Patient Name: Madhumita Dey

UHID NO: 1246027

Doctor’s Name: Dr A Maji & Dr Apratim Chatterjee (ILS Hospital)

Patient 7 days postpartum came to us with status Epilepticus. Initially managed in Emergency department, CT showed parasagittal hypodensities and posterior watershed hypodensities. Urgent MRI with MRV was done to rule out CVT.

Possibilities kept were:

1) PRES -initial vision loss followed by altered sensorium and seizure.

2) RCVS: No h/o thunderclap headache was odd.

Patient improved in GCS the next day, but had right sided complete hemiplegia. A repeat CT was done, no fresh areas of involvement were found. However an infarct and diffusion restriction was unlikely in PRES. Vasculitis profile, which came negative later, was sent keeping in mind the initial MRA revealed left sided beading appearance. However since she had this ongoing paresis, we decided to repeat the MRA again with contrast MRI in case we were missing an ADEM. Repeat MRA revealed bilateral gross increase of spasm in the cerebral vessels. With guarded prognosis, we started IVF almost @ 100 ml/hr and Nimodipine for diagnosis of RCVS. A differential of PACNS was kept, but in 1 day span such increase in PACNS was unlikely.

Hence steroids were withheld. Added to this was the challenge of postpartum cardiomyopathy with an EF of 30% and use of diuretics was challenging keeping a balance between fluid overload and intra-vascular fluid depletion as we needed to give IVF in a higher dose to reverse the cerebral vasospasm. Patient recovered very well and was extubated. The EF also improved to 64% now and is planned for discharge after few turbulent in-admission course. A mother was thus returned to her child with smile and we are so so happy.