiology, Massachusetts General Hospital, Boston, Massachusetts
Further Information

Publication History

Publication Date:
16 October 2007 (online)

ABSTRACT

Pregnancy can precipitate new neurological diseases as a result of the alterations in physiology that accompany the pregnant state. The pregnant patient presenting with neurological problems poses both diagnostic and therapeutic challenges, often forcing the clinician to rely on neuroimaging as part of the workup. This review discusses potential risks to the embryo and fetus posed by computed tomography (CT) and magnetic resonance imaging (MRI), the imaging studies most often used to study the central nervous system. Imaging features of a variety of neurological conditions associated with pregnancy are discussed, including pre-eclampsia and eclampsia, Wernicke's encephalopathy, cerebral venous thrombosis, ischemic stroke, postpartum angiopathy, and lymphocytic hypophysitis.

REFERENCES

  • 1 Wagner L K, Lester R G, Saldana L R. Exposure of the Pregnant Patient to Diagnostic Radiations: A Guide to Medical Management. Philadelphia; Lippincott 1985: 19-223
  • 2 Berlin L. Radiation exposure and the pregnant patient.  AJR Am J Roentgenol. 1996;  167 1377-1379
  • 3 Damilakis J, Prassopoulos P, Perisinakis K, Faflia C, Gourtsoyiannis N. CT of the sacroiliac joints: Dosimetry and optimal settings for a high-resolution technique.  Acta Radiol. 1997;  38 870-875
  • 4 Damilakis J, Perisinakis K, Voloudaki A, Gourtsoyiannis N. Estimation of fetal radiation dose from computed tomography scanning in late pregnancy: depth-dose data from routine examinations.  Invest Radiol. 2000;  35 527-533
  • 5 Wagner L K, Archer B R, Zeck O F. Conceptus dose from two state-of-the-art CT scanners.  Radiology. 1986;  159 787-792
  • 6 Mole R H. Irradiation of the embryo and fetus.  Br J Radiol. 1987;  60 17-31
  • 7 Giles D, Hewitt D, Stewart A, Webb J. Malignant disease in childhood and diagnostic irradiation in utero.  Lancet. 1956;  271 447
  • 8 Roberts P J, Given-Wilson R, Gifford D, Bryan G. Pregnancy and Work in Diagnostic Imaging. Report of a Joint Working Party of the Royal College of Radiologists and British Institute of Radiology. London; British Institute of Radiology 1992
  • 9 Mole R H. Childhood cancer after prenatal exposure to diagnostic x-ray examinations in Britain.  Br J Cancer. 1990;  62 152-168
  • 10 United Nations Scientific Committee on the Effects of Atomic Radiation .Ionizing Radiation: Levels and Effects. 1972 Report to the General Assembly, with annexes. Vol. II: Effects. New York, NY; United Nations 1972
  • 11 Muirhead C R, Cox R, Stather J W et al.. Estimates of Late Radiation Risks to the UK Population. Documents of the NRPB 4[4]. Chilton; National Radiological Protection Board 1993: 15-157
  • 12 Ginsberg J S, Hirsh J, Rainbow A J, Coates G. Risks to the fetus of radiologic procedures used in the diagnosis of maternal venous thromboembolic disease.  Thromb Haemost. 1989;  61 189-196
  • 13 Doll R, Wakeford R. Risk of childhood cancer from fetal irradiation.  Br J Radiol. 1997;  70 130-139
  • 14 Gilman E A, Kneale G W, Knox E G, Stewart A M. Pregnancy x-rays and childhood cancers: effects of exposure age and radiation dose.  J Radiol Prot. 1988;  8 3-8
  • 15 Benjamin S A, Lee A C, Angleton G M et al.. Neoplasms in young dogs after perinatal irradiation.  J Natl Cancer Inst. 1986;  77 563-571
  • 16 Idaho State University .Radiation and risk. Available at: http://www.physics.isu.edu/radinf/risk.htm Accessed December 10, 2006
  • 17 ACOG Committee on Obstetric Practice . ACOG Committee Opinion Number 299, September 2004. Guidelines for diagnostic imaging during pregnancy.  Obstet Gynecol. 2004;  104 647-651
  • 18 Nelson J A, Livingston J C, Moon R G. Mutagenic evaluation of radiographic contrast media.  Invest Radiol. 1982;  17 183-185
  • 19 Morisetti A, Tirone P, Luzzani F, de Haen C. Toxicologic safety assessment of iomeprol, a new x-ray contrast agent.  Eur J Radiol. 1994;  18(suppl 1) S21-S31
  • 20 Ralston W H, Robbins M S, James P. Reproductive, developmental, and genetic toxicity of ioversol.  Invest Radiol. 1989;  24(suppl 1) S16-S22
  • 21 Rodesch F, Camus M, Ermans A M, Dodion J, Delange F. Adverse effects of amniofetography on fetal thyroid function.  Am J Obstet Gynecol. 1976;  126 723-726
  • 22 Bona G, Zaffaroni M, Defilippi C, Gallina M R, Mostert M. Effects of iopamidol on neonatal thyroid function.  Eur J Radiol. 1992;  14 22-25
  • 23 Webb J A, Thomsen H S, Morcos S K. Members of Contrast Media Safety Committee of European Society of Urogenital Radiology (ESUR) . The use of iodinated and gadolinium contrast media during pregnancy and lactation.  Eur Radiol. 2005;  15 1234-1240
  • 24 Russell L B, Russell W L. An analysis of the changing radiation response of the developing mouse embryo.  J Cell Physiol. 1954;  43(suppl 1) 130-149
  • 25 Brent R L, Gorson R O. Radiation exposure in pregnancy. In: Moseley RD Jr., et al Current Problems in Radiology. Vol. 2. Chicago, IL; Year Book Medical Publishers Inc 1972: 1-48
  • 26 Blot W J, Miller R W. Mental retardation following in utero exposure to the atomic bombs of Hiroshima and Nagasaki.  Radiology. 1973;  106 617-619
  • 27 Yamazaki J N, Schull W J. Perinatal loss and neurological abnormalities among children of the atomic bomb: Nagasaki and Hiroshima revisited, 1949 to 1989.  JAMA. 1990;  264 605-609
  • 28 Otake M, Schull W J. In utero exposure to A-bomb radiation and mental retardation: a reassessment.  Br J Radiol. 1984;  57 409-414
  • 29 Dekaban A S. Abnormalities in children exposed to x-radiation during various stages of gestation: tentative timetable of radiation to the human fetus.  J Nucl Med. 1968;  9 471-477
  • 30 Stewart A, Kneale G W. Radiation dose effects in relation to obstetric x-rays and childhood cancers.  Lancet. 1970;  1 1185-1188
  • 31 Wakeford R, Little M P. Risk coefficients for childhood cancer after intrauterine irradiation: a review.  Int J Radiat Biol. 2003;  79 293-309
  • 32 Hall E J, Giaccia A J. Radiobiology for the Radiologist. Philadelphia; Lippincott Williams & Wilkins 2006
  • 33 Omnipaque [package insert]. Available at: http://www.amershamhealth-us.com/shared/pdfs/pi/Omnipaque.pdf Accessed December 18, 2006
  • 34 Heinrichs W L, Fong P, Flannery M et al.. Midgestational exposure of pregnant BALB/c mice to magnetic resonance imaging conditions.  Magn Reson Imaging. 1988;  6 305-313
  • 35 Tyndall D A, Sulik K K. Effects of magnetic resonance imaging on eye development in the C57BL/6J mouse.  Teratology. 1991;  43 263-275
  • 36 Yip Y P, Capriotti C, Talagala S L, Yip J W. Effects of MR exposure at 1.5T on early embryonic development of the chick.  J Magn Reson Imaging. 1994;  4 742-748
  • 37 Kanal E, Shellock F G, Talagala L. Safety considerations in MR imaging.  Radiology. 1990;  176 593-606
  • 38 National Radiological Protection Board .Principles for the Protection of Patients and Volunteers during Clinical Magnetic Resonance Diagnostic Procedures. Documents of the NRPB. Vol. 2, No. 1. London; HM Stationery Office 1991
  • 39 Shellock F G, Kanal E. Policies, guidelines, and recommendations for MR imaging safety and patient management.  J Magn Reson Imaging. 1991;  1 97-101
  • 40 Baker P N, Johnson I R, Harvey P R, Gowland P A, Mansfield P. A three-year follow-up of children imaged in utero with echo-planar magnetic resonance.  Am J Obstet Gynecol. 1994;  170 32-33
  • 41 Glover P, Hykin J, Gowland P, Wright J, Johnson I, Mansfield P. An assessment of the intrauterine sound intensity level during obstetric echo-planar magnetic resonance imaging.  Br J Radiol. 1995;  68 1090-1094
  • 42 Omniscan [package insert]. Available at: http://www.amershamhealth-us.com/shared/pdfs/pi/omniscan.pdf Accessed September 22, 2007
  • 43 Magnevist [package insert]. Available at: http://www.fda.gov/medwatch/SAFETY/2005/Jan_PI/Magnevist_PI.pdf Accessed December 18, 2006
  • 44 Kittner S J, Stern B J, Feeser B R et al.. Pregnancy and the risk of stroke.  N Engl J Med. 1996;  335 768-774
  • 45 Wilterdink J L, Easton J D. Cerebral ischemia in pregnancy.  Adv Neurol. 2002;  90 51-62
  • 46 Wilterdink J L, Feldmann E. Intracranial hemorrhage.  Adv Neurol. 2002;  90 63-74
  • 47 Xavier A R, Qureshi A I, Kirmani J F, Yahia A M, Bakshi R. Neuroimaging of stroke: a review.  South Med J. 2003;  96 367-379
  • 48 Grant P E, He J, Halpern E F et al.. Frequency and clinical context of decreased apparent diffusion coefficient reversal in the human brain.  Radiology. 2001;  221 43-50
  • 49 Grossman RI, Yousem DM The Requisites: Neuroradiology. 2nd ed. Philadelphia; Elsevier 2003: 173-241
  • 50 Brant-Zawadzki M, Atkinson D, Detrick M, Bradley W G, Scidmore G. Fluid-attenuated inversion recovery (FLAIR) for assessment of cerebral infarction. Initial clinical experience in 50 patients.  Stroke. 1996;  27 1187-1191
  • 51 Lovblad K O, Laubach H J, Baird A E et al.. Clinical experience with diffusion-weighted MR in patients with acute stroke.  AJNR Am J Neuroradiol. 1998;  19 1061-1066
  • 52 Singer M B, Chong J, Lu D et al.. Diffusion-weighted MRI in acute subcortical infarction.  Stroke. 1998;  29 133-136
  • 53 van Everdingen K J, van der Grond J, Kappelle L J et al.. Diffusion-weighted magnetic resonance imaging in acute stroke.  Stroke. 1998;  29 1783-1790
  • 54 Perkins C J, Kahya E, Roque C T, Roche P E, Newman G C. Fluid-attenuated inversion recovery and diffusion- and perfusion-weighted MRI abnormalities in 117 consecutive patients with stroke symptoms.  Stroke. 2001;  32 2774-2781
  • 55 Gonzalez R G, Schaefer P W, Buonanno F S et al.. Diffusion-weighted MR imaging: diagnostic accuracy in patients imaged within 6 hours of stroke symptom onset.  Radiology. 1999;  210 155-162
  • 56 Urbach H, Flacke S, Keller E et al.. Detectability and detection rate of acute cerebral hemisphere infarcts on CT and diffusion-weighted MRI.  Neuroradiology. 2000;  42 722-727
  • 57 Fiebach J B, Schellinger P D, Jansen O et al.. CT and diffusion-weighted MR imaging in randomized order: diffusion-weighted imaging results in higher accuracy and lower interrater variability in the diagnosis of hyperacute ischemic stroke.  Stroke. 2002;  33 2206-2210
  • 58 Mullins M E, Schaefer P W, Sorensen A G et al.. CT and conventional and diffusion-weighted MR imaging in acute stroke: study in 691 patients at presentation to the emergency department.  Radiology. 2002;  224 353-360
  • 59 Manzione J, Newman G C, Shapiro A, Santo-Ocampo R. Diffusion- and perfusion- weighted MR imaging of dural sinus thrombosis.  AJNR Am J Neuroradiol. 2000;  21 68-73
  • 60 Ducreux D, Oppwnheim C, Vandamme X et al.. Diffusion-weighted imaging patterns of brain damage associated cerebral venous thrombosis.  AJNR Am J Neuroradiol. 2001;  22 261-268
  • 61 Mullins M E, Grant P E, Wang B, Gonzalez R G, Schaeffer P W. Parenchymal abnormalities associated with cerebral venous sinus thrombosis: assessment with diffusion-weighted MR imaging.  AJNR Am J Neuroradiol. 2004;  25 1666-1675
  • 62 Bateman B T, Schumacher H C, Bushnell C D et al.. Intracerebral hemorrhage in pregnancy: frequency, risk factors, and outcome.  Neurology. 2006;  67 424-429
  • 63 Witlin A G, Friedman S A, Egerman R S, Frangieh A Y, Sibai B M. Cerebrovascular disorders complicating pregnancy: beyond eclampsia.  Am J Obstet Gynecol. 1997;  176 1139-1148
  • 64 Moodley J, Kalane G. A review of the management of eclampsia: practical issues.  Hypertens Pregnancy. 2006;  25 47-62
  • 65 Koch S, Rabinstein A, Falcone S, Forteza A. Diffusion-weighted imaging shows cytotoxic and vasogenic edema in eclampsia.  AJNR Am J Neuroradiol. 2001;  22 1068-1070
  • 66 Loureiro R, Leite C C, Kahhale S et al.. Diffusion imaging may predict reversible brain lesions in eclampsia and severe pre-eclampsia: initial experience.  Am J Obstet Gynecol. 2003;  189 1350-1355
  • 67 Finocchi V, Bozzao A, Bonamini M et al.. Magnetic resonance imaging in posterior reversible encephalopathy syndrome: report of three cases and review of literature.  Arch Gynecol Obstet. 2005;  271 79-85
  • 68 Shah A K, Whitty J E. Brain MRI in peripartum seizures: usefulness of combined T2 and diffusion weighted MR imaging.  J Neurol Sci. 1999;  166 122-125
  • 69 Provenzale J M, Petrella J R, Cruz L CH, Wong J C, Engelter S, Barboriak D P. Quantitative assessment of diffusion abnormalities in posterior reversible encephalopathy syndrome.  AJNR Am J Neuroradiol. 2001;  22 1455-1461
  • 70 Hinchey J, Chaves C, Appignani B et al.. A reversible posterior leukencephalopathy syndrome.  N Engl J Med. 1996;  334 494-500
  • 71 Covarrubias D J, Luetmer P H, Campeau N G. Posterior reversible encephalopathy syndrome: prognostic utility of quantitative diffusion-weighted MR images.  AJNR Am J Neuroradiol. 2002;  23 1038-1048
  • 72 Schaefer P W, Buonanno F S, Gonzalez R G, Schwamm L H. Diffusion-weighted imaging discriminates between cytotoxic and vasogenic edema in a patient with eclampsia.  Stroke. 1997;  28 1082-1085
  • 73 Ay H, Buonanno F S, Schaefer P W et al.. Posterior leukencephalopathy without severe hypertension: utility of diffusion-weighted MRI.  Neurology. 1998;  51 1369-1376
  • 74 Geijer B, Sundgren P C, Lindgren A, Brockstedt S, Stahlberg F, Holtas S. The value of b required to avoid T2 shine-through from old lacunar infarcts in diffusion-weighted imaging.  Neuroradiology. 2001;  43 511-517
  • 75 D'Aprile P, Farchi G, Pagliarulo R, Carella A. Thrombotic thrombocytopenic purpura: MR demonstration of reversible brain abnormalities.  AJNR Am J Neuroradiol. 1994;  15 19-20
  • 76 Singhal A B. Postpartum angiopathy with reversible posterior leukoencephalopathy.  Arch Neurol. 2004;  61 411-416
  • 77 Neudecker S, Stock K, Krasnianski M. Call-Fleming postpartum angiopathy in the puerperium: a reversible cerebral vasoconstriction syndrome.  Obstet Gynecol. 2006;  107 446-449
  • 78 Call G K, Fleming M C, Sealfon S, Levine H, Kistler J P, Fisher C M. Reversible cerebral segmental vasoconstriction.  Stroke. 1988;  19 1159-1170
  • 79 Singhal A B, Caviness V S, Begleiter A F, Mark E J, Rordorf G, Koroshetz W J. Cerebral vasoconstriction and stroke after use of serotonergic drugs.  Neurology. 2002;  58 130-133
  • 80 Ruggenenti P, Remuzzi G. The pathophysiology and management of thrombotic thrombocytopenic purpura.  Eur J Haematol. 1996;  56 191-207
  • 81 Bakshi R, Shaikh Z A, Bates V E, Kinkel P R. Thrombotic thrombocytopenic purpura: Brain CT and MRI findings in 12 patients.  Neurology. 1999;  52 1285-1288
  • 82 Kanaan I, Jallu A, Kanaan H. Management strategy for meningioma in pregnancy: a clinical study.  Skull Base. 2003;  13 197-203
  • 83 Mamelak A N, Withers G J, Wang X. Choriocarcinoma brain metastasis in a patient with viable intrauterine pregnancy.  J Neurosurg. 2002;  97 477-481
  • 84 Biousse V, Newman N J, Oyaizu N M. Precipitating factors in pituitary apoplexy.  J Neurol Neurosurg Psychiatry. 2001;  71 542-545
  • 85 Masding M G, Lees P D, Gawne-Cain M L, Sandeman D D. Visual field compression by a non-secreting pituitary tumour during pregnancy.  J R Soc Med. 2003;  96 27-28
  • 86 Kelestimur F. Sheehan's syndrome.  Pituitary. 2003;  6 181-188
  • 87 Stelmach M, O'Day J. Rapid change in visual fields associated with suprasellar lymphocytic hypophysitis.  J Clin Neuroophthalmol. 1991;  11 19-24
  • 88 Flanagan D E, Ibrahim A E, Ellison D W, Armitage M, Gawne-Cain M, Lees P D. Inflammatory hypophysitis-the spectrum of disease.  Acta Neurochir (Wien). 2002;  144 47-56
  • 89 McCutcheon I E, Oldfield E H. Lymphocytic adenohypophysitis presenting as infertility. Case report.  J Neurosurg. 1991;  74 821-826
  • 90 Horvath E, Vidal S, Syro L V, Kovacs K, Smyth H S, Uribe H. Severe lymphocytic adenohypophysitis with selective disappearance of prolactin cells: a histologic, ultrastructural and immunoelectron microscopic study.  Acta Neuropathol (Berl). 2001;  101 631-637
  • 91 Miyagi K, Shingaki T, Ito K et al.. Lymphocytic infundibulo-hypophysitis with diabetes insipidus as a new clinical entity: a case report and review of the literature.  No Shinkei Geka. 1997;  25 169-175
  • 92 Ikeda H, Okudaira Y. Spontaneous regression of pituitary mass in temporal association with pregnancy.  Neuroradiology. 1987;  29 488-492
  • 93 Osborn A. Diagnostic Neuroradiology. St. Louis; CV Mosby 1994
  • 94 Elster A D. Modern imaging of the pituitary.  Radiology. 1993;  187 1-14
  • 95 Ikeda H, Yoshimoto T. Visual disturbances in patients with pituitary adenoma.  Acta Neurol Scand. 1995;  92 157-160
  • 96 Saeki N, Uchino Y, Murai H et al.. MR imaging study of edema-like change along the optic tract in patients with pituitary region tumors.  AJNR Am J Neuroradiol. 2003;  24 336-342
  • 97 Arita K, Uozumi T, Yano T et al.. MRI visualization of complete bilateral optic nerve involvement by pituitary adenoma: a case report.  Neuroradiology. 1993;  35 549-550
  • 98 Gallucci M, Bozzao A, Splendiani A, Masciocchi C, Passariello R. Wernicke encephalopathy: MR findings in five patients.  AJNR Am J Neuroradiol. 1990;  11 887-892
  • 99 Chung S P, Kim S W, Yoo I S et al.. Magnetic resonance imaging as a diagnostic adjunct to Wernicke encephalopathy in the ED.  Am J Emerg Med. 2003;  21 497-502
  • 100 Togay-Isikay C, Yigit A, Mutluer N. Wernicke's encephalopathy due to hyperemesis gravidarum. Diffusion-weighted imaging abnormalities in Wernicke encephalopathy: reversible cytotoxic edema? An under-recognised condition.  Aust N Z J Obstet Gynaecol. 2001;  41 453-456
  • 101 Chu K, Kang D W, Kim H J, Lee Y S, Park S H. Diffusion-weighted imaging abnormalities in Wernicke encephalopathy: reversible cytotoxic edema.  Arch Neurol. 2002;  59 123-127
  • 102 Confavreux C, Hutchinson M, Hours M M et al.. Rate of pregnancy-related relapse in multiple sclerosis. Pregnancy in multiple sclerosis group.  N Engl J Med. 1998;  339 285-291
  • 103 Soldan S S, Alavrez Retuerto A I, Sicotte N L, Voskuhl R R. Immune modulation in multiple sclerosis patients treated with pregnancy hormone estriol.  J Immunol. 2003;  171 6267-6274
  • 104 Sandhu F S, Dillon W P. Spinal epidural abscess: evaluation with contrast-enhanced MR imaging.  AJNR Am J Neuroradiol. 1991;  12 1087-1093
  • 105 Yonekawa Y, Mehdorn H M, Nishikaw M. Spontaneous spinal epidural hematoma during pregnancy.  Surg Neurol. 1975;  3 327-328
  • 106 Osei E K, Faulkner K. Fetal doses from radiological examinations.  Br J Radiol. 1999;  72 773-780

Steven David BrassM.D. M.P.H. F.R.C.P.C. 

Associate Director of Neurology Clinic, Assistant Professor of Neurology, Department of Neurology, Massachusetts General Hospital

55 Fruit Street, Wang Building, Suite 835, Boston, MA 02114

Email: sbrass@partners.org

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