Neuroimaging during Pregnancy

Joshua P Klein; Liangge Hsu

doi:10.1055/s-0031-1293535

Seminars in Neurology, Table of Contents

Semin Neurol 2011; 31(4): 361-373
DOI: 10.1055/s-0031-1293535

Neuroimaging during Pregnancy

Joshua P. Klein¹ ^, ² , Liangge Hsu¹

¹Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
²Department of Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts

Abstract

ABSTRACT

Pregnancy can be associated with a wide variety of neurologic problems, resulting from alterations in physiology of the pregnant state. The pregnant patient presenting with neurologic symptoms poses both diagnostic and therapeutic challenges. The physician will often require some form of neuroimaging as part of their ongoing evaluation. This review discusses potential risks to the embryo and fetus that can be caused by undergoing computed tomography (CT) and magnetic resonance imaging (MRI), including those associated with the administration of intravenous contrast. Neurologic diseases or syndromes specifically associated with pregnancy are also discussed.

KEYWORDS

Radiation safety - contrast - computed tomography - magnetic resonance imaging - stroke - vasoconstriction - eclampsia - lactation

Full Text

References

REFERENCES

1 American College of Radiology (ACR) .ACR Guidelines and Technical Standards. Practice guideline for imaging pregnant or potentially pregnant adolescents and women with ionizing radiation. 1st ed. Reston, VA: American College of Radiology; 2008: 1-15
2 American College of Radiology. ACR practice guideline for the use of intravascular contrast media. Reston, VA: American College of Radiology; 2007: 1-6
3 Kanal E, Barkovich A J, Bell C ACR Blue Ribbon Panel on MR Safety et al. ACR guidance document for safe MR practices: 2007. AJR Am J Roentgenol. 2007; 188 (6) 1447-1474
4 ACOG committee opinion guidelines for diagnostic imaging during pregnancy. Obstet Gynecol. 2004; 104 (3) 647-651
5 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 (6) 1234-1240
6 Wagner L K, Lester R G, Saldana L R. Exposure of the Pregnant Patient to Diagnostic Radiations: A Guide to Medical Management. Philadelphia, PA: Lippincott; 1985: 19-223
7 Berlin L. Radiation exposure and the pregnant patient. AJR Am J Roentgenol. 1996; 167 (6) 1377-1379
8 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 (5) 870-875
9 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 (9) 527-533
10 Wagner L K, Archer B R, Zeck O F. Conceptus dose from two state-of-the-art CT scanners. Radiology. 1986; 159 (3) 787-792
11 Mole R H. Irradiation of the embryo and fetus. Br J Radiol. 1987; 60 (709) 17-31
12 Stewart A WJ, Giles D, Hewitt D. Malignant disease in childhood and diagnostic irradiation in utero. Lancet. 1956; 2 447
13 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
14 Mole R H. Childhood cancer after prenatal exposure to diagnostic X-ray examinations in Britain. Br J Cancer. 1990; 62 (1) 152-168
15 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
16 Muirhead C R, Cox R, Stather J W et al.. Estimates of late radiation risks to the UK population. Documents of the NRPB. Chilton. 1993; 4 (4) 17-157
17 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 (2) 189-196
18 Doll R, Wakeford R. Risk of childhood cancer from fetal irradiation. Br J Radiol. 1997; 70 130-139
19 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
20 Benjamin S A, Lee A C, Angleton G M et al.. Neoplasms in young dogs after perinatal irradiation. J Natl Cancer Inst. 1986; 77 (2) 563-571
21 Nelson J A, Livingston G K, Moon R G. Mutagenic evaluation of radiographic contrast media. Invest Radiol. 1982; 17 (2) 183-185
22 Morisetti A, Tirone P, Luzzani F, de Haën C. Toxicologic safety assessment of iomeprol, a new x-ray contrast agent. Eur J Radiol. 1994; 18 21-31
23 Ralston W H, Robbins M S, James P. Reproductive, developmental, and genetic toxicity of ioversol. Invest Radiol. 1989; 24 16-22
24 Rodesch F, Camus M, Ermans A M, Dodion J, Delange F. Adverse effect of amniofetography on fetal thyroid function. Am J Obstet Gynecol. 1976; 126 (6) 723-726
25 Bona G, Zaffaroni M, Defilippi C, Gallina M R, Mostert M. Effects of iopamidol on neonatal thyroid function. Eur J Radiol. 1992; 14 (1) 22-25
26 Russell L B, Russell W L. An analysis of the changing radiation response of the developing mouse embryo. J Cell Physiol Suppl. 1954; 43 (Suppl. 1) 103-149
27 Brent R L, Ghorson R O. Radiation exposure in pregnancy. Curr Probl Radiol. 1972; 2 1-48
28 Blot W J, Miller R W. Mental retardation following in utero exposure to the atomic bombs of Hiroshima and Nagasaki. Radiology. 1973; 106 (3) 617-619
29 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 (5) 605-609
30 Otake M, Schull W J. In utero exposure to A-bomb radiation and mental retardation; a reassessment. Br J Radiol. 1984; 57 (677) 409-414
31 Dekaban A S. Abnormalities in children exposed to x-radiation during various stages of gestation: tentative timetable of radiation injury to the human fetus. I. J Nucl Med. 1968; 9 (9) 471-477
32 Stewart A, Kneale G W. Radiation dose effects in relation to obstetric x-rays and childhood cancers. Lancet. 1970; 1 (7658) 1185-1188
33 Wakeford R, Little M P. Risk coefficients for childhood cancer after intrauterine irradiation: a review. Int J Radiat Biol. 2003; 79 (5) 293-309
34 Hall E J, Giaccia A J. Radiobiology for the Radiologist. Philadelphia; Lippincott, Williams, and Wilkins, 2006
35 Osei E K, Faulkner K. Fetal doses from radiological examinations. Br J Radiol. 1999; 72 (860) 773-780
36 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 (3) 305-313
37 Tyndall D A, Sulik K K. Effects of magnetic resonance imaging on eye development in the C57BL/6J mouse. Teratology. 1991; 43 (3) 263-275
38 Yip Y P, Capriotti C, Talagala S L, Yip J W. Effects of MR exposure at 1.5 T on early embryonic development of the chick. J Magn Reson Imaging. 1994; 4 (5) 742-748
39 Kanal E, Shellock F G, Talagala L. Safety considerations in MR imaging. Radiology. 1990; 176 (3) 593-606
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 (1 Pt 1) 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 (814) 1090-1094
42 Kittner S J, Stern B J, Feeser B R et al.. Pregnancy and the risk of stroke. N Engl J Med. 1996; 335 (11) 768-774
43 Wilterdink J L, Easton J D. Cerebral ischemia in pregnancy. Adv Neurol. 2002; 90 51-62
44 Wilterdink J L, Feldmann E. Intracranial hemorrhage. Adv Neurol. 2002; 90 63-74
45 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 (1) 68-73
46 Ducreux D, Oppenheim C, Vandamme X et al.. Diffusion-weighted imaging patterns of brain damage associated with cerebral venous thrombosis. AJNR Am J Neuroradiol. 2001; 22 (2) 261-268
47 Mullins M E, Grant P E, Wang B, Gonzalez R G, Schaefer P W. Parenchymal abnormalities associated with cerebral venous sinus thrombosis: assessment with diffusion-weighted MR imaging. AJNR Am J Neuroradiol. 2004; 25 (10) 1666-1675
48 Bateman B T, Schumacher H C, Bushnell C D et al.. Intracerebral hemorrhage in pregnancy: frequency, risk factors, and outcome. Neurology. 2006; 67 (3) 424-429
49 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 (6) 1139-1145 discussion 1145-1148
50 Moodley J, Kalane G. A review of the management of eclampsia: practical issues. Hypertens Pregnancy. 2006; 25 (2) 47-62
51 Koch S, Rabinstein A, Falcone S, Forteza A. Diffusion-weighted imaging shows cytotoxic and vasogenic edema in eclampsia. AJNR Am J Neuroradiol. 2001; 22 (6) 1068-1070
52 Loureiro R, Leite C C, Kahhale S et al.. Diffusion imaging may predict reversible brain lesions in eclampsia and severe preeclampsia: initial experience. Am J Obstet Gynecol. 2003; 189 (5) 1350-1355
53 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 (1) 79-85
54 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 (2) 122-125
55 Provenzale J M, Petrella J R, Cruz Jr 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 (8) 1455-1461
56 Hinchey J, Chaves C, Appignani B et al.. A reversible posterior leukoencephalopathy syndrome. N Engl J Med. 1996; 334 (8) 494-500
57 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 (6) 1038-1048
58 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 (5) 1082-1085
59 Ay H, Buonanno F S, Schaefer P W et al.. Posterior leukoencephalopathy without severe hypertension: utility of diffusion-weighted MRI. Neurology. 1998; 51 (5) 1369-1376
60 D'Aprile P, Farchi G, Pagliarulo R, Carella A. Thrombotic thrombocytopenic purpura: MR demonstration of reversible brain abnormalities. AJNR Am J Neuroradiol. 1994; 15 (1) 19-20
61 Ruggenenti P, Remuzzi G. The pathophysiology and management of thrombotic thrombocytopenic purpura. Eur J Haematol. 1996; 56 (4) 191-207
62 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 (6) 1285-1288
63 Singhal A B. Postpartum angiopathy with reversible posterior leukoencephalopathy. Arch Neurol. 2004; 61 (3) 411-416
64 Neudecker S, Stock K, Krasnianski M. Call-Fleming postpartum angiopathy in the puerperium: a reversible cerebral vasoconstriction syndrome. Obstet Gynecol. 2006; 107 (2 Pt 2) 446-449
65 Call G K, Fleming M C, Sealfon S, Levine H, Kistler J P, Fisher C M. Reversible cerebral segmental vasoconstriction. Stroke. 1988; 19 (9) 1159-1170
66 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 (1) 130-133
67 Kanaan I, Jallu A, Kanaan H. Management strategy for meningioma in pregnancy: A clinical study. Skull Base. 2003; 13 (4) 197-203
68 Mamelak A N, Withers G J, Wang X. Choriocarcinoma brain metastasis in a patient with viable intrauterine pregnancy. Case report. J Neurosurg. 2002; 97 (2) 477-481
69 Biousse V, Newman N J, Oyesiku N M. Precipitating factors in pituitary apoplexy. J Neurol Neurosurg Psychiatry. 2001; 71 (4) 542-545
70 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 (1) 27-28
71 Keleştimur F. Sheehan's syndrome. Pituitary. 2003; 6 (4) 181-188
72 Stelmach M, O'Day J. Rapid change in visual fields associated with suprasellar lymphocytic hypophysitis. J Clin Neuroophthalmol. 1991; 11 (1) 19-24
73 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 (1) 47-56
74 McCutcheon I E, Oldfield E H. Lymphocytic adenohypophysitis presenting as infertility. Case report. J Neurosurg. 1991; 74 (5) 821-826
75 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. 2001; 101 (6) 631-637
76 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 (2) 169-175
77 Ikeda H, Okudaira Y. Spontaneous regression of pituitary mass in temporal association with pregnancy. Neuroradiology. 1987; 29 (5) 488-492
78 Ikeda H, Yoshimoto T. Visual disturbances in patients with pituitary adenoma. Acta Neurol Scand. 1995; 92 (2) 157-160
79 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 (3) 336-342
80 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 (7) 549-550
81 Gallucci M, Bozzao A, Splendiani A, Masciocchi C, Passariello R. Wernicke encephalopathy: MR findings in five patients. AJNR Am J Neuroradiol. 1990; 11 (5) 887-892
82 Chung S P, Kim S W, Yoo I S, Lim Y S, Lee G. Magnetic resonance imaging as a diagnostic adjunct to Wernicke encephalopathy in the ED. Am J Emerg Med. 2003; 21 (6) 497-502
83 Togay-Işikay C, Yiğit A, Mutluer N. Wernicke's encephalopathy due to hyperemesis gravidarum: an under-recognised condition. Aust N Z J Obstet Gynaecol. 2001; 41 (4) 453-456
84 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 (1) 123-127
85 Confavreux C, Hutchinson M, Hours M M, Cortinovis-Tourniaire P, Moreau T. Pregnancy in Multiple Sclerosis Group . Rate of pregnancy-related relapse in multiple sclerosis. N Engl J Med. 1998; 339 (5) 285-291
86 Soldan S S, Alvarez Retuerto A I, Sicotte N L, Voskuhl R R. Immune modulation in multiple sclerosis patients treated with the pregnancy hormone estriol. J Immunol. 2003; 171 (11) 6267-6274
87 Sandhu F S, Dillon W P. Spinal epidural abscess: evaluation with contrast-enhanced MR imaging. AJNR Am J Neuroradiol. 1991; 12 (6) 1087-1093
88 Yonekawa Y, Mehdorn H M, Nishikawa M. Spontaneous spinal epidural hematoma during pregnancy. Surg Neurol. 1975; 3 (6) 327-328

Joshua P KleinM.D. Ph.D.

Department of Neurology, Brigham and Women's Hospital

75 Francis Street, Boston, MA 02115

Email: jpklein@partners.org