Cerebral embolism as the initial manifestation of peripartum cardiomyopathy

Hodgman, Mark T.; Pessin, Michael S.; Homans, D. C.; Panis, Walter; Prager, Robert J.; Lathi, Ellen; Criscitiello, Modestino G.

doi:10.1212/wnl.32.6.668

Cited by 28 publications

(9 citation statements)

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“…Patients most commonly present with signs and symptoms of systolic heart disease, but with (unnoticed) progression of the disease the heart may dilate and thrombus formation in the ventricles may occur. Neurological symptoms can arise in case of cerebral embolization [11], but also thromboembolism in the lower extremities has been described [12]. Therefore, as is also demonstrated in our case, PPCM may present with predominantly noncardial symptoms.…”

Section: Discussionsupporting

confidence: 77%

Ischemic neuropathy and rhabdomyolysis as presenting symptoms of postpartum cardiomyopathy

Helmich

Laarhoven

Schoonderwaldt

et al. 2008

J Thromb Thrombolysis

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Rhabdomyolysis and peripheral neuropathy are two distinct disease entities which are rarely encountered in combination. We present a woman with rhabdomyolysis and peripheral neuropathy 3 weeks postpartum. Her symptoms were caused by bilateral femoral artery thrombosis due to postpartum cardiomyopathy (PPCM). This demonstrates that PPCM may present with predominantly non-cardial symptoms and underscores the importance of rapidly recognizing this disorder.Keywords Postpartum cardiomyopathy Á Neuropathy Á Rhabdomyolysis Case reportA 22-year-old woman was referred from another hospital to our department of neurology because of severe rhabdomyolysis (CK levels of [13,000 U/l) and muscle weakness of both legs. Five days before admission she suffered from acute muscle cramps, followed by muscle weakness in both legs and numbness of both feet. Her medical history revealed preeclampsia 1 month earlier and she delivered a healthy baby 3 weeks before presentation. She used folic acid and ferrofumarate because of the recent pregnancy and nitrofurantoine because of a urinary tract infection. She did not smoke and used no alcohol. Neurological examination revealed a paresis of the anterior tibial and extensor hallucis longus muscles on both sides (left [ right). There was sock-shaped hyposensibility without pain. Both feet were warm and had a normal color. The right leg was edematous and arterial pulsations were absent in the right foot. Electromyography showed multiple neuropathies in distal branches of the left peroneal, posterior tibial, sural and superficial peroneal nerves. Muscle biopsy revealed no abnormalities. On angiography of the legs thrombosis of the right internal iliac artery, the right proximal superficial femoral artery (AFS), the left AFS, popliteal and anterior tibial arteries was observed as well as an infarction of the right kidney (Fig. 1). The chest X-ray showed a widened mediastinum and echocardiography revealed a decreased left ventricular function (ejection fraction 30%). No thrombophilic risk factors were found and there was no evidence for an autoimmune disease (normal levels of homocysteine, antithrombin, protein C and S, factor V mutation, prothrombin mutation, lupus anticoagulant, anticardiolipin, ANA, ANCA, complement C3 and C4 all negative). Based on a cardiomyopathy in the context of her recent pregnancy, postpartum cardiomyopathy (PPCM) was diagnosed. Later, when asked for earlier symptoms of cardiomyopathy, the patient mentioned that she had been progressively dyspnoeic in the last weeks of her pregnancy. Thrombectomy of the occluded arteries was performed and anticoagulation (low molecular weight heparin) was started. Thereafter the patient was treated with a vitamin K antagonist, acetylsalicylic acid and an ace-inhibitor. After 8 months the patient had only mild neuropathic pain in her left foot, which responded well to gabapentin. Her heart

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Section: Discussionsupporting

confidence: 77%

Ischemic neuropathy and rhabdomyolysis as presenting symptoms of postpartum cardiomyopathy

Helmich

Laarhoven

Schoonderwaldt

et al. 2008

J Thromb Thrombolysis

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“…Cerebral embolism and stroke have been reported as the initial manifestation. 18 Previous reports of acute ischemia of the leg described women with several months of known ventricular dysfunction prior to a peripheral embolic event. 19 Another case presented by Paul JG et.al, who was a young, healthy, postpartum female developed acute ischemia of the left leg, and asymptomatic arterial insufficiency of the right lower leg, as the presenting symptoms of peripartum cardiomyopathy, she was anticoagulated with heparin & managed conservatively.…”

Section: Discussionmentioning

confidence: 99%

Anaesthetic Management of a Patient with Peripartum Cardiomyopathy: A Case Report

Saha¹,

Islam

Ahmed

et al. 2016

Birdem Med J

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Peripartum cardiomyopathy is a rare affliction of healthy, young, females characterized by congestive heart failure, intracardiac thrombus, and frequently death. PPCM is associated with a hypercoagulative state, which can cause thromboembolic complications, may be, the initial demonstration off peripartum cardiomyopathy, which is usually an intracardiac thrombosis. Lower extremity embolism is uncommon. We present a case of 22 yr old female a known case of preeclamtic toxaemia associated with bronchial asthma underwent caesarian section at 36 wks of pregnancy & developed severe respiratory distress and needed mechanical ventilation. Two weeks after delivery she developed low back pain with parasthesia of both lower limbs associated with shortness of breath & diagnosed as a case of infra-renal aortic thrombus extending down to common illiac arteries associated with postpartum dilated cardiomyopathy and admitted at our hospital for embolectomy. Infiltration anaesthesia and conscious sedation with invasive monitoring was planned. Surgery and anaesthesia proceeded uneventfully.

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“…It is not unusual for PC to present with signs and symptoms of embolism [39]. Embolic phenomena in one scries was the second most frequent complication of this disease, following digitalis toxici ty [7], The systemic incidence of embolism in PC has been estimated to range from 25 to 40% [2].…”

Section: Discussionmentioning

confidence: 99%

Peripartum Cardiomyopathy and Stroke

Dyken

Biller

1994

Cerebrovasc Dis

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In the United States, peripartum cardiomyopathy (PC) is an uncommon form of dilated cardiomyopathy, which, when associated with stroke, results in a high mortality rate. The estimated incidence of PC at the University of Iowa Hospitals and Clinics from 1/1/1976 to 7/1/1993 averaged only 1 out of every 8,135 deliveries. Of the total 5 cases diagnosed, only 1 presented with neurologic manifestations. Through the use of echocardiography, cine-computerized tomography and magnetic resonance imaging, a large left ventricular mural thrombus in a diffusely hypokinetic heart was found. Newer cardiac imaging techniques are improving our ability to diagnose the cause of stroke in the younger population, including women in the peripartum period, allowing early institution of appropriate medical treatment and hopefully improving prognosis.

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Cerebral embolism as the initial manifestation of peripartum cardiomyopathy

Cited by 28 publications

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Ischemic neuropathy and rhabdomyolysis as presenting symptoms of postpartum cardiomyopathy

Ischemic neuropathy and rhabdomyolysis as presenting symptoms of postpartum cardiomyopathy

Anaesthetic Management of a Patient with Peripartum Cardiomyopathy: A Case Report

Peripartum Cardiomyopathy and Stroke

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