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Hinduja A, Habetz K, Raina SK, Fitzgerald RT. Predictors of intensive care unit utilization in patients with posterior reversible encephalopathy syndrome. Acta Neurol Belg 2017; 117:201-206. [PMID: 27680733 DOI: 10.1007/s13760-016-0703-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Accepted: 09/21/2016] [Indexed: 10/20/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is an acute neurological syndrome that requires prompt, aggressive management to improve outcomes. Our aim was to identify factors that would necessitate care in the intensive care unit (ICU) in patients with PRES and the outcomes on discharge following ICU stay. We retrospectively reviewed the medical records and radiological data of adult PRES patients admitted to our tertiary care medical center. We dichotomized them into two groups based on their need for ICU care and compared their clinical, laboratory, imaging characteristics and discharge outcomes. Outcomes were defined using the modified Rankin Score (mRS) and Glasgow Outcome Score (GOS) on discharge. Out of 100 patients, 67 % required admission to the ICU. On univariate analysis, factors associated with ICU admission were atrial fibrillation (19.4 vs 0 %; p ≤ 0.05), encephalopathy from PRES (89.6 vs 66.7 %; p < 0.05), low Glasgow Coma Score (GCS) (11 ± 4 vs 14 ± 2; p = 0.01) and cortical involvement on imaging (89.6 vs 72.7 %, p = 0.03). On multivariate logistic regression analysis, encephalopathy (odds ratio 10.22; 95 % CI (1.14-91.55; p = 0.04) was the sole predictor of ICU utilization. This correlated with a GCS <12 (odds ratio 5.53; 95 % CI (1.05-29.22; p = 0.04). Despite worse functional outcomes following ICU care based on mRS (2.3 ± 2.1 vs 1.3 ± 1.4, p = 0.02) and GOS (3.9 ± 1.3 vs 4.6 ± 0.7, p ≤ 0.05), only a borderline increase in mortality was observed (10.4 vs 0 %, p = 0.05). The presence of PRES-related encephalopathy might aid in prompt identification of patients who require ICU care.
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Hayashi Y, Kimura A, Nakamura H, Mimuro M, Iwasaki Y, Hara A, Yoshida M, Inuzuka T. Neuropathological findings from an autopsied case showing posterior reversible encephalopathy syndrome-like neuroradiological findings associated with premedication including tacrolimus for autologous peripheral blood stem cell transplantation. J Neurol Sci 2017; 375:382-387. [PMID: 28320172 DOI: 10.1016/j.jns.2017.02.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 02/06/2017] [Accepted: 02/13/2017] [Indexed: 12/27/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is diagnosed based on neuroradiological findings. Typically, PRES is reversible and presents with a good outcome; however, fatal outcomes have been reported. We report an autopsied case showing PRES-like neuroradiological findings associated with premedication including tacrolimus for autologous peripheral blood stem cell transplantation in a 28-year-old woman with a 2-year history of acute myeloid sarcoma/acute myeloid leukemia. Neurological examination revealed disturbed consciousness, muscle weakness in all extremities, and bilaterally diminished tendon reflexes. Brain fluid attenuated inversion recovery MRI showed multiple bilateral hyper-intensity areas in the posterior white matter and left corona radiate. She died of respiratory arrest within 24h after PRES diagnosis. Neuropathological examination revealed diffuse cerebral edema, multiple cerebral hematomas that extended into the lateral ventricles and subarachnoid cavities, and multiple microbleeds predominantly in the inferior surface of the occipital white matter. Microscopic findings revealed paler myelin sheaths, enlargement of the vascular endothelium, leakage of plasma components and red blood cells, and clasmatodendrosis within the occipital white matter. Cerebral herniation and diffuse cerebral edema due to vascular endothelial dysfunction were concluded to be the cause of death. These pathological findings may aid in the pathophysiological recognition of acute-stage PRES.
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Affiliation(s)
- Yuichi Hayashi
- Department of Neurology and Geriatrics, Gifu University Graduate School of Medicine, Gifu 501-1194, Japan.
| | - Akio Kimura
- Department of Neurology and Geriatrics, Gifu University Graduate School of Medicine, Gifu 501-1194, Japan
| | - Hiroshi Nakamura
- Department of Hematology, Gifu University Graduate School of Medicine, Gifu 501-1194, Japan
| | - Maya Mimuro
- Department of Neuropathology, Institute for Medical Science of Aging, Aichi Medical University, Nagakute 480-1195, Japan
| | - Yasushi Iwasaki
- Department of Neuropathology, Institute for Medical Science of Aging, Aichi Medical University, Nagakute 480-1195, Japan
| | - Akira Hara
- Department of Tumor Pathology, Gifu University Graduate School of Medicine, Gifu 501-1194, Japan
| | - Mari Yoshida
- Department of Neuropathology, Institute for Medical Science of Aging, Aichi Medical University, Nagakute 480-1195, Japan
| | - Takashi Inuzuka
- Department of Neurology and Geriatrics, Gifu University Graduate School of Medicine, Gifu 501-1194, Japan
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Magsi S, Zafar A. Malignant Posterior Reversible Encephalopathy Syndrome-An Exacting Challenge for Neurocritical Care Physicians. Neurohospitalist 2017; 7:196-199. [PMID: 28974999 DOI: 10.1177/1941874416688989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We report a case of malignant posterior reversible encephalopathy syndrome (PRES) in a 62-year-old Caucasian female with a complex medical history and comorbidities admitted for bowel resection and lysis of iatrogenic bowel adhesions and enterocutaneous fistulas. Postoperatively, the patient developed sudden bilateral visual loss with no other neurologic deficits. Computed tomography scan showed very severe PRES-like changes, confirmed on magnetic resonance imaging (MRI). Systolic blood pressure remained around 170 mm HG. The patient was obtunded and remained unresponsive after MRI, with minimal response and a deteriorating clinical condition. The patient was given hyperosmolar therapy with a mannitol bolus. She recovered well with near resolution of imaging findings.
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Ollivier M, Bertrand A, Clarençon F, Gerber S, Deltour S, Domont F, Trunet S, Dormont D, Leclercq D. Neuroimaging features in posterior reversible encephalopathy syndrome: A pictorial review. J Neurol Sci 2017; 373:188-200. [DOI: 10.1016/j.jns.2016.12.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 12/06/2016] [Accepted: 12/07/2016] [Indexed: 10/20/2022]
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Spectrum of cerebral spinal fluid findings in patients with posterior reversible encephalopathy syndrome. J Neurol 2016; 263:30-4. [PMID: 26477022 DOI: 10.1007/s00415-015-7928-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 10/02/2015] [Accepted: 10/03/2015] [Indexed: 10/22/2022]
Abstract
The purpose of this study is to characterize the spectrum of cerebrospinal fluid (CSF) findings in patients with posterior reversible encephalopathy syndrome (PRES)and determine its associations with severity of edema. In this retrospective cross-sectional study electronic medical reports were screened for patients with PRES. Clinical and laboratory data closest to onset of clinical symptoms were collected. Neuroimaging reports from all patients were categorized according to the presence of vasogenic edema,cytotoxic edema and contrast enhancement. From Jan 1999to Feb 2015, 87 patients with PRES and CSF findings were included. Mean total protein levels were 793 ± 929 mg/l. Median cell counts were 2/μl (IQR 1-4). Eight patients had cell counts[6/μl with a maximum of 41/μl. In 31 patients with extended CSF analysis, mean CSF/serum albuminquotient (QAlb) was 10.1 (IQR 6-17.3). An elevated QAlb (age-adjusted) was found in 74 % of these 31 patients. PRES patients with severe edema had higher mean total protein levels in CSF (mean difference = 407 mg/l; 95 %CI 187-628). Significant correlations were found for edema severity with levels of CSF protein (r = 0.48, p<0.001) as well with QAlb (r = 0.44, p = 0.013). This study shows that total protein in CSF and QAlb are elevated and correlate with severity of edema in PRES patients, whereas pleocytosis was rare in our cohort. This supports the theory that PRES is caused by a dysfunctional blood brain barrier.
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Siebert E, Bohner G, Liebig T, Endres M, Liman TG. Factors associated with fatal outcome in posterior reversible encephalopathy syndrome: a retrospective analysis of the Berlin PRES study. J Neurol 2016; 264:237-242. [PMID: 27815684 DOI: 10.1007/s00415-016-8328-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 10/25/2016] [Accepted: 10/25/2016] [Indexed: 01/23/2023]
Abstract
Although often reversible, fatal outcome in posterior reversible encephalopathy syndrome (PRES) is well known. However, data on predictors of PRES-associated in-hospital death are scarce. In this study, we aimed to investigate predictors of in-hospital death in a large cohort. Radiological report databases between January 1999 and February 2015 were retrospectively searched for patients with PRES. Patients were included if they met criteria for PRES after detailed investigation of clinical charts and imaging studies. Various clinical, paraclinical and brain MRI data as well as data on in-hospital mortality were analyzed. 151 patients were included into the study, 64% were female. Seventeen (11.2%) patients died during hospital stay. In univariate analyses, higher age (p = 0.04), higher levels of C-reactive protein (p < 0.001), etiology of PRES (sepsis and chemotherapy; p = 0.02), altered coagulation (p = 0.002), altered mental state at onset (p = 0.03), and subarachnoid hemorrhage (SAH; p = 0.01) were related to in-hospital death. In multivariate analyses adjusted for age and sex, elevated CRP levels (OR 1.1 95% CI 1.1-1.2), altered coagulation (OR 5.1 95% CI 1.8-14.7), subarachnoid hemorrhage (OR 10.1 95% CI 2.2-46.1) and altered mental state (OR 3.3; 95% CI 1.1-9.4) were independently associated with in-hospital death. Altered mental state, subarachnoid hemorrhage as well as the higher levels of CRP and altered coagulation were significantly more frequent in patients who died in hospital. However, prospective studies are warranted to establish predictors of fatality in patients with PRES.
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Affiliation(s)
- Eberhard Siebert
- Institut für Neuroradiologie, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - G Bohner
- Institut für Neuroradiologie, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - T Liebig
- Institut für Neuroradiologie, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - M Endres
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Klinik für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Disease (DZNE), Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - T G Liman
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Klinik für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Issa G, Nasser S, Kodsi S, Farhat Z. Diffuse leukoencephalopathy in a 29-year-old male with hypertensive emergency. BJR Case Rep 2016; 2:20150199. [PMID: 30460008 PMCID: PMC6243316 DOI: 10.1259/bjrcr.20150199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 02/14/2016] [Accepted: 03/31/2016] [Indexed: 11/05/2022] Open
Abstract
Severe hypertension is associated with multiple symptoms that reflect the end-organ damage effect of rapidly increasing blood pressure. Encephalopathy is a manifestation of the clinical spectrum of hypertensive emergencies. Hypertensive encephalopathy was initially described as part of the posterior reversible encephalopathy syndrome, which mostly involved the parieto-occipital white matter of the brain. A more detailed review of this syndrome reveals many cases where the brain abnormalities are distributed in a more random pattern. We describe a case of diffuse leukoencephalopthy in a young male who presented with altered mental status, ataxia, and blurred vision. This is the most diffuse brain involvement ever described in hypertensive statuses.
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Affiliation(s)
- Ghada Issa
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical Center, Baltimore, MD, USA
| | - Samer Nasser
- Department of Nephrology, Conemaugh Memorial Medical Center, Johnstown, PA, USA
| | - Samir Kodsi
- Department of Diagnostic Radiology, Conemaugh Memorial Medical Center, Johnstown, PA, USA
| | - Zein Farhat
- Department of Health Services Research, University of Maryland, Baltimore, MD, USA
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Shields LBE, Johnson JR, Shields CB. Posterior reversible encephalopathy syndrome following a thoracic discectomy–induced dural leak: case report. J Neurosurg Spine 2016; 25:586-590. [DOI: 10.3171/2016.4.spine1623] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological syndrome characterized by headaches, altered mental status, seizures, and visual disturbances. Classic MRI findings include white matter changes of the parieto-occipital regions. This syndrome has been encountered in myriad medical illnesses, including hypertension, preeclampsia/eclampsia, and immunosuppressive conditions. While the pathogenesis of the disorder is unclear, vasoconstriction and hypoperfusion leading to brain ischemia and vasogenic edema have been implicated as potential mechanisms. The authors present, to the best of their knowledge, the first case of PRES following a thoracic spinal surgery–induced dural leak noted on resection of the fifth rib during a thoracotomy for a T4–5 discectomy. Brain MRI revealed large areas of increased FLAIR and T2 hyperintensity in the superior posterior frontal lobes, superior and medial parietal lobes, and bilateral occipital lobes. Following repair of the CSF leak, the patient's symptoms resolved. Spinal surgeons should be alert to the potentially life-threatening condition of PRES, especially in a hypertensive patient who experiences surgery-induced dural leakage. The development of a severe positional headache with neurological signs is a red flag that suggests the presence of PRES. Prompt attention to the diagnosis and treatment of this condition by repairing the dural leak via surgery or expeditious blood patch increases the likelihood of a favorable outcome.
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Affiliation(s)
| | | | - Christopher B. Shields
- 1Norton Neuroscience Institute,
- 2Norton Healthcare; and
- 3Department of Anatomical Science and Neurobiology, University of Louisville, School of Medicine, Louisville, Kentucky
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Gao B, Lerner A, Law M. The Clinical Outcome of Posterior Reversible Encephalopathy Syndrome. AJNR Am J Neuroradiol 2016; 37:E55-6. [PMID: 27365328 DOI: 10.3174/ajnr.a4853] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- B Gao
- Department of Radiology Yantai Yuhuangding Hospital Qingdao University Yantai, Shandong, China Department of Radiology Keck School of Medicine University of Southern California Los Angeles, California
| | - A Lerner
- Department of Radiology Keck School of Medicine University of Southern California Los Angeles, California
| | - M Law
- Department of Radiology Keck School of Medicine University of Southern California Los Angeles, California
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Hinduja A, Habetz K, Raina S, Ramakrishnaiah R, Fitzgerald RT. Predictors of poor outcome in patients with posterior reversible encephalopathy syndrome. Int J Neurosci 2016; 127:135-144. [PMID: 26892843 DOI: 10.3109/00207454.2016.1152966] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE Posterior reversible encephalopathy syndrome (PRES) is an acute neurotoxic syndrome that, although characteristically reversible, can be fatal or result in long-term disability in a subset of patients. Our aim was to identify factors associated with poor discharge outcome in PRES patients. MATERIALS AND METHODS We retrospectively reviewed the clinical and radiological records of all patients with PRES admitted at our tertiary care medical center from 2007 to 2014. They were divided based their modified Rankin Score at discharge and compared for their baseline variables, clinical, laboratory and imaging features. Poor outcome was defined by a modified Rankin scale 2-6 and was subdivided based on the primary mechanism that led to poor outcome. RESULTS Out of 100 PRES subjects, 36% had poor discharge outcomes. Factors associated with poor outcomes on univariate analysis were history of diabetes mellitus, coma, high Charlson comorbidity index, post-transplantation, autoimmune condition, lack of systolic or diastolic hypertension, elevated blood urea nitrogen and involvement of the corpus callosum. On multivariate analysis, only prior diabetes mellitus odd ratio (OR) = 6.8 (95% CI 1.1-42.1, p = 0.04), corpus callosum involvement (OR = 11.7; 95% CI 2.4-57.4, p = 0.00) were associated with poor outcome. Poor outcome also correlated with increased length of hospital stay (OR = 7.9; 95% CI 1.3-49.7, p = 0.03). CONCLUSION Large prospective studies incorporating serial blood glucose values and advanced imaging studies are required to validate these findings.
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Affiliation(s)
- Archana Hinduja
- a Department of Neurology , University of Arkansas for Medical Sciences , Little Rock , AR , US
| | - Kenneth Habetz
- b Department of Pediatric Neurology , Arkansas Children Hospital , Little Rock , AR , US
| | - Sunil Raina
- c Department of Community Medicine , Dr RP Government Medical College , Tanda , India
| | - Raghu Ramakrishnaiah
- d Department of Radiology , University of Arkansas for Medical Sciences , Little Rock , AR , US
| | - Ryan T Fitzgerald
- d Department of Radiology , University of Arkansas for Medical Sciences , Little Rock , AR , US
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Christopoulou F, Rizos EC, Kosta P, Argyropoulou MI, Elisaf M. Does this patient have hypertensive encephalopathy? ACTA ACUST UNITED AC 2016; 10:399-403. [PMID: 26896240 DOI: 10.1016/j.jash.2016.01.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Revised: 09/03/2015] [Accepted: 01/13/2016] [Indexed: 11/25/2022]
Abstract
A 63-year-old man was admitted to our hospital for further investigation and management of brain metastases. The patient was initially presented with a 4-day history of confusion. On the day of admission, the patient was confused, agitated, disorientated in place and time, and had visual disturbances. His blood pressure was repeatedly recorded high, with levels of systolic blood pressure between 170-210 mm Hg. A brain magnetic resonance imaging showed areas of high signal on T2 and fluid-attenuated inversion recovery images, located bilaterally in the white matter of the occipital regions and unilateral in the left frontal lobe, suggestive of posterior reversible encephalopathy syndrome. Aggressive treatment of hypertension resulted in complete resolution of the clinical and radiologic features of the syndrome.
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Affiliation(s)
| | - Evangelos C Rizos
- Department of Internal Medicine, University Hospital of Ioannina, Ioannina, Greece
| | - Paraskevi Kosta
- Radiology Department, Medical School, University Hospital of Ioannina, Ioannina, Greece
| | - Maria I Argyropoulou
- Radiology Department, Medical School, University Hospital of Ioannina, Ioannina, Greece
| | - Moses Elisaf
- Department of Internal Medicine, University Hospital of Ioannina, Ioannina, Greece.
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Babi MA, Gorman MJ, Cipolla MJ, Allen G, Al Jerdi S, Clouser R, Commichau C. Ondansetron-related hemorrhagic posterior reversible encephalopathy syndrome (PRES) following gastric bypass. SPRINGERPLUS 2016; 5:18. [PMID: 26759757 PMCID: PMC4703598 DOI: 10.1186/s40064-015-1644-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 12/20/2015] [Indexed: 02/06/2023]
Abstract
Background Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiographic syndrome formally recognized in 1996, which describes specific changes noted on neuroimaging thought to be related to impaired cerebral blood flow autoregulation and endothelial dysfunction. We report a case of PRES in the setting of increased ingestion of ondansetron; complicated by hemorrhagic transformation and refractory intracranial hypertension. We hypothesize an association of 5-HT3 antagonism and PRES. Findings This is a case study report; with review of previously published literature through PubMed search. We describe the case of a 25 year old man following bariatric surgery who increased his ingestion of ondansetron, taking up to 40 tablets/day due to excessive nausea and vomiting. The patient was hospitalized for progressively more severe headache of 1 week’s duration. Computed tomography (CT) revealed bilateral cerebral edema in the parietal and occipital lobes in the setting of elevated blood pressure (BP). Three days into his admission, following improvement in his BP with oral anti-hypertensive but continued use of the ondansetron, the patient developed near complete blindness. CT head imaging revealed progression of the posterior cerebral edema and intraparenchymal hemorrhage. He was admitted to our ICU and despite supportive treatment, his neurological examination worsened while CT head imaging findings remained stable. Invasive multimodality monitoring revealed elevated intracranial pressure. The patient was aggressively treated and after a prolonged hospitalization and rehabilitation course, made a significant recovery. Conclusion This case highlights a very rare potential neurological complication of ondansetron, a commonly used medication. We hypothesize an underlying association between PRES and 5-HT3 antagonism, via the latter’s potential role in endothelial dysfunction. Prompt recognition and treatment of PRES is essential, in order to prevent secondary cerebral injury and the associated potentially grave consequences.
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Affiliation(s)
- M Alain Babi
- Department of Neurological Sciences, The University of Vermont Medical Center and the University of Vermont College of Medicine, Burlington, VT 05405 USA ; Division of Neuro-critical care, Department of Neurology, Duke University Hospital, DUMC 2900, Durham, NC 27710 USA
| | - Mark J Gorman
- Department of Neurological Sciences, The University of Vermont Medical Center and the University of Vermont College of Medicine, Burlington, VT 05405 USA
| | - Marilyn J Cipolla
- Department of Neurological Sciences, The University of Vermont Medical Center and the University of Vermont College of Medicine, Burlington, VT 05405 USA
| | - Gilman Allen
- Department of Medicine, Division of Pulmonary Medicine and Critical Care, The University of Vermont Medical Center and the University of Vermont College of Medicine, Burlington, VT 05405 USA
| | - Salman Al Jerdi
- Department of Neurological Sciences, The University of Vermont Medical Center and the University of Vermont College of Medicine, Burlington, VT 05405 USA
| | - Ryan Clouser
- Department of Medicine, Division of Pulmonary Medicine and Critical Care, The University of Vermont Medical Center and the University of Vermont College of Medicine, Burlington, VT 05405 USA
| | - Christopher Commichau
- Department of Neurological Sciences, The University of Vermont Medical Center and the University of Vermont College of Medicine, Burlington, VT 05405 USA
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Martins WA, Marrone LCP. Malignant Posterior Reversible Encephalopathy Syndrome: A Case of Posterior Irreversible Encephalopathy Syndrome. J Clin Neurol 2015; 12:236-7. [PMID: 26541497 PMCID: PMC4828572 DOI: 10.3988/jcn.2016.12.2.236] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 07/13/2015] [Accepted: 07/16/2015] [Indexed: 11/17/2022] Open
Affiliation(s)
- William Alves Martins
- Department of Neurology, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil.
| | - Luiz Carlos Porcello Marrone
- Department of Neurology, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
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Gao B, Yu BX, Li RS, Zhang G, Xie HZ, Liu FL, Lv C. Cytotoxic Edema in Posterior Reversible Encephalopathy Syndrome: Correlation of MRI Features with Serum Albumin Levels. AJNR Am J Neuroradiol 2015; 36:1884-9. [PMID: 26138140 DOI: 10.3174/ajnr.a4379] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 02/28/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE Posterior reversible encephalopathy syndrome is a clinicoradiologic entity with typical MR imaging showing predominant vasogenic and occasional cytotoxic edema. It is unclear whether MR imaging correlates with levels of serum albumin. We determined potential risk factors for development of cytotoxic edema in posterior reversible encephalopathy syndrome. MATERIALS AND METHODS Seventy-nine cases with typical clinical symptoms and characteristic neuroradiologic findings conformed to posterior reversible encephalopathy syndrome diagnostic criteria and were included in this study. FLAIR, DWI, and ADC maps were interpreted to evaluate the severity and type of edema. MR imaging was correlated with the levels of serum albumin, and cytotoxic edema was compared with the location and severity of brain edema. RESULTS Pure vasogenic edema was found in 53 cases (67.09%), and vasogenic edema complicated with cytotoxic components, in 26 patients (32.91%). There was no difference in serum albumin levels between patients with cytotoxic components and those with vasogenic edema (P = .983). There was a significant difference in the edema scale scores between patients with cytotoxic edema and those with vasogenic edema (P = .006). The percentage of cytotoxic edema located in the area with higher scale scores of edema was significantly larger than that in areas with lower scale scores of edema (P = .002). CONCLUSIONS Serum albumin may contribute to the development of edema in PRES but is not a decisive factor for edema type. Cytotoxic edema in posterior reversible encephalopathy syndrome is probably related to regional decreased perfusion and arteriolopathy. Further work should be undertaken to discover the pathophysiologic mechanisms involved.
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Affiliation(s)
- B Gao
- From the Department of Radiology (B.G., B.X.Y., R.S.L., G.Z., H.Z.X., F.L.L.), Yantai Yuhuangding Hospital, Qingdao University, Shandong Province, China Department of Radiology (B.G.), Zhongda Hospital, Southeast University, Nanjing, China
| | - B X Yu
- From the Department of Radiology (B.G., B.X.Y., R.S.L., G.Z., H.Z.X., F.L.L.), Yantai Yuhuangding Hospital, Qingdao University, Shandong Province, China
| | - R S Li
- From the Department of Radiology (B.G., B.X.Y., R.S.L., G.Z., H.Z.X., F.L.L.), Yantai Yuhuangding Hospital, Qingdao University, Shandong Province, China
| | - G Zhang
- From the Department of Radiology (B.G., B.X.Y., R.S.L., G.Z., H.Z.X., F.L.L.), Yantai Yuhuangding Hospital, Qingdao University, Shandong Province, China
| | - H Z Xie
- From the Department of Radiology (B.G., B.X.Y., R.S.L., G.Z., H.Z.X., F.L.L.), Yantai Yuhuangding Hospital, Qingdao University, Shandong Province, China
| | - F L Liu
- From the Department of Radiology (B.G., B.X.Y., R.S.L., G.Z., H.Z.X., F.L.L.), Yantai Yuhuangding Hospital, Qingdao University, Shandong Province, China
| | - C Lv
- Department of Neurology (C.L.), Yantai City Yantaishan Hospital and Yantai Sino-France Friendship Hospital, Shandong Province, China.
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