Highlight
This study highlights: 1) The presence of silent cerebral infarcts in one-third of women with eclampsia detected via MRI; 2) Higher systolic blood pressure prior to eclampsia episodes as a strong clinical predictor; 3) Impaired hearing before seizures strongly associated with cerebral infarcts; 4) Potential clinical utility of these markers to guide neuroimaging and neurological follow-up.
Study Background
Eclampsia, characterized by new-onset seizures in pregnancy often accompanied by severe hypertension and neurological complications, poses significant risks for acute and long-term brain injury. Neurological sequelae following eclampsia include cerebral infarction, which may be clinically silent but contributes to morbidity. Magnetic resonance imaging (MRI) studies in eclamptic women have demonstrated incidences of silent cerebral infarcts ranging from 30% to 40%, raising concern about underrecognized brain injury. However, routine neuroimaging for all affected women is impractical in most settings, given resource constraints and accessibility issues, particularly in low-resource environments.
Identifying simple, clinical predictors of silent cerebral infarcts could stratify women at highest risk, facilitating targeted neuroimaging and timely intervention to mitigate long-term neurological deficits. This study conducted at Tygerberg Hospital, a tertiary center in Cape Town, South Africa, aims to evaluate clinical markers predictive of cerebral infarction detected by MRI in women after eclampsia.
Study Design
This prospective observational cross-sectional study enrolled 49 women diagnosed with eclampsia at Tygerberg Hospital. Participants underwent standardized clinical assessments for symptoms and signs associated with eclampsia, including detailed neurological and audiological evaluation prior to the eclamptic seizure event where possible.
Brain MRI was performed to identify cerebral infarcts, including subclinical lesions. The principal analysis utilized logistic regression to examine the association of clinical variables with presence of cerebral infarcts. Variables with significance at the 20% level in univariable analysis were included using stepwise selection in multivariable modeling. Diagnostic performance metrics including sensitivity, specificity, and area under the receiver operating characteristic (ROC) curve were calculated to assess the predictive value of identified markers.
Key Findings
Of 49 women with eclampsia studied, 16 (33%) had cerebral infarcts detected on MRI, consistent with literature-reported rates. Two clinical factors emerged as the strongest independent predictors of silent cerebral infarcts:
- Highest Systolic Blood Pressure Prior to Seizure: Elevated systolic blood pressure showed a significant association with cerebral infarcts. This aligns with the pathophysiological understanding that severe hypertension can contribute to cerebral endothelial damage, blood-brain barrier disruption, and ischemic injury.
- Impaired Hearing Prior to Seizure: Hearing impairment before seizure onset was strongly related to the presence of infarcts, suggesting involvement of brainstem or central auditory pathways vulnerable to ischemic injury in eclampsia.
The combined use of these clinical markers produced an ROC area under the curve (AUC) of 0.72 (95% CI 0.56–0.88), indicating moderate discriminatory ability. At a chosen risk threshold of 43%, sensitivity was 60% (95% CI 36%–80%) and specificity was 84% (95% CI 67%–93%), demonstrating a reasonable balance between correctly identifying infarcts and limiting false positives.
These findings suggest potential utility in clinical settings to identify women at elevated risk for silent cerebral infarcts after eclampsia, who might benefit from neuroimaging and neurological follow-up.
Expert Commentary and Mechanistic Insights
This study contributes valuable clinical prognostic information amid scarce data on accessible markers for silent cerebral infarcts post-eclampsia. The association of high systolic blood pressure with infarcts is biologically plausible, consistent with cerebral autoregulatory impairment and hypertensive encephalopathy mechanisms in eclampsia. Similarly, hearing loss may reflect ischemic injury impacting auditory pathways, although further studies are needed to elucidate specific neuroanatomical correlations.
Limitations include the relatively small sample size and single-center design, which may affect generalizability. The moderate sensitivity indicates some infarcts would be missed using clinical markers alone, emphasizing need for additional predictive tools or biomarkers. Also, confirmation by external cohorts and evaluation in diverse populations are necessary before clinical implementation.
From a clinical standpoint, the identification of simple bedside markers could help prioritize neuroimaging resources, reduce delayed diagnosis of cerebral injury, and guide targeted neurological surveillance to improve outcomes in this vulnerable population.
Conclusions
In women with eclampsia, impaired hearing and elevated systolic blood pressure prior to seizure are significantly associated with the presence of silent cerebral infarcts identified by MRI. These clinical markers represent promising, practical tools for risk stratification that may support decisions on neuroimaging and neurological follow-up. Further validation in larger and diverse cohorts is required to confirm their predictive value and optimization of clinical pathways.
Future research should focus on integrating these clinical parameters with other potential biomarkers to enhance early identification of at-risk women, ultimately aiming to reduce long-term neurological morbidity following eclampsia.
Funding and ClinicalTrials.gov
The original study was performed at Tygerberg Hospital, South Africa, with no specific funding disclosed. Clinical trial registration details were not reported.
References
1. Bergman L, et al. Impaired Hearing and Systolic Blood Pressure as Potential Markers of Cerebral Infarction After Eclampsia: A Cross-Sectional Study. BJOG. 2026;133(8):1679-1688. PMID: 41876090.
2. Magee LA, Pels A, Helewa M, Rey E, von Dadelszen P. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy. Pregnancy Hypertens. 2014;4(2):105-145.
3. Sibai BM. Diagnosis, prevention and management of eclampsia. Obstet Gynecol. 2005;105(2):402-410.
4. Illanes SE, et al. Silent cerebral infarcts post-preeclampsia and eclampsia: critical implications. Stroke. 2018;49(6):1436-1442.
