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Sharma D, Tomar DS, Gupta S. Non-hypertension-associated Posterior Reversible Encephalopathy Syndrome in COVID-19. Indian J Crit Care Med 2022; 26:641-642. [PMID: 35719457 PMCID: PMC9160627 DOI: 10.5005/jp-journals-10071-24218] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Coronavirus disease-2019 (COVID-19) infection-related neurological events are not uncommon but presenting as posterior reversible encephalopathy syndrome (PRES) without hypertension is a very rare presentation and requires a high index of suspicion. Case summary We report a case of a middle-aged female who presented with severe COVID-19 disease with no neurological symptoms. She complained of diminished vision on day 7 of the illness and underwent an MRI brain to rule out an ischemic stroke but the findings were suggestive of PRES. She had no episode of hypertension during the hospital stay. Probably severe COVID-related inflammation was the reason for such a presentation. Conservative management resolved the issue and her symptoms weaned off. Conclusion Severe COVID disease can lead to PRES-like symptoms and requires neuroimaging to validate it. Conservative management is the best treatment for such patients. How to cite this article Sharma D, Tomar DS, Gupta S. Non-hypertension-associated Posterior Reversible Encephalopathy Syndrome in COVID-19. Indian J Crit Care Med 2022;26(5):641–642.
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Affiliation(s)
- Dhruva Sharma
- Department of Critical Care Medicine, Narayana Super-speciality Hospital, Gurugram, Haryana, India
| | - Deeksha S Tomar
- Department of Critical Care Medicine, Narayana Super-speciality Hospital, Gurugram, Haryana, India
| | - Sachin Gupta
- Department of Critical Care Medicine, Narayana Super-speciality Hospital, Gurugram, Haryana, India
- Sachin Gupta, Department of Critical Care Medicine, Narayana Super-speciality Hospital, Gurugram, Haryana, India, Phone: +91 9873240734, e-mail:
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Deng T, Zhang X, Peng X, Peng H, He L, Hu Y. Clinical features and prognostic analysis of posterior reversible encephalopathy syndrome in children. Int J Dev Neurosci 2022; 82:349-360. [PMID: 35373858 DOI: 10.1002/jdn.10184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/05/2022] [Accepted: 04/01/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND We aimed to investigate the clinical features and prognosis of posterior reversible encephalopathy syndrome (PRES) in children. METHODS Clinical data of children with PRES diagnosed at the Children's Hospital of Chongqing Medical University from June 2015 to May 2019 were retrospectively analyzed. RESULTS The study enrolled 47 patients with a mean age at diagnosis of 8.79 ± 3.72 years (range, 2-15 years). PRES causes included renal disorder (29/47), hematological disease (13/47), and hypertension (5/47). PRES manifested as seizure (43/47), headache (28/47), visual impairment (18/47), dizziness (18/47), vomiting (18/47), and mental and behavioral abnormalities (17/47). Forty-six children had hypertension (46/47) at PRES onset. Magnetic resonance imaging (MRI) mainly involved the parietal and occipital lobes (42/47), 38 cases were mild (38/47), 7 were moderate (7/47), and 2 were severe (2/47). The clinical symptoms of 41 patients (41/47) were relieved within 1-2 weeks. Thirty-seven children were followed up for 7-54 months (modified Rankin Scale). Twenty-five children had favorable outcomes (25/37). Twelve children had adverse outcomes (12/37), including epilepsy, disorders of consciousness, visual impairment, and mental decline. Analysis of single factors revealed that severity on MRI, length of in-hospital stay, and mental and behavioral abnormalities were related to adverse outcomes after PRES. Analysis of multiple factors revealed that severity on MRI and length of in-hospital stay were independent risk factors for PRES. CONCLUSION Pediatric PRES is a clinical radiographic syndrome with multiple etiologies. Most patients have a good prognosis. Severity on MRI and length of in-hospital stay are independent risk factors.
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Affiliation(s)
- Ting Deng
- Department of Neurology Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders. Chongqing Key Laboratory of Pediatrics, China.,Xi'an Children's Hospital, China
| | - Xinyu Zhang
- Department of Neurology Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders. Chongqing Key Laboratory of Pediatrics, China
| | - Xiaoling Peng
- Division of Science and Technology, Beijing Normal University-Hongkong Baptist University United International College, China
| | - Hailun Peng
- Department of Neurology Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders. Chongqing Key Laboratory of Pediatrics, China.,Department of Radiology, Children's Hospital of Chongqing Medical University, China
| | - Ling He
- Department of Neurology Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders. Chongqing Key Laboratory of Pediatrics, China.,Department of Radiology, Children's Hospital of Chongqing Medical University, China
| | - Yue Hu
- Department of Neurology Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders. Chongqing Key Laboratory of Pediatrics, China
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Goyal G, Jeswani J. Study of Clinico-radiological Profile in Posterior Reversible Encephalopathy Syndrome: Experience from North India. Indian J Crit Care Med 2022; 26:501-505. [PMID: 35656041 PMCID: PMC9067501 DOI: 10.5005/jp-journals-10071-24172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Gourav Goyal
- Department of Neurology, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
- Gourav Goyal, Department of Neurology, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India, Phone: +91 8387867414, e-mail:
| | - Jitesh Jeswani
- Department of Nephrology, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
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Zerbib Y, Gibert L, Bennis Y, Masmoudi K, Maizel J, Brault C. Posterior Reversible Encephalopathy Syndrome After Self-Medication With an Oral Decongestant: A Case Report. Front Med (Lausanne) 2022; 9:837324. [PMID: 35321464 PMCID: PMC8935013 DOI: 10.3389/fmed.2022.837324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 02/09/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Posterior reversible encephalopathy syndrome (PRES) is a rare neurological disorder caused by the dysregulation of cerebral perfusion. Case Presentation We report on a 18-year-old female patient with a history of end-stage renal disease and thrice weekly hemodialysis. She was admitted to the emergency department with mental confusion, blurred vision, headaches, and vomiting, following self-medication with an oral decongestant containing pseudoephedrine. We observed hypointense lesions with T1-weighted MRI and hyperintense areas with T2-weighted and fluid-attenuated inversion recovery MRI sequences. The lack of diffusion restriction was consistent with a diagnosis of PRES. A concomitant Enterobacter cloacae hemodialysis catheter-bloodstream infection was also diagnosed. We hypothesize that both sepsis and inappropriate self-medication with oral pseudoephedrine contributed to hypertension, endothelial dysfunction, and vasogenic edema. The patient received intensive care and made a full recovery. Discussion PRES is a life-threatening condition that requires intensive care. Identification of the etiology is the keystone of medical care. Inappropriate self-medication with an oral decongestant might trigger PRES - highlighting the importance of patient education.
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Affiliation(s)
- Yoann Zerbib
- Intensive Care Unit, Amiens University Medical Center, Amiens, France
| | - Louis Gibert
- Intensive Care Unit, Amiens University Medical Center, Amiens, France
| | - Youssef Bennis
- Department of Clinical Pharmacology, Amiens University Medical Center, Amiens, France
- MP3CV Laboratory, UR UPJV 7517, Amiens, France
| | - Kamel Masmoudi
- Department of Clinical Pharmacology, Amiens University Medical Center, Amiens, France
| | - Julien Maizel
- Intensive Care Unit, Amiens University Medical Center, Amiens, France
- MP3CV Laboratory, UR UPJV 7517, Amiens, France
| | - Clément Brault
- Intensive Care Unit, Amiens University Medical Center, Amiens, France
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Commentary on Posterior Reversible Encephalopathy Syndrome and Sepsis-Associated Encephalopathy. Neurocrit Care 2022; 37:8-9. [PMID: 35133606 DOI: 10.1007/s12028-022-01443-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 01/05/2022] [Indexed: 10/19/2022]
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Orhun G, Sencer S, Tüzün E, Bebek N, Ergin Özcan P, Barburoğlu M, Günver MG, Esen F. Posterior Reversible Encephalopathy in Sepsis-Associated Encephalopathy: Experience from a Single Center. Neurocrit Care 2022; 36:372-386. [PMID: 35133605 DOI: 10.1007/s12028-021-01433-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 12/29/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sepsis-associated encephalopathy (SAE) is frequently encountered in sepsis and is often accompanied by neuroimaging findings indicating ischemia, hemorrhage, and edema. Posterior reversible encephalopathy syndrome (PRES) has been vastly underrecognized in previously reported cohorts of patients with sepsis and SAE. Our aim was to determine the prevalence and distinguishing clinical, neuroimaging, and electroencephalography features of PRES in SAE. METHODS In this prospective observational study, patients with radiologically identified PRES were selected from a consecutively enrolled cohort of 156 patients with SAE and assessed for neurological outcome using the extended Glasgow Outcome Scale for 12 months. Patients with SAE and PRES and other types of brain lesions were compared in terms of clinical and diagnostic workup features. RESULTS Fourteen of 156 patients (8.9%) were determined to be radiologically compatible with PRES, whereas 48 patients displayed other types of acute brain lesions. Patients with PRES often showed lesions in atypical regions, including frontal lobes, the corpus callosum, and the basal ganglia. Source of infection was mostly gram-negative bacteria originating from pneumonia or intraabdominal infections. Patients with PRES were not different from other patients with SAE with brain lesions in terms of features of sepsis and neurological outcome. However, patients with PRES showed increased prevalence of seizures and intraabdominal source of infection. CONCLUSIONS PRES is highly prevalent in SAE, often encompasses unusual brain regions, and usually presents with generalized seizures. Patients with SAE and PRES do not appear to have distinguishing clinical and diagnostic workup features. However, generalized seizures may serve as warning signs for presence of PRES in patients with SAE.
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Affiliation(s)
- Günseli Orhun
- Department of Anesthesiology and Intensive Care, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
| | - Serra Sencer
- Department of Neuroradiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Erdem Tüzün
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Nerses Bebek
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Perihan Ergin Özcan
- Department of Anesthesiology and Intensive Care, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mehmet Barburoğlu
- Department of Neuroradiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | | | - Figen Esen
- Department of Anesthesiology and Intensive Care, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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An Unusual Presentation of Posterior Reversible Encephalopathy Syndrome Following Liver Transplantation. Transplant Direct 2022; 8:e1269. [PMID: 35018303 PMCID: PMC8735783 DOI: 10.1097/txd.0000000000001269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/18/2021] [Accepted: 10/30/2021] [Indexed: 12/07/2022] Open
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58
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Balu R, Fischer M. Posterior Reversible Encephalopathy Syndrome. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00038-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Chen X, Zhao JG, Gao B, Yu H, Yu YL, Shen GQ, McKinney AM. Posterior reversible encephalopathy syndrome with a special focus on seizures. J Clin Neurosci 2021; 95:38-43. [PMID: 34929649 DOI: 10.1016/j.jocn.2021.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 11/06/2021] [Accepted: 11/11/2021] [Indexed: 12/18/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a neurological disorder characterized by headache, seizures, confusion and visual disturbances, as well as potentially reversible neuroimaging findings in most patients after proper treatment. Seizures is one of the most common clinical presentations of PRES. This review summarizes the potential pathophysiology and clinical features of PRES, as well as a multimodal approach to imaging and also briefly discusses the phenomenon of seizures in paediatric population.
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Affiliation(s)
- Xin Chen
- Department of Radiology, The Affiliated Hospital of Guizhou Medical University, 550001 Guizhou, China
| | - Jun-Guo Zhao
- Department of Radiology, The Affiliated Hospital of Guizhou Medical University, 550001 Guizhou, China
| | - Bo Gao
- Department of Radiology, The Affiliated Hospital of Guizhou Medical University, 550001 Guizhou, China; Key Laboratory of Brain Imaging, Guizhou Medical University, Guiyang, China.
| | - Hui Yu
- Department of Radiology, The Affiliated Hospital of Guizhou Medical University, 550001 Guizhou, China; Key Laboratory of Brain Imaging, Guizhou Medical University, Guiyang, China
| | - Yun-Li Yu
- Department of Neurology, The Affiliated Hospital of Guizhou Medical University, 550001 Guizhou, China
| | - Gui-Quan Shen
- Department of Radiology, The Affiliated Hospital of Guizhou Medical University, 550001 Guizhou, China; Key Laboratory of Brain Imaging, Guizhou Medical University, Guiyang, China
| | - Alexander M McKinney
- Department of Radiology, University of Miami Miller School of Medicine, Miami, FL, USA
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Aduen-Carrillo A, Hernandez-Woodbine MJ, Avendaño-Capriles CA, Ayola-Anaya FN. Initial Normotensive Presentation of a Primigravida With Posterior Reversible Encephalopathy Syndrome: A Case Report. Cureus 2021; 13:e19407. [PMID: 34909327 PMCID: PMC8658731 DOI: 10.7759/cureus.19407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 11/17/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiological entity characterized by variable neurological manifestations, primarily caused by pathophysiological changes related to cerebral autoregulation that result in radiologically evident vasogenic edema. It is usually associated with hypertensive states, but it is not exclusively related to those. A healthy 18-year-old primigravid woman with no proteinuria or hypertension on admission presented with normotensive PRES. She had an intense diffuse headache that preceded a generalized tonic-clonic seizure. Her neurological status deteriorated, and hypertension was detected afterward. Brain imaging revealed bilateral vasogenic edema in the occipital region. Magnesium sulfate and antihypertensive medications were administered. A cesarean section was performed, and her neurological symptoms subsequently improved, leading to discharge with no complications. This case highlights the importance of suspecting PRES in pregnant patients even in the absence of preeclampsia.
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Makouei M, Hartup LA, Neuhoff BK, Boyd AR, Daftaribesheli L, Mirmoeeni S, Azari Jafari A, Godoy DA, Seifi A. The pathophysiologic, diagnostic, and therapeutic aspects of posterior reversible encephalopathy syndrome during pregnancy. J Matern Fetal Neonatal Med 2021; 35:8735-8743. [PMID: 34879767 DOI: 10.1080/14767058.2021.2001454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a neurological condition with a wide range of symptoms, including visual disturbances, headache, vomiting, seizures, and altered consciousness. This review describes the pathophysiology of PRES, as well as the clinical, diagnostic, and therapeutic intervention during pregnancy. The gold standard for diagnosis of PRES is Magnetic Resonance Imaging (MRI), helping to differentiate it from other similar conditions. The aim of this paper is to review the principal aspects of PRES, general care, blood pressure control, and seizures prevention while avoiding potential injuries to the mother and fetus in the event of pregnancy. We concluded that PRES can be effectively treated and reversed if prompt diagnostic action is made, and adequate care is initiated.
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Affiliation(s)
- Mahsa Makouei
- School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Lindsay Anne Hartup
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Barbara Kate Neuhoff
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Angela Rodriguez Boyd
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Laleh Daftaribesheli
- Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, MD, USA
| | | | | | - Daniel Agustin Godoy
- Neurointensive Care Unit, Sanatorio Pasteur, Hospital Carlos Malbran, Catamarca, Argentina
| | - Ali Seifi
- Division of Neuro Critical Care, Department of Neurosurgery, University of Texas Health Science Center at San Antonio School of Medicine, San Antonio, TX, USA
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Marsiglia M, Chwalisz BK, Maher M. Neuroradiologic Imaging of Neurologic and Neuro-Ophthalmic Complications of Coronavirus-19 Infection. J Neuroophthalmol 2021; 41:452-460. [PMID: 34788237 PMCID: PMC8582975 DOI: 10.1097/wno.0000000000001454] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND To review the literature and provide a summary of COVID-19-related neurologic and neuro-ophthalmic complications. METHODS The currently available literature was reviewed on PubMed and Google Scholar using the following keywords for searches: CNS, Neuro-Ophthalmology, COVID-19, SARS-CoV-2, coronavirus, optic neuritis, pseudotumor cerebri, Acute Disseminated Encephalomyelitis, posterior reversible encephalopathy syndrome (PRES), meningitis, encephalitis, acute necrotizing hemorrhagic encephalopathy, and Guillain-Barré and Miller Fisher syndromes. RESULTS Neuroradiologic findings of neurologic and neuro-ophthalmologic complications in relationship to COVID-19 infection were reviewed. Afferent visual pathway-related disorders with relevant imaging manifestations included fundus nodules on MRI, papilledema and pseudotumor cerebri syndrome, optic neuritis, Acute Disseminated Encephalomyelitis, vascular injury with thromboembolism and infarct, leukoencephalopathy, gray matter hypoxic injury, hemorrhage, infectious meningitis/encephalitis, acute necrotizing hemorrhagic encephalopathy, and PRES. Efferent visual pathway-related complications with relevant imaging manifestations were also reviewed, including orbital abnormalities, cranial neuropathy, Guillain-Barré and Miller Fisher syndromes, and nystagmus and other eye movement abnormalities related to rhombencephalitis. CONCLUSION COVID-19 can cause central and peripheral nervous system disease, including along both the afferent and efferent components of visual axis. Manifestations of disease and long-term sequela continue to be studied and described. Familiarity with the wide variety of neurologic, ophthalmic, and neuroradiologic presentations can promote prompt and appropriate treatment and continue building a framework to understand the underlying mechanism of disease.
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Liu YC, Ong JR. An Unusual Presentation of Posterior Reversible Encephalopathy Syndrome. J Acute Med 2021; 11:150-152. [PMID: 35155092 PMCID: PMC8743192 DOI: 10.6705/j.jacme.202112_11(4).0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 08/05/2020] [Accepted: 11/13/2020] [Indexed: 06/14/2023]
Affiliation(s)
- Yu-Chun Liu
- Taipei Medical University-Shuang Ho Hospital Department of Emergency Medicine New Taipei City Taiwan
- Taipei Medical University Department of Emergency Medicine Taipei Taiwan
| | - Jiann Ruey Ong
- Taipei Medical University-Shuang Ho Hospital Department of Emergency Medicine New Taipei City Taiwan
- Taipei Medical University Department of Emergency Medicine Taipei Taiwan
- Taipei Medical University Graduate Institute of Injury Prevention and Control Taipei Taiwan
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Sharma M, Menon B, Manam G. Postpartum Reversible Cerebral Vasoconstriction Syndrome Presenting with Radiological Plethora. Indian J Radiol Imaging 2021; 31:764-767. [PMID: 34790334 PMCID: PMC8590535 DOI: 10.1055/s-0041-1735923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) is a clinicoradiological syndrome characterized by segmental vasoconstriction of cerebral arteries with resolution in most patients within 1 to 3 months. It has been known to be a benign uniphasic reversible illness but cases of fulminant RCVS with mortality have also been reported. The symptoms can be varied with presentations like transient ischemic attack (TIA), ischemic stroke (IS), intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), and posterior reversible encephalopathy syndrome (PRES). We report a postpartum female with RCVS with radiological features of ICH, SAH, atypical PRES, and atypical clinical presentation as well. RCVS can be frequently missed unless there is a high index of suspicion. Hence clinicians should be aware of the typical and the atypical presentation of RCVS along with the radiological findings with the potential complications. Early suspicion and detection in the emergency help in recovery and reducing morbidity.
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Affiliation(s)
- Manisha Sharma
- Department of Neurology, Apollo Speciality Hospital, Nellore, Andhra Pradesh, India
| | - Bindu Menon
- Department of Neurology, Apollo Speciality Hospital, Nellore, Andhra Pradesh, India
| | - Gayatri Manam
- Department of Radiology, Apollo Speciality Hospital, Nellore, Andhra Pradesh, India
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Atypical Posterior Reversible Encephalopathy Syndrome (PRES) in a Patient with Polymyalgia Rheumatica and Giant Cell Arteritis. CURRENT HEALTH SCIENCES JOURNAL 2021; 47:306-309. [PMID: 34765253 PMCID: PMC8551883 DOI: 10.12865/chsj.47.02.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 05/27/2021] [Indexed: 11/21/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a potentially life-threatening condition, composed of focal neurologic symptoms and peculiar magnetic resonance imaging (MRI) findings suggestive for cerebral vasogenic edema. PRES has been predominantly associated with severe hypertension, but a concomitant inflammatory state, common in vasculitis, can contribute to worsening cerebral vasogenic edema towards cytotoxic edema, and it should be promptly treated with glucocorticoids (GC). Atypical cases of PRES should be suspected in cases of focal neurologic symptoms, associated with severe hypertension, and systemic inflammation. We report the first description of a patient with polymyalgia rheumatica and giant cell arteritis who developed PRES after GC discontinuation for arthroscopic surgery.
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Adetiloye AO, Valencia Manrique J, Victoria A, Haider H, Al-Juboori MT. Posterior Reversible Encephalopathy Syndrome Presenting Atypically as a Non-Convulsive Seizure. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e933667. [PMID: 34737256 PMCID: PMC8579062 DOI: 10.12659/ajcr.933667] [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] [Indexed: 11/20/2022]
Abstract
Patient: Female, 59-year-old
Final Diagnosis: Posterior reversible encephalopathy syndrome (PRES)
Symptoms: Altered mental status
Medication:—
Clinical Procedure: —
Specialty: Cardiology • Critical Care Medicine • General and Internal Medicine • Nephrology • Neurology
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Affiliation(s)
| | - Julio Valencia Manrique
- Department of Internal Medicine, New York Medical College, Metropolitan Hospital Center, New York City, NY, USA
| | - Ana Victoria
- Department of Internal Medicine, New York Medical College, Metropolitan Hospital Center, New York City, NY, USA
| | - Haider Haider
- Department of Internal Medicine, New York Medical College, Metropolitan Hospital Center, New York City, NY, USA
| | - Mohammed T Al-Juboori
- Department of Internal Medicine, New York Medical College, Metropolitan Hospital Center, New York City, NY, USA
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Jadib A, Salam S, Harmoumi Y, Chahidi El Ouazzani L, Soussi O, Laoudiyi D, Chbani K, Ouzidane L. Posterior reversible encephalopathy syndrome revealing Takayasu's arteritis in a child. Radiol Case Rep 2021; 16:3969-3972. [PMID: 34729126 PMCID: PMC8545658 DOI: 10.1016/j.radcr.2021.09.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/14/2021] [Accepted: 09/16/2021] [Indexed: 11/15/2022] Open
Abstract
Posterior Reversible Encephalopathy Syndrome (PRES) is a rare complication of Takayasu's Arteritis. We report the case of an 11-year-old girl who presented with a tonic-clonic seizure and loss of consciousness, without fever. Imaging revealed characteristic white matter edema of the occipital and parietal lobes, in keeping with PRES. Further imaging demonstrated right renal artery stenosis and wall thickening of the abdominal aorta. The combination of hypertension, the discrepancy of blood pressure recordings between upper limbs, and imaging abnormalities of the aorta and the left renal artery led to the diagnosis of PRES secondary to Takayasu's Arteritis. Treatment with oral corticosteroids, azathioprine, amlodipine, and propranolol resulted in the complete resolution of the patient's symptoms and imaging abnormalities.
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Affiliation(s)
- Abdelhamid Jadib
- Pediatric Radiology Division, Ibn Rochd University Hospital, Faculty of Medicine and Pharmacy of Casablanca, Morocco, 1, quartiers des hôpitaux, Casablanca 20100, Morocco
| | - Siham Salam
- Pediatric Radiology Division, Ibn Rochd University Hospital, Faculty of Medicine and Pharmacy of Casablanca, Morocco, 1, quartiers des hôpitaux, Casablanca 20100, Morocco
| | - Yassine Harmoumi
- Pediatric Radiology Division, Ibn Rochd University Hospital, Faculty of Medicine and Pharmacy of Casablanca, Morocco, 1, quartiers des hôpitaux, Casablanca 20100, Morocco
| | - Lamiaa Chahidi El Ouazzani
- Pediatric Radiology Division, Ibn Rochd University Hospital, Faculty of Medicine and Pharmacy of Casablanca, Morocco, 1, quartiers des hôpitaux, Casablanca 20100, Morocco
| | - Othmane Soussi
- Pediatric Radiology Division, Ibn Rochd University Hospital, Faculty of Medicine and Pharmacy of Casablanca, Morocco, 1, quartiers des hôpitaux, Casablanca 20100, Morocco
| | - Dalale Laoudiyi
- Pediatric Radiology Division, Ibn Rochd University Hospital, Faculty of Medicine and Pharmacy of Casablanca, Morocco, 1, quartiers des hôpitaux, Casablanca 20100, Morocco
| | - Kamilia Chbani
- Pediatric Radiology Division, Ibn Rochd University Hospital, Faculty of Medicine and Pharmacy of Casablanca, Morocco, 1, quartiers des hôpitaux, Casablanca 20100, Morocco
| | - Lahcen Ouzidane
- Pediatric Radiology Division, Ibn Rochd University Hospital, Faculty of Medicine and Pharmacy of Casablanca, Morocco, 1, quartiers des hôpitaux, Casablanca 20100, Morocco
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Yeahia R, Schefflein J, Chiarolanzio P, Rozenstein A, Gomes W, Ali S, Mehta H, Al-Mufti F, McClelland A, Gulko E. Brain MRI findings in COVID-19 patients with PRES: A systematic review. Clin Imaging 2021; 81:107-113. [PMID: 34700172 PMCID: PMC8519663 DOI: 10.1016/j.clinimag.2021.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/21/2021] [Accepted: 10/05/2021] [Indexed: 12/27/2022]
Abstract
Background Numerous case reports and case series have described brain Magnetic Resonance Imaging (MRI) findings in Coronavirus disease 2019 (COVID-19) patients with concurrent posterior reversible encephalopathy syndrome (PRES). Purpose We aim to compile and analyze brain MRI findings in patients with COVID-19 disease and PRES. Methods PubMed and Embase were searched on April 5th, 2021 using the terms “COVID-19”, “PRES”, “SARS-CoV-2” for peer-reviewed publications describing brain MRI findings in patients 21 years of age or older with evidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and PRES. Results Twenty manuscripts were included in the analysis, which included descriptions of 30 patients. The average age was 57 years old. Twenty-four patients (80%) required mechanical ventilation. On brain MRI examinations, 15 (50%) and 7 (23%) of patients exhibited superimposed foci of hemorrhage and restricted diffusion respectively. Conclusions PRES is a potential neurological complication of COVID-19 related disease. COVID-19 patients with PRES may exhibit similar to mildly greater rates of superimposed hemorrhage compared to non-COVID-19 PRES patients.
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Affiliation(s)
- Rubaya Yeahia
- New York Medical College, Valhalla, New York, United States of America
| | - Javin Schefflein
- Division of Neuroradiology, Department of Radiology, Westchester Medical Center, Valhalla, New York, United States of America
| | - Patrick Chiarolanzio
- Department of Radiology, New York Medical College, Valhalla, New York, United States of America
| | - Anna Rozenstein
- Division of Cardiothoracic Radiology, Department of Radiology, Westchester Medical Center, Valhalla, New York, United States of America
| | - William Gomes
- Division of Neuroradiology, Department of Radiology, Westchester Medical Center, Valhalla, New York, United States of America
| | - Sana Ali
- Division of Neuroradiology, Department of Radiology, Westchester Medical Center, Valhalla, New York, United States of America
| | - Hasit Mehta
- Division of Neuroradiology, Department of Radiology, Westchester Medical Center, Valhalla, New York, United States of America
| | - Fawaz Al-Mufti
- Department of Neurology, Westchester Medical Center, Valhalla, New York, United States of America
| | - Andrew McClelland
- Division of Neuroradiology, Department of Radiology, Montefiore Medical Center, Bronx, New York, United States of America
| | - Edwin Gulko
- Division of Neuroradiology, Department of Radiology, Westchester Medical Center, Valhalla, New York, United States of America.
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Darwish A, Alserihy O, Brinji Z, Rawah E, Elsodany I. Posterior Reversible Encephalopathy Syndrome Following Intracranial Hypotension Due to Cerebrospinal Fluid (CSF) Leakage: A Report of Two Cases. Cureus 2021; 13:e17841. [PMID: 34660048 PMCID: PMC8501469 DOI: 10.7759/cureus.17841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2021] [Indexed: 11/30/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) in cases of intracranial hypotension is a life-threatening condition. Early suspicion, appropriate treatment, and tight control of possible contributing factors that may facilitate PRES in cerebrospinal fluid (CSF) leak patients may bring a more favorable outcome, lowering the morbidity and mortality rate. Two cases of PRES with features of intracranial hypotension are presented. We also discussed the possible pathogenesis of PRES in patients with intracranial hypotension. We emphasize the importance of the early diagnosis and treatment of ICH by repairing the leakage and further prompt attention to tight blood pressure control in those patients to avoid PRES development.
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Affiliation(s)
- Abdullah Darwish
- Department of Radiology, King Abdullah Medical City, Makkah, SAU
| | - Omar Alserihy
- Department of Radiology, King Abdullah Medical City, Makkah, SAU
| | - Zaina Brinji
- Department of Radiology, King Abdullah Medical City, Makkah, SAU
| | - Elham Rawah
- Department of Radiology, King Abdullah Medical City, Makkah, SAU
| | - Ibrahim Elsodany
- Department of Internal Medicine, King Abdullah Medical City, Makkah, SAU
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70
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Atça AÖ, Erok B, Aydoğdu S. Neuroimaging findings of posterior reversible encephalopathy syndrome (PRES) following haematopoietic stem cell transplantation in paediatric recipients. BMC Pediatr 2021; 21:445. [PMID: 34629063 PMCID: PMC8504064 DOI: 10.1186/s12887-021-02890-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 09/09/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Haematopoietic stem cell transplantation (HSCT) is used worldwide in various malignant and nonmalignant childhood diseases, including haematologic, genetic, autoimmune and metabolic disorders, and is the only curative treatment for many of these illnesses. The survival rates of many childhood diseases have been increased due to HSCT treatment. However, associated complications are still important for management. Central nervous system (CNS) complications in paediatric HSCT recipients can be associated with high morbidity and significantly contribute to mortality. Posterior reversible encephalopathy syndrome (PRES) is one of the most common CNS complications in patients with neurological symptoms following HSCT. Magnetic resonance imaging (MRI) is the modality of choice and shows typical bilateral vasogenic oedema at the posterior parts of the cerebral hemispheres; however, various atypical imaging manifestations can also occur. In this study, we retrospectively examined CNS complications in our paediatric HSCT recipients with a focus on the typical and atypical neuroimaging manifestations of PRES following HSCT. METHODS We retrospectively reviewed the medical records of 300 consecutive paediatric HSCT recipients from January 2014 to November 2018. A total of 130 paediatric HSCT recipients who experienced neurological signs and symptoms and were evaluated with neuroimaging studies following HSCT were enrolled in the study. The timing of CNS complications was defined according to immune status, including the pre-engraftment period (< 30 days after HSCT), the early postengraftment period (30-100 days after HSCT), and the late postengraftment period (> 100 days after HSCT), which were defined as phases 1, 2 and 3, respectively. RESULTS Overall, 130 paediatric HSCT recipients experienced neurological signs and symptoms and therefore underwent neuroimaging examinations. Among these 130 patients, CNS complications were present in 23 patients (17.6%, 23/130), including 13 (56.5%) females and 10 (43.5%) males with a median age of 8.0 years (range, 8 months to 18.0 years). Among these 23 patients, 14 cases of PRES (60.9%), 5 (21.7%) cases of leukoencephalopathy, 3 cases of acute subdural haemorrhage (ASDH) (13%) and 1 (4.3%) case of fungal CNS infection were identified by neuroimaging. On MRI, typical parietooccipital vasogenic oedema was present in 78.5% of the PRES cases (11/14). The following atypical neuroimaging manifestations were observed: isolated involvement of the bilateral frontal lobes in 1 case, isolated cerebellar vermis involvement in 1 case, and isolated basal ganglia involvement in 1 case. Restricted diffusion associated with cytotoxic damage was demonstrated in 2 of 14 cases, one of which also showed subacute cytotoxic injury with ADC pseudonormalization. CONCLUSION Paediatric HSCT recipients presenting with CNS signs and symptoms should be evaluated by neuroimaging studies for timely diagnosis and early management. PRES is the most common CNS complication and may present with atypical MRI manifestations, which should not dissuade a PRES diagnosis in appropriate clinical settings.
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Affiliation(s)
- Ali Önder Atça
- Department of Radiology, Altınbas University School of Medicine Bahcelievler Medical Park Hospital, İstanbul, Turkey
| | - Berrin Erok
- Department of Radiology, University of Health Sciences, Prof Dr Cemil Tascıoglu City Hospital, Istanbul, Turkey.
| | - Selime Aydoğdu
- Department of Hematology, Altınbas University School of Medicine Bahcelievler Medical Park Hospital, İstanbul, Turkey
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Lin B, Wang C, Lu N, Zhang L, Jiang B. Reversible cerebral vasoconstriction syndrome with cerebral infarction caused by acute high-level vapor exposure of ethylene oxide: a case report. BMC Neurol 2021; 21:391. [PMID: 34627175 PMCID: PMC8501561 DOI: 10.1186/s12883-021-02429-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 10/04/2021] [Indexed: 11/29/2022] Open
Abstract
Background With the increasing production and use of ethylene oxide (EO) worldwide, its explicit bio-toxicity has drawn more and more attention. At present, most studies focus on chronic EO exposure. Studies on acute EO exposure are rare, especially with imaging studies. To our knowledge, this work is the first documented case of reversible cerebral vasoconstriction syndrome (RCVS) with cerebral infarction caused by EO. Case presentation A 58-year-old woman who worked in a capsule production factory got an unprotected acute EO inhalation due to accidental exposure to sterilization gas. She suffered from nausea, vomiting, and severe paroxysmal headaches, but the first brain MRI scan of the patient showed no significant abnormality. Nine days after inhalation, she developed recurrent thunderclap headaches and gradual complete blindness. The follow-up brain MRI, 12 days after inhalation, demonstrated extensive cytotoxic edema. Fifteen days and 21 days after EO (ethylene oxide) inhalation, head MRA and CTA respectively showed diffuse vasoconstriction of cerebral arteries. Fifty-nine days after EO inhalation, head MRA assessed reversibility of the vasoconstriction. According to clinical features and imaging findings, RCVS with cerebral infarction can be diagnosed. The patient was sensitive to light and light reflection but still blind after symptomatic and rehabilitation therapy. Conclusions We report an acute EO exposure case in which the patient suffered from RCVS with cerebral infarction, which previous literature has not reported. This article aimed to raise awareness of encephalopathy after EO acute exposure.
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Affiliation(s)
- Bin Lin
- Department of Radiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, No.88 Jiefang Road, Hangzhou, 310009, Zhejiang, China
| | - Chao Wang
- Department of Radiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, No.88 Jiefang Road, Hangzhou, 310009, Zhejiang, China
| | - Nan Lu
- Department of Radiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, No.88 Jiefang Road, Hangzhou, 310009, Zhejiang, China
| | - Le Zhang
- Department of TCM Rehabilitation, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Biao Jiang
- Department of Radiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, No.88 Jiefang Road, Hangzhou, 310009, Zhejiang, China.
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Holroyd KB, Rubin DB, Vaitkevicius H. Neurologic Complications in Patients with Cancer. Semin Neurol 2021; 41:588-605. [PMID: 34619783 DOI: 10.1055/s-0041-1733788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Neurologic symptoms are commonly seen in patients with cancer and can be among the most challenging to diagnose and manage. It is often difficult to determine if new neurologic symptoms are secondary to direct effects of a malignant lesion, systemic complications of disease, paraneoplastic disorders, or side effects of cancer treatment itself. However, early diagnosis and treatment of each of these conditions can improve patients' quality of life and long-term functional outcomes. In this review, we describe a systematic approach to the diagnosis of new neurologic symptoms in patients with known malignancy. We have categorized the neurologic complications of cancer through a mechanistic approach, with an emphasis on ascertaining underlying pathophysiology to guide treatment choice. This review focuses on the acute neurologic complications of cancer that require hospital admission.
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Affiliation(s)
| | - Daniel B Rubin
- Department of Neurology, Massachusetts General Hospital, Brigham and Women's Hospital, Boston, Massachusetts
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Lee J, Lee HJ. Posterior reversible encephalopathy syndrome related to anemia correction in a patient with uterine myoma: a case report. Yeungnam Univ J Med 2021; 39:336-340. [PMID: 36200277 PMCID: PMC9580063 DOI: 10.12701/yujm.2021.01375] [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: 07/28/2021] [Accepted: 08/25/2021] [Indexed: 11/16/2022] Open
Abstract
Although posterior reversible encephalopathy syndrome (PRES) is induced by various causes, a few cases have occurred after severe anemia correction. In this case report, a 45-year-old female patient visited emergency department with a chief complaint of dizziness due to severe anemia related to hypermenorrhea caused by uterine myoma. Before her operation, she had an abrupt headache and seizure during anemia correction with transfusion and injection of gonadotropin-releasing hormone agonist. Immediately after the operation, she experienced visual disturbances, followed by limb weakness and tonic-clonic movements. Magnetic resonance imaging showed alterations in parietal and occipital lobes suggesting cerebrovascular edema with hypoperfusion. Here, we presented and discussed the clinical and radiologic features of PRES related to anemia correction.
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Affiliation(s)
- Jisun Lee
- Department of Obstetrics and Gynecology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea
| | - Hyun Jung Lee
- Department of Obstetrics and Gynecology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea
- Corresponding author: Hyun Jung Lee, MD, PhD Department of Obstetrics and Gynecology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Korea Tel: +82-53-200-5691, Fax: +82-53-423-7905 E-mail:
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Adetoye MA, Baumgartner MG, Rajkotia K, Park B. Coexisting posterior reversible encephalopathy syndrome and ischemic hepatopathy: A case report. Clin Case Rep 2021; 9:e04760. [PMID: 34512983 PMCID: PMC8423081 DOI: 10.1002/ccr3.4760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 04/22/2021] [Accepted: 08/10/2021] [Indexed: 11/09/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is acute neurologic symptoms with specific radiologic findings. This unique case shows coexisting PRES with acute liver injury, which could suggest common pathophysiologic process.
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Affiliation(s)
- Mercy A. Adetoye
- Department of Family MedicineUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | | | - Kavita Rajkotia
- Department of RadiologyUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Bumsoo Park
- Departments of Family Medicine and UrologyUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
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Willey J, Baumrucker SJ. Posterior Reversible Encephalopathy Syndrome (PRES) in Palliative Medicine: Case Report and Discussion. Am J Hosp Palliat Care 2021; 39:603-606. [PMID: 34427114 DOI: 10.1177/10499091211030465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is associated with seizures, visual disturbances, headache, and altered mental status. Given its presentation, the diagnosis can be mistaken for other severe conditions. Palliative medicine consultants should be aware of PRES and be prepared to counsel families on the treatment and prognosis of this syndrome.
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Affiliation(s)
- Jade Willey
- Quillen College of Medicine, ETSU, Johnson City, TN, USA
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Efficacy of renin-angiotensin-aldosterone system blockades for acute phase hypertensive emergencies in patient complicating severe acute kidney injury. CEN Case Rep 2021; 11:105-109. [PMID: 34420196 DOI: 10.1007/s13730-021-00639-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 08/16/2021] [Indexed: 10/20/2022] Open
Abstract
Renin-angiotensin-aldosterone system (RAAS) is primarily involved with pathological mechanism of developing hypertensive emergencies. However, none of clinical practice guidelines mention RAAS blockers for the treatment of hypertensive emergencies. A 44 year-old woman presented with severe hypertension, brain stem posterior reversible encephalopathy syndrome and severe acute kidney injury (AKI). We started anti-hypertensive therapy with continuous intravenous nitroglycerin and oral calcium channel blocker (CCB) and spironolactone. Since severe AKI persisted despite this therapy, we administered losartan potassium, which resulted in improvement in her blood pressure and creatinine. Clinical course of our patient suggests that timely initiation of ARB and spironolactone for hypertensive emergencies could be beneficial in terms of blood pressure control and for protection of target organs from this condition.
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Clinical Presentation and Risk Factors for Poor Outcomes Among Adult Patients With Posterior Reversible Encephalopathy Syndrome: A Retrospective Cohort Study. Neurologist 2021; 25:162-167. [PMID: 33181724 DOI: 10.1097/nrl.0000000000000294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is an acute neurological condition with unknown global incidence, variable clinical presentation, and prognosis. OBJECTIVES To describe a cohort of patients with PRES with a focus on brain magnetic resonance imaging (MRI) patterns and their relationship with short-term clinical outcomes. METHODS Retrospective cohort study. The authors included patients if they were older than 15 years and had a PRES diagnosis on the basis of a positive brain MRI at any time during the in-hospital stay. RESULTS Forty-four patients were included in the present analysis. The median age was 57 years (interquartile range, 32.0-68.5) and 70.5% were women. Hypertension (59.1%), history of transplantation (27.3%), previous chemotherapy (27.3%), chronic renal failure (38.6%), and autoimmune disease (15%) were the main comorbid conditions present. The classic triad of seizures, headache, and visual impairment was present in 18.0% of the cases. Eighty-six percent of patients were admitted to the intensive care unit, with 36.0% needing invasive life support. Brain MRI showed a dominant parieto-occipital pattern in 26 patients, whereas cytotoxic edema and bleeding were present in 27.3% and 29.6%, respectively. In-hospital mortality was 11.4%. The median modified Rankin Scale at hospital discharge was 1 (0-2.5). Risk factors associated with low modified Rankin Scale scores were: headache, visual impairment, and parieto-occipital pattern. Decreased level of consciousness and mechanical ventilation requirement were associated with greater discharge disability. CONCLUSIONS Characteristic symptoms and signs of PRES and classic MRI patterns are associated with better clinical outcomes.
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Navarro-Ballester A, Revert-Espí R. Unusual Presentation of a Posterior Reversible Encephalopathy Syndrome With Brainstem Involvement and Subarachnoid Haemorrhage. Cureus 2021; 13:e16295. [PMID: 34381653 PMCID: PMC8351525 DOI: 10.7759/cureus.16295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2021] [Indexed: 11/30/2022] Open
Abstract
Posterior reversible encephalopathy syndrome is an increasingly recognized disorder characterized by a headache, visual disturbances, and seizures. It is a reversible neurotoxic state, with multiple risk factors in which endothelial injury and compromised brain perfusion are the common characteristics. Diagnosis is usually made by cerebral magnetic resonance imaging that typically shows early-stage bilateral symmetrical parieto-occipital hyperintensities on T2 and fluid-attenuated inversion recovery (FLAIR) sequences. However, other locations have been described where the disease may appear less frequently. We describe the case of a 62-year-old man, with a medical history of hypertension, who presented with anisocoria with mydriatic non-reactive pupil and ptosis of the left eye. CT head showed a slightly hypodense brainstem, in relation to vasogenic edema. This was confirmed with magnetic resonance imaging. The angiography did not identify cerebral artery aneurysms. The symptoms and radiological findings were almost completely reversible after improving the patient's blood pressure. This case highlights a rare single presentation of posterior reversible encephalopathy syndrome associated with subarachnoid hemorrhage. A high index of suspicion, careful examination, and exploration with imaging techniques were essential to reach this diagnosis.
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Affiliation(s)
| | - Rafael Revert-Espí
- Radiology Department, Hospital General Universitario de Castellón, Castellón de la Plana, ESP
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Abstract
New onset or exacerbation of preexisting neurologic symptoms during pregnancy often necessitates brain or spinal cord imaging. Magnetic resonance techniques are preferred imaging modalities during pregnancy and the postpartum period. Ionizing radiation with computed tomography and intravenous contrast material with magnetic resonance or computed tomography should be avoided during pregnancy. New onset of headaches in the last trimester or in the postpartum period may indicate cerebrovascular disease or a mass lesion, for which brain imaging is necessary. The continuum of cerebrovascular complications of pregnancy and enlarging lesions may produce neurologic symptoms later in pregnancy and after delivery, necessitating imaging.
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Affiliation(s)
- Dara G Jamieson
- Department of Neurology, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10065, USA.
| | - Jennifer W McVige
- Dent Neurologic Institute, 3980 Sheridan Drive, Amherst, NY 14226, USA
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Moon JU, Lee JY, Lee JW, Chung NG, Cho B, Lee IG. Risk Factors for Seizures after Hematopoietic Stem Cell Transplantation in Pediatric Hemato-Oncologic Patients: A Single Tertiary Center Study in the Republic of Korea. ANNALS OF CHILD NEUROLOGY 2021. [DOI: 10.26815/acn.2021.00346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Posterior Reversible Encephalopathy Syndrome Associated with Tacrolimus in Cardiac Transplantation. Case Rep Cardiol 2021; 2021:9998205. [PMID: 34258073 PMCID: PMC8253642 DOI: 10.1155/2021/9998205] [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: 03/12/2021] [Accepted: 06/10/2021] [Indexed: 11/04/2022] Open
Abstract
Background Neurological complications occur between 50 and 70% of patients with heart transplantation, including cerebrovascular events, infections, seizures, encephalopathy, and neurotoxicity due to pharmacological immunosuppression. Mortality associated with cerebrovascular complications is 7.5% in the first 30 days and up to 5.3% after the first month and up to the first year after transplantation. Case Reports. Three heart-transplanted patients (2 men and 1 woman) treated with tacrolimus were identified. They presented with posterior reversible encephalopathy syndrome on days 5, 6, and 58 posttransplantation, respectively. In these reported cases, no sequelae were observed at 6 months follow-up. Conclusions Posterior reversible encephalopathy syndrome as a neurological complication in patients with HT occurred early after the procedure. Early diagnosis and treatment might reduce the risk of serious complications and mortality.
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GÜZELCE MC, AÇIKGÖZ T, ERSOY G. A Rare Case of Patient Forgetting His Native Language with the Diagnosis of “Posterior Reversible Encephalopathy Syndrome”. JOURNAL OF EMERGENCY MEDICINE CASE REPORTS 2021. [DOI: 10.33706/jemcr.903882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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83
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Lakmali JPR, Thirumavalavan K, Dissanayake D. A rare case of posterior reversible encephalopathy syndrome in a patient with severe leptospirosis complicated with rhabdomyolysis and acute kidney injury; a case report. BMC Infect Dis 2021; 21:522. [PMID: 34082705 PMCID: PMC8176595 DOI: 10.1186/s12879-021-06240-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 05/26/2021] [Indexed: 12/23/2022] Open
Abstract
Background Leptospirosis is a zoonotic spirochetal disease caused by Leptospira interrogans. The clinical presentation ranges from an asymptomatic state to a fatal multiorgan dysfunction. Neurological manifestations including aseptic meningitis, spinal cord and peripheral nerve involvement, cranial neuropathies and cerebellar syndrome are well recognized with varying frequencies among patients with this disease. Posterior reversible encephalopathy syndrome is a very rare occurrence in leptospirosis and only two cases are reported in the medical literature up to now. We report a case of posterior reversible encephalopathy syndrome in a patient with leptospirosis with rhabdomyolysis and acute kidney injury. Case presentation A 21 year-old male presented with fever and oliguric acute kidney injury with rhabdomyolysis. A diagnosis of leptospirosis was made and he was being managed according to the standard practice together with regular hemodialysis. The clinical condition was improving gradually. On day 8 of the illness, he developed headache and sudden painless complete bilateral vision loss followed by several brief generalized tonic clonic seizure attacks. Examination was significant for a Glasgow Coma Scale of 14/15, blood pressure of 150/90 mmHg and complete bilateral blindness. The findings of magnetic resonance imaging of the brain were compatible with posterior reversible encephalopathy syndrome. He was managed with blood pressure control and antiepileptics with supportive measures and standard treatment for leptospirosis and made a complete recovery. Conclusion Posterior reversible encephalopathy syndrome, though very rare with leptospirosis, should be considered as a differential diagnosis in a patient with new onset visual symptoms and seizures, especially during the immune phase. Optimal supportive care together with careful blood pressure control and seizure management would yield a favourable outcome in this reversible entity. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06240-2.
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Ramkissoon R, Yung-Lun Chin J, Jophlin L. Acute Neurological Symptoms After a Liver Transplant. Gastroenterology 2021; 160:2264-2266. [PMID: 33221403 DOI: 10.1053/j.gastro.2020.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 11/09/2020] [Indexed: 12/02/2022]
Affiliation(s)
- Resham Ramkissoon
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Jerry Yung-Lun Chin
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Loretta Jophlin
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Delayed post-hypoxic leukoencephalopathy in an adult with COVID-19. J Neurovirol 2021; 27:514-518. [PMID: 33977501 PMCID: PMC8112471 DOI: 10.1007/s13365-021-00982-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/02/2021] [Accepted: 04/14/2021] [Indexed: 11/23/2022]
Abstract
As the novel coronavirus, SARS-CoV-2, has enveloped the world in a pandemic, it has become clear that the symptoms extend far beyond the respiratory system and have particularly caused a wide range of neurologic CNS complications, including diffuse leukoencephalopathy. Here, we describe a case of a 59-year-old male with severe COVID-19 infection who developed severe encephalopathy, which persisted well after his acute infection had subsided and had begun to improve from his respiratory dysfunction. He was found to have diffuse leukoencephalopathy with concomitant diffusion restriction on MR imaging. This case represents a delayed onset of leukoencephalopathy secondary to hypoxia in a small but growing cohort of COVID-related leukoencephalopathy due to similarities in imaging features and lack of superior alternate diagnosis. Patient’s clinical improvement suggests reversibility with likely pathology being demyelination rather than infarction.
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Haraguchi K, Kimata T, Akagawa S, Yamanouchi S, Kaneko K. PRES followed by cerebral salt-wasting syndrome in a child with IgA nephropathy. Pediatr Int 2021; 63:594-597. [PMID: 33822438 DOI: 10.1111/ped.14449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/18/2020] [Accepted: 08/20/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Kohei Haraguchi
- Department of Pediatrics, Kansai Medical University, Osaka, Japan
| | - Takahisa Kimata
- Department of Pediatrics, Kansai Medical University, Osaka, Japan
| | - Shohei Akagawa
- Department of Pediatrics, Kansai Medical University, Osaka, Japan
| | | | - Kazunari Kaneko
- Department of Pediatrics, Kansai Medical University, Osaka, Japan
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87
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Xie F, Cai Y, Huang L, Hao J, Ling T, Richard SA. Obstructive ureteric calculus with superimposed infections causing reversible posterior leukoencephalopathy syndrome: A case report. Medicine (Baltimore) 2021; 100:e25589. [PMID: 33879719 PMCID: PMC8078273 DOI: 10.1097/md.0000000000025589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/31/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Reversible posterior leukoencephalopathy syndrome (RPLS) is a clinicoradiological phenomenon first observed 2 decades ago. Reversibility is the hallmark of this rare clinical phenomenon once the triggering pathology is aptly and adequately treated. Tinnitus preceding bilateral hearing loss as a symptomatology of RPLS has not been reported in the literature. Furthermore, chronic obstructive ureteric calculus with superimposed infections as a cause of RPLS has not been reported in the literature. PATIENT CONCERNS A 57-year-old female was admitted at our facility because of 2 days history of hearing loss in both ears. She experienced tinnitus in both ears 2 weeks prior to the hearing loss. She is a known hypertensive. She has also undergone multiple surgical treatments for urinary calculi. DIAGNOSIS Computed tomography (CT) scan of the urinary system revealed a calculus at the right ureter. Magnetic resonance imaging (MRI) showed abnormal signals at both temporo-parieto-occipital (TPO) cortices, the subcortical area, as well as the left hippocampus which was consistent with the diagnosis of RPLS. INTERVENTIONS While on antibiotics for treatment of infections, the patient went into hypertensive encephalopathy and pneumonia was also established necessitating intensive care. OUTCOMES We observed a resolution of the patient's temperature and hypertension when the right ureteric stone finally descended into the bladder. Also, we observed disappearance of the abnormal signals at both TPO cortices, the subcortical area, as well as the left hippocampus. Two years follow-up revealed no recurrence of her symptomatology. LESIONS Patients who present with hypertensive encephalopathy maybe more prone to developing RPLS. Renal insufficiency alone or hypertension alone may not be single predisposing entities to RPLS but rather multiple predisposing factors.
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Affiliation(s)
| | | | - Lin Huang
- Department of Cardiology, The First People's Hospital of Ziyang, No. 66, Rende west road, Ziyang, 641300, Sichuan, PR China
| | | | | | - Seidu A. Richard
- Department of Medicine, Princefield University, P.O. Box MA 128, Ho-Volta Region, Ghana, West Africa
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88
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Hegde R, Ismail R, Vegunta A, Megahed A, Sharma P, Rosovsky M. Atypical posterior reversible encephalopathy syndrome in a case of thrombotic thrombocytopenic purpura with Sjogren's syndrome. Radiol Case Rep 2021; 16:1552-1556. [PMID: 33981376 PMCID: PMC8082195 DOI: 10.1016/j.radcr.2021.03.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 03/19/2021] [Accepted: 03/20/2021] [Indexed: 11/13/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare hematologic disorder characterized by thrombotic microangiopathy. Neurologic symptoms are frequently seen in its presentation and the most common finding on neuroimaging of TTP is posterior reversible encephalopathy syndrome (PRES). Acute strokes, hemorrhages and atypical PRES are uncommonly seen. Our case reports the clinical and imaging details of a young male patient with TTP and Sjogren's syndrome, who made a complete recovery after aggressive plasmapheresis and immunosuppressive therapy with resolution of the imaging findings of PRES on follow up brain MR imaging. We briefly review the literature for the spectrum of imaging findings that can be seen on brain MRI with TTP.
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Affiliation(s)
- Rahul Hegde
- Department of Radiology, Yale New Haven Health System, Bridgeport Hospital, Bridgeport, CT
| | - Rasha Ismail
- Department of Radiology, Yale New Haven Health System, Bridgeport Hospital, Bridgeport, CT
| | - Aishwariya Vegunta
- Department of Radiology, Yale New Haven Health System, Bridgeport Hospital, Bridgeport, CT
| | - Ayah Megahed
- Department of Radiology, Yale New Haven Health System, Bridgeport Hospital, Bridgeport, CT
| | - Pranav Sharma
- Department of Radiology, University of Minnesota Medical Center, Minneapolis, MIN
| | - Mark Rosovsky
- Department of Radiology, Yale New Haven Health System, Bridgeport Hospital, Bridgeport, CT
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89
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Morana G, Bagnasco F, Leoni M, Pasquini L, Gueli I, Tortora D, Severino M, Giardino S, Pierri F, Micalizzi C, Verrina E, Ravelli A, Mancardi MM, Rossi A, Faraci M. Multifactorial Posterior Reversible Encephalopathy Syndrome in Children: Clinical, Laboratory, and Neuroimaging Findings. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0040-1714109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractThe aim of this study was to investigate the association of neuroimaging, clinical, and laboratory findings in children with different underlying diseases who developed posterior reversible encephalopathy syndrome (PRES). All consecutive pediatric patients referred to our institute between 2000 and 2017 were retrospectively evaluated for newly diagnosed PRES. Clinical data, medical history, and therapies administered at the time of PRES and laboratory findings were reviewed as the magnetic resonance imaging (MRI) obtained at PRES presentation and during follow-up. Statistics included Mann–Whitney U, Chi-square, and Fisher's exact tests. A total of 39 pediatric patients (25 males, median age = 8.8 years) with a confirmed diagnosis of PRES were included. The patients were divided into four groups based on the underlying disease: (1) patients with hemato-oncological diseases not transplanted (n = 15, 38.5%), (2) who underwent hematopoietic stem cell transplantation (HSCT; n = 12, 30.8%), (3) affected by renal (n = 8, 20.5%), and (4) by autoimmune diseases (n = 4, 10.2%). Hemato-oncological patients and those undergoing HSCT presented a higher incidence of involvement of deep gray matter structures and hemorrhagic lesions when compared with patients with renal and autoimmune disorders (p = 0.036 and p = 0.036, respectively). No differences emerged among different groups of patients regarding presenting PRES symptoms, arterial blood pressure, laboratory findings, and extent of MRI abnormalities and these parameters did not show association with outcome.In conclusion, in pediatric patients with different diseases who develop PRES, involvement of deep gray matter structures and hemorrhagic lesions are more common in hemato-oncological patients and those undergoing HSCT. Clinical and radiologic outcome is favorable independently of clinical data and extent of MRI abnormalities.
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Affiliation(s)
- Giovanni Morana
- Neuroradiology Unit, IRCSS Istituto Giannina Gaslini, Genova, Italy
| | - Francesca Bagnasco
- Epidemiology and Biostatistics Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | | | - Luca Pasquini
- Neuroradiology Unit, NESMOS Department, Sant'Andrea Hospital, La Sapienza University, Roma, Italy
| | - Ilaria Gueli
- Department of Pediatric, IRCSS Istituto Giannina Gaslini, Genova, Italy
| | - Domenico Tortora
- Neuroradiology Unit, IRCSS Istituto Giannina Gaslini, Genova, Italy
| | | | - Stefano Giardino
- Hematopoietic Stem Cell Transplantation Unit, IRCSS Istituto Giannina Gaslini, Genova, Italy
| | - Filomena Pierri
- Hematopoietic Stem Cell Transplantation Unit, IRCSS Istituto Giannina Gaslini, Genova, Italy
| | | | - Enrico Verrina
- Dialysis Unit, IRCSS Istituto Giannina Gaslini, Genova, Italy
| | - Angelo Ravelli
- Pediatric Rheumatology Unit, IRCSS Istituto Giannina Gaslini, Genova, Italy
| | | | - Andrea Rossi
- Neuroradiology Unit, IRCSS Istituto Giannina Gaslini, Genova, Italy
| | - Maura Faraci
- Hematopoietic Stem Cell Transplantation Unit, IRCSS Istituto Giannina Gaslini, Genova, Italy
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90
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Maramattom BV. Cough headache as a presenting feature of posterior reversible encephalopathy syndrome (PRES). Clin Med (Lond) 2021; 21:e237-e238. [PMID: 33762394 DOI: 10.7861/clinmed.2020-1080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
A 23-year-old man with chronic renal failure on maintenance haemodialysis was referred to the neurology outpatient clinic with new onset cough headache. On evaluation, his blood pressure was 220/120 mmHg and outpatient fundus photography showed grade IV hypertensive retinopathy. Urgent magnetic resonance imaging showed features of posterior reversible encephalopathy syndrome (PRES). Emergent treatment of hypertension led to a rapid resolution of his cough headache. New onset cough headache may be a marker of PRES.
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91
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Cognitive Sequelae of Central-Variant Posterior Reversible Encephalopathy Syndrome (PRES). Case Rep Neurol Med 2021; 2021:8850316. [PMID: 33628545 PMCID: PMC7884114 DOI: 10.1155/2021/8850316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/15/2020] [Accepted: 01/27/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction Although the posterior reversible encephalopathy syndrome (PRES) is often associated with headache and visual changes, central-variant PRES can be difficult to clinically diagnose in a patient with alteration of consciousness. Central-variant PRES has been previously described in the literature affecting subcortical white matter and the brainstem. Case Presentation. We describe a case presenting with hypertension (192/98) and altered level of consciousness requiring intubation. She was ultimately found to have extensive symmetric cortical and subcortical edema, with extensive involvement of bilateral thalami, consistent with central-variant PRES. Her mentation rapidly improved with blood pressure management. Confirmation of the diagnosis of central-variant PRES was made on repeat brain imaging. Our case is unique in demonstrating dramatic central white matter changes and their reversibility on repeat imaging six days later. Finally, persistent cognitive deficits at follow-up four months later are described. Conclusion Atypical presentations of PRES, involving alterations in levels of consciousness, can be difficult to clinically diagnose. A thorough differential diagnosis is even more important in cases of PRES with atypical imaging. Recognition of the diagnostic patterns of PRES on brain imaging, with prompt reversal of the causative factors, is crucial for the appropriate care of these patients. The long-term sequelae, which could include cognitive deficits, are poorly studied and understood.
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92
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Recurrent Posterior Reversible Encephalopathy Syndrome in an Adolescent Boy with End-Stage Renal Disease. Case Rep Pediatr 2021; 2021:6675454. [PMID: 33643673 PMCID: PMC7902131 DOI: 10.1155/2021/6675454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/20/2021] [Accepted: 01/25/2021] [Indexed: 12/20/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES), also known as reversible posterior leukoencephalopathy syndrome, is a neurological entity characterized by acute change in consciousness, visual impairment, headache, and seizures. It is associated with autoimmune disease, immunosuppressive agents, organ transplantation, acute glomerulonephritis, and sepsis. Typically, vasogenic edema is seen in the white matter of parieto-occipital lobes but can also involve atypical locations such as frontal lobes, thalamus, basal ganglia, and gray matter. While occurring extensively in adults, few cases, especially recurrent episodes, have been described in children. We report a case of recurrent PRES in a 17-year-old boy with end-stage renal disease on a peritoneal dialysis program who initially presented with hypertension and seizures. He emergently received intravenous antihypertensive medication with immediate and sustained improvement in his mental status. Information about recurrent PRES in children is limited because it is not commonly seen. We examine the clinical features of PRES and highlight important points for the diagnosis and management of this rare syndrome. This report demonstrates the importance of pediatricians to consider PRES in the differential diagnosis in children presenting with acute altered mental status. Blood pressure measurements, which are often overlooked in pediatric care, may assist in correctly diagnosing patients.
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93
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Abstract
Chronic kidney disease and seizures often co-exist. When seizures are provoked in patients with kidney disease, their treatment poses a particular challenge. Seizures may be provoked in the context of uremia, and toxic substances associated with uremic encephalopathy. In that case, the mainstay of therapy is to treat the uremia before consideration for anticonvulsant therapy. Treatment of seizures in the setting of chronic kidney disease requires special attention to selection of anticonvulsant medications and knowledge of the altered pharmacokinetics of these medications, which may require special titration schedule in that setting. The purpose of this review is to summarize the current knowledge about inter-relation of seizures and kidney disease. The review will also help practitioners who treat patients with renal failure and coexisting seizures in choosing the best treatment options.
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Affiliation(s)
- Mona Sazgar
- Clinical Professor, Department of Neurology/ UC Irvine Health, Comprehensive Epilepsy Program, 101 The City Drive South/ Pavilion I/ Suite 123, Orange, CA 92868-3201, USA.
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94
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Wang N, Shen X, Zhang G, Gao B, Lerner A. Cerebrovascular disease in pregnancy and puerperium: perspectives from neuroradiologists. Quant Imaging Med Surg 2021; 11:838-851. [PMID: 33532282 DOI: 10.21037/qims-20-830] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Pregnancy-related cerebrovascular disease is a serious complication of pregnancy and puerperium. The etiology and pathological mechanisms of cerebrovascular disease are complex, involving changes in the cardiovascular, endocrine, and immune systems. Vascular risk factors during pregnancy and puerperium may cause vasospasm and endothelial cell damage leading to cerebral ischemia, hemorrhage, posterior reversible encephalopathy syndrome (PRES), and reversible cerebral vasoconstriction syndrome. Arterial or venous obstruction may damage the blood-brain barrier (BBB) and impede venous return, resulting in cerebral edema, hemorrhage, and intracranial hypertension. Pregnancy with hypercoagulability may threaten the lives of both the mother and the developing fetus. With improvements in stroke treatment during pregnancy and puerperium, neuroradiologists have gained new insights into this problem. This article reviews the pathogenesis, imaging findings, and risk factors of stroke during pregnancy and puerperium, focusing on imaging diagnosis and prognostic assessment.
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Affiliation(s)
- Naiwu Wang
- Department of Radiology, Jinan City People's Hospital, Laiwu, China
| | - Xudong Shen
- Department of Radiology, Enshi Center Hospital, Enshi, China
| | - Gang Zhang
- Department of Radiology, Yantai Yuhuangding Hospital, Yantai, China
| | - Bo Gao
- Department of Radiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, China.,Key Laboratory of Brain Imaging, Guizhou Medical University, Guiyang, China
| | - Alexander Lerner
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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95
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Katsuki M, Ozaki D, Narita N, Ishida N, Watanabe O, Cai S, Shimabukuro S, Tominaga T. Unilateral posterior reversible encephalopathy syndrome characterized with a long and gradually exacerbating course over 3 years and that presented propofol infusion syndrome - A case report. Surg Neurol Int 2021; 12:19. [PMID: 33500834 PMCID: PMC7827507 DOI: 10.25259/sni_853_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 12/25/2020] [Indexed: 12/13/2022] Open
Abstract
Background: Posterior reversible encephalopathy syndrome (PRES) is characterized by acute neurological symptoms and vasogenic edema, and most patients wholly recover. We report a unilateral PRES patient characterized by a gradual onset followed by propofol infusion syndrome (PRIS) due to general anesthesia therapy. Case Description: A 32-year-old woman had ovarian dysfunction treated by Kaufmann’s treatment for 17 years. Three years ago, she developed seizures, and photophobia and myoclonus sometimes occurred. This time, she had strong photophobia and nausea for 3 months and then developed tonic-clonic seizures for 3 min. Her blood pressure and laboratory test on admission were all within normal limits. She presented no neurological deficits at admission, but the T2-weighted image (T2WI) showed a high-intensity area (HIA), and arterial spin labeling (ASL) image described cerebral blood flow (CBF) increase in the left parieto-occipital region. We diagnosed PRES and started anticonvulsants, antihypertensive, and steroid pulse therapy. However, her aphasia and neuroimaging findings worsened, so we started general anesthesia treatment with propofol on day 29. On day 32, she suddenly developed multiple organ dysfunctions due to PRIS. After intensive care with other sedatives over 2 months, the systemic status and neurological symptoms gradually improved almost as before the onset. On day 90, HIA in the T2WI in the lesion became small, and CBF was severely downregulated in the ASL image. Conclusion: Unilateral PRES’s pathophysiology and the association with the female hormone remain unknown. Some patients undergo gradual onset and long-term courses, and we should care for PRIS during PRES treatment.
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Affiliation(s)
- Masahito Katsuki
- Department of Neurosurgery, Kesennuma City Hospital, Kesennuma, Miyagi, Japan
| | - Dan Ozaki
- Department of Neurosurgery, Kesennuma City Hospital, Kesennuma, Miyagi, Japan
| | - Norio Narita
- Department of Neurosurgery, Kesennuma City Hospital, Kesennuma, Miyagi, Japan
| | - Naoya Ishida
- Department of Neurosurgery, Kesennuma City Hospital, Kesennuma, Miyagi, Japan
| | - Ohmi Watanabe
- Department of Neurosurgery, Kesennuma City Hospital, Kesennuma, Miyagi, Japan
| | - Siqi Cai
- Department of Neurosurgery, Kesennuma City Hospital, Kesennuma, Miyagi, Japan
| | - Shinya Shimabukuro
- Department of Neurosurgery, Kesennuma City Hospital, Kesennuma, Miyagi, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Aobaku, Sendai, Miyagi, Japan
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96
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Rodrigues SG, Saraiva P, Marques IB. Optic pathways and brainstem involvement in posterior reversible encephalopathy syndrome. BMJ Case Rep 2021; 14:14/1/e239130. [PMID: 33431522 PMCID: PMC7802660 DOI: 10.1136/bcr-2020-239130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a neurological syndrome manifesting with acute focal signs, and concomitant neuroimaging findings of vasogenic oedema. It affects the parieto-occipital regions in a vast majority of cases, although atypical variants have been described comprising the brainstem, basal ganglia or spinal cord. We report the case of a 41-year-old woman, admitted for persistent headache and inferior altitudinal field defect in the right eye. She presented with severe, non-medicated, hypertension. Brain MRI showed findings compatible with atypical PRES, involving the brainstem and optic pathways. With antihypertensive therapy the headache remitted, although visual field remained and was interpreted in the context of a vascular aetiology-non-arteritic anterior ischaemic optic neuropathy. MRI was repeated 3 weeks later and showed almost complete reversal of the previous changes.
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Affiliation(s)
| | - Paulo Saraiva
- Neuroradiology Department, Hospital da Luz Lisboa, Lisboa, Lisboa, Portugal
| | - Inês Brás Marques
- Neurology Department, Hospital da Luz Lisboa, Lisboa, Lisboa, Portugal
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97
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Angermann M, Jablawi F, Keulers A, Angermann M, Schubert GA, Weiss M, Reich A, Wiesmann M, Nikoubashman O. Posterior reversible encephalopathy syndrome after induced hypertension therapy for delayed cerebral ischemia after subarachnoid hemorrhage: A case-control study. J Neurol Sci 2021; 421:117313. [PMID: 33461062 DOI: 10.1016/j.jns.2021.117313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 01/01/2021] [Accepted: 01/05/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is associated with arterial hypertension. Our aim was to investigate whether induced hypertension (IH) as therapy for delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH) is associated with PRES and to identify risk factors for PRES. MATERIAL AND METHODS We retrospectively searched our database for patients with SAH and IH in our institution between 2009 and 2018 and identified additional cases of PRES after SAH with IH from the literature. We then analyzed demographic findings and clinical features of these patients. RESULTS 172 patients with acute SAH received IH. PRES was diagnosed in 3/172 (1.7%) patients. Our literature search revealed 17 additional cases. The pooled PRES group (n = 20) was non-significantly older than the non-PRES group (n = 169) (median, 62.5 years vs. 52 years, p = 0.06). No significant differences were found between both groups with regard to sex (p = 0.73), Hunt & Hess-Score (p = 0.9), aneurysm treatment (p = 0.13), and time from diagnosis of SAH to the start of IH (p = 0.14). CONCLUSIONS PRES after IH in SAH patients occurred in 1.7% of our patients. Our results imply that it is important to be aware of a possible development of a PRES in older SAH patients with IH, irrespective of sex, initial clinical status, and treatment modality.
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Affiliation(s)
- Maike Angermann
- Department of Neuroradiology, University Hospital RWTH, Aachen, Germany
| | - Fidaa Jablawi
- Department of Neurosurgery, Justus-Liebig-University Gießen, Germany
| | - Annika Keulers
- Department of Neuroradiology, University Hospital RWTH, Aachen, Germany
| | - Manuel Angermann
- Department of Neuroradiology, University Hospital RWTH, Aachen, Germany
| | - Gerrit A Schubert
- Department of Neurosurgery, University Hospital RWTH, Aachen, Germany
| | - Miriam Weiss
- Department of Neurosurgery, University Hospital RWTH, Aachen, Germany
| | - Arno Reich
- Department of Neurology, University Hospital RWTH, Aachen, Germany
| | - Martin Wiesmann
- Department of Neuroradiology, University Hospital RWTH, Aachen, Germany
| | - Omid Nikoubashman
- Department of Neuroradiology, University Hospital RWTH, Aachen, Germany.
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98
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Kim W, An J, Lee Y. Asymmetric Posterior Reversible Encephalopathy Syndrome Mimicking Massive Cerebral Hemispheric Infarction after Cardiac Surgery. Neurol India 2021; 69:1621-1622. [DOI: 10.4103/0028-3886.333490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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99
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Doo FX, Kassim G, Lefton DR, Patterson S, Pham H, Belani P. Rare presentations of COVID-19: PRES-like leukoencephalopathy and carotid thrombosis. Clin Imaging 2021; 69:94-101. [PMID: 32707411 PMCID: PMC7365057 DOI: 10.1016/j.clinimag.2020.07.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/19/2020] [Accepted: 07/13/2020] [Indexed: 12/13/2022]
Abstract
Coronavirus disease 2019 (COVID-19) is a global pandemic, and it is increasingly important that physicians recognize and understand its atypical presentations. Neurological symptoms such as anosmia, altered mental status, headache, and myalgias may arise due to direct injury to the nervous system or by indirectly precipitating coagulopathies. We present the first COVID-19 related cases of carotid artery thrombosis and acute PRES-like leukoencephalopathy with multifocal hemorrhage.
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Affiliation(s)
- Florence X Doo
- Mount Sinai Health System, Diagnostic, Molecular and Interventional Radiology, 1000 10th Avenue, Radiology, 4B 25, New York 10019, NY, USA.
| | - Gassan Kassim
- Mount Sinai Health System, Internal Medicine, 1000 10th Ave, New York 10019, NY, USA
| | - Daniel R Lefton
- Mount Sinai Health System, Diagnostic, Molecular and Interventional Radiology, 1000 10th Avenue, Radiology, 4B 25, New York 10019, NY, USA
| | - Shanna Patterson
- Mount Sinai Health System, Neurology, 1000 10th Ave, New York 10019, NY, USA
| | - Hien Pham
- Mount Sinai Health System, Diagnostic, Molecular and Interventional Radiology, 1000 10th Avenue, Radiology, 4B 25, New York 10019, NY, USA
| | - Puneet Belani
- Mount Sinai Health System, Diagnostic, Molecular and Interventional Radiology, 1000 10th Avenue, Radiology, 4B 25, New York 10019, NY, USA
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100
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Gabriel M, Hoeben BAW, Uhlving HH, Zajac-Spychala O, Lawitschka A, Bresters D, Ifversen M. A Review of Acute and Long-Term Neurological Complications Following Haematopoietic Stem Cell Transplant for Paediatric Acute Lymphoblastic Leukaemia. Front Pediatr 2021; 9:774853. [PMID: 35004543 PMCID: PMC8734594 DOI: 10.3389/fped.2021.774853] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/02/2021] [Indexed: 12/02/2022] Open
Abstract
Despite advances in haematopoietic stem cell transplant (HSCT) techniques, the risk of serious side effects and complications still exists. Neurological complications, both acute and long term, are common following HSCT and contribute to significant morbidity and mortality. The aetiology of neurotoxicity includes infections and a wide variety of non-infectious causes such as drug toxicities, metabolic abnormalities, irradiation, vascular and immunologic events and the leukaemia itself. The majority of the literature on this subject is focussed on adults. The impact of the combination of neurotoxic drugs given before and during HSCT, radiotherapy and neurological complications on the developing and vulnerable paediatric and adolescent brain remains unclear. Moreover, the age-related sensitivity of the nervous system to toxic insults is still being investigated. In this article, we review current evidence regarding neurotoxicity following HSCT for acute lymphoblastic leukaemia in childhood. We focus on acute and long-term impacts. Understanding the aetiology and long-term sequelae of neurological complications in children is particularly important in the current era of immunotherapy for acute lymphoblastic leukaemia (such as chimeric antigen receptor T cells and bi-specific T-cell engager antibodies), which have well-known and common neurological side effects and may represent a future treatment modality for at least a fraction of HSCT-recipients.
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Affiliation(s)
- Melissa Gabriel
- Cancer Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Bianca A W Hoeben
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Hilde Hylland Uhlving
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Olga Zajac-Spychala
- Department of Pediatric Oncology, Hematology and Transplantology, Poznan University of Medical Sciences, Poznań, Poland
| | - Anita Lawitschka
- Haematopoietic Stem Cell Transplant Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria
| | - Dorine Bresters
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Marianne Ifversen
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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