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DOI: 10.1148/rg.271065046
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Imaging of Neurologic Disorders Associated with Pregnancy and the Postpartum Period1

Imad T. Zak, MD, Harjot S. Dulai, MD and Karl K. Kish, MD

1 From the Department of Radiology, Wayne State University, DRH 3L-8, 4201 St Antoine, Detroit, MI 48201. Presented as an education exhibit at the 2005 RSNA Annual Meeting. Received March 28, 2006; revision requested May 11 and received June 29; accepted June 29. All authors have no financial relationships to disclose.

Figure 1
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  		Figure 1a.  Reversible ischemia in an 18-year-old woman with sickle cell trait who developed weakness 4 days after cesarean section. (a) Axial fluid-attenuated inversion-recovery (FLAIR) magnetic resonance (MR) image shows bilateral gyral thickening (arrows) in the frontal and parietal lobes, which is presumably due to cytotoxic edema. (b) Axial gadolinium-enhanced T1-weighted MR image shows cortical enhancement (arrows), a finding characteristic of reversible or incomplete ischemia. Computed tomography (CT) performed 6 weeks later showed mild encephalomalacia.

 

Figure 1
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  		Figure 1b.  Reversible ischemia in an 18-year-old woman with sickle cell trait who developed weakness 4 days after cesarean section. (a) Axial fluid-attenuated inversion-recovery (FLAIR) magnetic resonance (MR) image shows bilateral gyral thickening (arrows) in the frontal and parietal lobes, which is presumably due to cytotoxic edema. (b) Axial gadolinium-enhanced T1-weighted MR image shows cortical enhancement (arrows), a finding characteristic of reversible or incomplete ischemia. Computed tomography (CT) performed 6 weeks later showed mild encephalomalacia.

 

Figure 2
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  		Figure 2a.  Complete (irreversible) cerebral infarctions in a 24-year-old woman who developed cortical blindness after difficult labor. (a) Axial diffusion-weighted MR image shows restricted diffusion in both occipital lobes, primarily in the arterial watershed zones. (b) Axial FLAIR MR image shows corresponding edema and mass effect. MR imaging performed 7 weeks later showed corresponding laminar necrosis and cortical atrophy.

 

Figure 2
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  		Figure 2b.  Complete (irreversible) cerebral infarctions in a 24-year-old woman who developed cortical blindness after difficult labor. (a) Axial diffusion-weighted MR image shows restricted diffusion in both occipital lobes, primarily in the arterial watershed zones. (b) Axial FLAIR MR image shows corresponding edema and mass effect. MR imaging performed 7 weeks later showed corresponding laminar necrosis and cortical atrophy.

 

Figure 3
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  		Figure 3.  Idiopathic SAH in a 27-year-old woman who developed a sudden sharp headache after vaginal delivery. Axial unenhanced CT scan shows localized SAH over the right frontal convexity (arrows). A four-vessel cerebral angiogram was normal. (Courtesy of A. K. Shah, MD, Wayne State University, Detroit, Mich.)

 

Figure 4
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  		Figure 4.  Posterior reversible encephalopathy syndrome in a 28-year-old woman who was 36 weeks pregnant and presented with eclampsia. Coronal FLAIR MR image shows vasogenic edema involving the cortex and subcortical white matter (arrows).

 

Figure 5
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  		Figure 5a.  Posterior reversible encephalopathy syndrome in a 32-year-old woman with sickle cell trait who was 36 weeks pregnant and presented with eclampsia. (a) Axial FLAIR MR image shows symmetric edema in the thalami and basal ganglia. (b) Axial FLAIR MR image shows diffuse edema in the pons. Follow-up MR images obtained 2 months later were normal.

 

Figure 5
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  		Figure 5b.  Posterior reversible encephalopathy syndrome in a 32-year-old woman with sickle cell trait who was 36 weeks pregnant and presented with eclampsia. (a) Axial FLAIR MR image shows symmetric edema in the thalami and basal ganglia. (b) Axial FLAIR MR image shows diffuse edema in the pons. Follow-up MR images obtained 2 months later were normal.

 

Figure 6
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  		Figure 6a.  PCA in a 38-year-old woman who experienced a severe headache and a seizure 2 weeks after childbirth. (a) Axial unenhanced CT scan obtained at admission shows a cerebral hematoma in the left frontal lobe. (b) Axial T2-weighted MR image obtained after 2 days of evacuation shows a new hematoma in the right frontal lobe and residual hemorrhage in the left frontal lobe. (c, d) Right carotid angiogram (c) and magnified view with region-of-interest circles (d) show multifocal stenoses and a beaded appearance of the peripheral branches of the anterior and middle cerebral arteries. The findings are characteristic of the angiitis of PCA, which affects the small- and medium-caliber arteries beyond the proximal segments of the major cerebral arteries.

 

Figure 6
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  		Figure 6b.  PCA in a 38-year-old woman who experienced a severe headache and a seizure 2 weeks after childbirth. (a) Axial unenhanced CT scan obtained at admission shows a cerebral hematoma in the left frontal lobe. (b) Axial T2-weighted MR image obtained after 2 days of evacuation shows a new hematoma in the right frontal lobe and residual hemorrhage in the left frontal lobe. (c, d) Right carotid angiogram (c) and magnified view with region-of-interest circles (d) show multifocal stenoses and a beaded appearance of the peripheral branches of the anterior and middle cerebral arteries. The findings are characteristic of the angiitis of PCA, which affects the small- and medium-caliber arteries beyond the proximal segments of the major cerebral arteries.

 

Figure 6
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  		Figure 6c.  PCA in a 38-year-old woman who experienced a severe headache and a seizure 2 weeks after childbirth. (a) Axial unenhanced CT scan obtained at admission shows a cerebral hematoma in the left frontal lobe. (b) Axial T2-weighted MR image obtained after 2 days of evacuation shows a new hematoma in the right frontal lobe and residual hemorrhage in the left frontal lobe. (c, d) Right carotid angiogram (c) and magnified view with region-of-interest circles (d) show multifocal stenoses and a beaded appearance of the peripheral branches of the anterior and middle cerebral arteries. The findings are characteristic of the angiitis of PCA, which affects the small- and medium-caliber arteries beyond the proximal segments of the major cerebral arteries.

 

Figure 6
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  		Figure 6d.  PCA in a 38-year-old woman who experienced a severe headache and a seizure 2 weeks after childbirth. (a) Axial unenhanced CT scan obtained at admission shows a cerebral hematoma in the left frontal lobe. (b) Axial T2-weighted MR image obtained after 2 days of evacuation shows a new hematoma in the right frontal lobe and residual hemorrhage in the left frontal lobe. (c, d) Right carotid angiogram (c) and magnified view with region-of-interest circles (d) show multifocal stenoses and a beaded appearance of the peripheral branches of the anterior and middle cerebral arteries. The findings are characteristic of the angiitis of PCA, which affects the small- and medium-caliber arteries beyond the proximal segments of the major cerebral arteries.

 

Figure 7
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  		Figure 7a.  Thrombosis of the superior sagittal sinus and venous infarction in a 25-year-old woman who was 34 weeks pregnant and developed headaches and blurring of vision. (a) Axial CT scan shows high attenuation in the superior sagittal sinus (curved arrows) and focal hemorrhage in the left parietal lobe at the gray-white matter interface (straight arrow). (b–d) Sagittal T1-weighted (b), axial T2-weighted (c), and axial FLAIR (d) MR images show high signal intensity in the superior sagittal sinus (arrow). (e) Axial gadolinium-enhanced T1-weighted MR image shows a filling defect (empty delta sign) (arrow) in the superior sagittal sinus. (f) On a three-dimensional time-of-flight MR venogram, the superior sagittal sinus is not visualized because of extensive thrombosis.

 

Figure 7
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  		Figure 7b.  Thrombosis of the superior sagittal sinus and venous infarction in a 25-year-old woman who was 34 weeks pregnant and developed headaches and blurring of vision. (a) Axial CT scan shows high attenuation in the superior sagittal sinus (curved arrows) and focal hemorrhage in the left parietal lobe at the gray-white matter interface (straight arrow). (b–d) Sagittal T1-weighted (b), axial T2-weighted (c), and axial FLAIR (d) MR images show high signal intensity in the superior sagittal sinus (arrow). (e) Axial gadolinium-enhanced T1-weighted MR image shows a filling defect (empty delta sign) (arrow) in the superior sagittal sinus. (f) On a three-dimensional time-of-flight MR venogram, the superior sagittal sinus is not visualized because of extensive thrombosis.

 

Figure 7
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  		Figure 7c.  Thrombosis of the superior sagittal sinus and venous infarction in a 25-year-old woman who was 34 weeks pregnant and developed headaches and blurring of vision. (a) Axial CT scan shows high attenuation in the superior sagittal sinus (curved arrows) and focal hemorrhage in the left parietal lobe at the gray-white matter interface (straight arrow). (b–d) Sagittal T1-weighted (b), axial T2-weighted (c), and axial FLAIR (d) MR images show high signal intensity in the superior sagittal sinus (arrow). (e) Axial gadolinium-enhanced T1-weighted MR image shows a filling defect (empty delta sign) (arrow) in the superior sagittal sinus. (f) On a three-dimensional time-of-flight MR venogram, the superior sagittal sinus is not visualized because of extensive thrombosis.

 

Figure 7
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  		Figure 7d.  Thrombosis of the superior sagittal sinus and venous infarction in a 25-year-old woman who was 34 weeks pregnant and developed headaches and blurring of vision. (a) Axial CT scan shows high attenuation in the superior sagittal sinus (curved arrows) and focal hemorrhage in the left parietal lobe at the gray-white matter interface (straight arrow). (b–d) Sagittal T1-weighted (b), axial T2-weighted (c), and axial FLAIR (d) MR images show high signal intensity in the superior sagittal sinus (arrow). (e) Axial gadolinium-enhanced T1-weighted MR image shows a filling defect (empty delta sign) (arrow) in the superior sagittal sinus. (f) On a three-dimensional time-of-flight MR venogram, the superior sagittal sinus is not visualized because of extensive thrombosis.

 

Figure 7
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  		Figure 7e.  Thrombosis of the superior sagittal sinus and venous infarction in a 25-year-old woman who was 34 weeks pregnant and developed headaches and blurring of vision. (a) Axial CT scan shows high attenuation in the superior sagittal sinus (curved arrows) and focal hemorrhage in the left parietal lobe at the gray-white matter interface (straight arrow). (b–d) Sagittal T1-weighted (b), axial T2-weighted (c), and axial FLAIR (d) MR images show high signal intensity in the superior sagittal sinus (arrow). (e) Axial gadolinium-enhanced T1-weighted MR image shows a filling defect (empty delta sign) (arrow) in the superior sagittal sinus. (f) On a three-dimensional time-of-flight MR venogram, the superior sagittal sinus is not visualized because of extensive thrombosis.

 

Figure 7
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  		Figure 7f.  Thrombosis of the superior sagittal sinus and venous infarction in a 25-year-old woman who was 34 weeks pregnant and developed headaches and blurring of vision. (a) Axial CT scan shows high attenuation in the superior sagittal sinus (curved arrows) and focal hemorrhage in the left parietal lobe at the gray-white matter interface (straight arrow). (b–d) Sagittal T1-weighted (b), axial T2-weighted (c), and axial FLAIR (d) MR images show high signal intensity in the superior sagittal sinus (arrow). (e) Axial gadolinium-enhanced T1-weighted MR image shows a filling defect (empty delta sign) (arrow) in the superior sagittal sinus. (f) On a three-dimensional time-of-flight MR venogram, the superior sagittal sinus is not visualized because of extensive thrombosis.

 

Figure 8
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  		Figure 8.  Pituitary apoplexy in a 24-year-old woman who was 20 weeks pregnant and presented with a sudden sharp headache behind the eyes. Sagittal T1-weighted MR image shows hemorrhage in a prominent pituitary gland (arrow).

 

Figure 9
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  		Figure 9a.  Pituitary apoplexy in a 44-year-old woman who developed headaches 3 weeks after childbirth. Her prolactin level was 19.9 ng/mL. (a) Coronal T1-weighted MR image shows an enlarged, poorly enhancing pituitary gland (arrow). (b) MR image obtained 4 weeks later shows atrophy of the pituitary with a partial empty sella appearance.

 

Figure 9
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  		Figure 9b.  Pituitary apoplexy in a 44-year-old woman who developed headaches 3 weeks after childbirth. Her prolactin level was 19.9 ng/mL. (a) Coronal T1-weighted MR image shows an enlarged, poorly enhancing pituitary gland (arrow). (b) MR image obtained 4 weeks later shows atrophy of the pituitary with a partial empty sella appearance.

 

Figure 10
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  		Figure 10.  Sheehan syndrome in a 37-year-old woman who presented with a clinical picture of pan-hypopituitarism 3 months after complicated delivery. Sagittal gadolinium-enhanced T1-weighted MR image shows an empty sella with herniation of the optic chiasm (arrow) into the sella turcica.

 

Figure 11
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  		Figure 11a.  Lymphocytic adenohypophysitis in a 28-year-old woman who developed a severe headache 4 days after normal vaginal delivery. (a) Sagittal T1-weighted MR image shows mild enlargement and homogeneous enhancement of the pituitary gland (arrow). (b) Sagittal T1-weighted MR image obtained 3 weeks later shows spontaneous regression of the pituitary to a normal size.

 

Figure 11
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  		Figure 11b.  Lymphocytic adenohypophysitis in a 28-year-old woman who developed a severe headache 4 days after normal vaginal delivery. (a) Sagittal T1-weighted MR image shows mild enlargement and homogeneous enhancement of the pituitary gland (arrow). (b) Sagittal T1-weighted MR image obtained 3 weeks later shows spontaneous regression of the pituitary to a normal size.

 

Figure 12
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  		Figure 12a.  Prolactinoma in a 27-year-old woman who was 32 weeks pregnant and presented with headaches, visual disturbances, and a prolactin level of 290 ng/mL. Unenhanced coronal (a) and sagittal (b) T1-weighted MR images show a large sellar and suprasellar tumor that causes mild compression of the optic chiasm (arrow).

 

Figure 12
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  		Figure 12b.  Prolactinoma in a 27-year-old woman who was 32 weeks pregnant and presented with headaches, visual disturbances, and a prolactin level of 290 ng/mL. Unenhanced coronal (a) and sagittal (b) T1-weighted MR images show a large sellar and suprasellar tumor that causes mild compression of the optic chiasm (arrow).

 

Figure 13
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  		Figure 13a.  Calvarial osteomyelitis complicated by pachymeningitis and epidural abscess in a 17-year-old girl who was 28 weeks pregnant and experienced a seizure. (a) Sagittal T1-weighted MR image shows diffuse low signal intensity in the bone marrow and an elliptical extraaxial lesion in the midline anteriorly (arrow). (b) Axial FLAIR MR image shows the elliptical extraaxial hyperintense lesion lying over the superior sagittal sinus anteriorly. (c) Three-dimensional time-of-flight MR venogram shows interruption of the superior sagittal sinus anteriorly (arrows). (d) Sagittal gadolinium-enhanced T1-weighted MR image shows enhancement consistent with osteomyelitis of the frontal bone (solid straight arrow) and clearly demonstrates the epidural abscess (open straight arrow) with pachymeningitis (curved arrows). Further questioning of the patient disclosed sickle cell trait and a recent history of pneumonia.

 

Figure 13
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  		Figure 13b.  Calvarial osteomyelitis complicated by pachymeningitis and epidural abscess in a 17-year-old girl who was 28 weeks pregnant and experienced a seizure. (a) Sagittal T1-weighted MR image shows diffuse low signal intensity in the bone marrow and an elliptical extraaxial lesion in the midline anteriorly (arrow). (b) Axial FLAIR MR image shows the elliptical extraaxial hyperintense lesion lying over the superior sagittal sinus anteriorly. (c) Three-dimensional time-of-flight MR venogram shows interruption of the superior sagittal sinus anteriorly (arrows). (d) Sagittal gadolinium-enhanced T1-weighted MR image shows enhancement consistent with osteomyelitis of the frontal bone (solid straight arrow) and clearly demonstrates the epidural abscess (open straight arrow) with pachymeningitis (curved arrows). Further questioning of the patient disclosed sickle cell trait and a recent history of pneumonia.

 

Figure 13
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  		Figure 13c.  Calvarial osteomyelitis complicated by pachymeningitis and epidural abscess in a 17-year-old girl who was 28 weeks pregnant and experienced a seizure. (a) Sagittal T1-weighted MR image shows diffuse low signal intensity in the bone marrow and an elliptical extraaxial lesion in the midline anteriorly (arrow). (b) Axial FLAIR MR image shows the elliptical extraaxial hyperintense lesion lying over the superior sagittal sinus anteriorly. (c) Three-dimensional time-of-flight MR venogram shows interruption of the superior sagittal sinus anteriorly (arrows). (d) Sagittal gadolinium-enhanced T1-weighted MR image shows enhancement consistent with osteomyelitis of the frontal bone (solid straight arrow) and clearly demonstrates the epidural abscess (open straight arrow) with pachymeningitis (curved arrows). Further questioning of the patient disclosed sickle cell trait and a recent history of pneumonia.

 

Figure 13
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  		Figure 13d.  Calvarial osteomyelitis complicated by pachymeningitis and epidural abscess in a 17-year-old girl who was 28 weeks pregnant and experienced a seizure. (a) Sagittal T1-weighted MR image shows diffuse low signal intensity in the bone marrow and an elliptical extraaxial lesion in the midline anteriorly (arrow). (b) Axial FLAIR MR image shows the elliptical extraaxial hyperintense lesion lying over the superior sagittal sinus anteriorly. (c) Three-dimensional time-of-flight MR venogram shows interruption of the superior sagittal sinus anteriorly (arrows). (d) Sagittal gadolinium-enhanced T1-weighted MR image shows enhancement consistent with osteomyelitis of the frontal bone (solid straight arrow) and clearly demonstrates the epidural abscess (open straight arrow) with pachymeningitis (curved arrows). Further questioning of the patient disclosed sickle cell trait and a recent history of pneumonia.

 




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