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Zappella N, Perier F, Pico F, Palette C, Muret A, Merceron S, Girbovan A, Marquion F, Legriel S. Duloxetine-related posterior reversible encephalopathy syndrome: A case report. Medicine (Baltimore) 2016; 95:e4556. [PMID: 27537580 PMCID: PMC5370806 DOI: 10.1097/md.0000000000004556] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) has well-established links with several drugs. Whether a link also exists with serotonin-norepinephrine reuptake inhibitor such as duloxetine is unclear. METHODS We report on a patient who developed PRES with a coma and myoclonus related to hypertensive encephalopathy a few days after starting duloxetine treatment. Magnetic resonance imaging was performed and catecholamine metabolites assayed. RESULTS The patient achieved a full recovery after aggressive antihypertensive therapy and intravenous anticonvulsant therapy. CONCLUSIONS The clinical history, blood and urinary catecholamine and serotonin levels, and response to treatment strongly suggest that PRES was induced by duloxetine. Duloxetine should be added to the list of causes of PRES.
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Affiliation(s)
| | | | | | | | - Alexandre Muret
- Emergency Department, Centre Hospitalier de Versailles – Site André Mignot, rue de Versailles, Le Chesnay cedex
| | | | | | | | - Stephane Legriel
- Intensive Care Unit
- Paris Descartes University, Sorbonne Paris Cité–Medical School
- INSERM U970, Paris Cardiovascular Research Center, Paris, France
- Correspondence: Stephane Legriel, Intensive Care Unit, Centre Hospitalier de Versailles - Site André Mignot, 177 rue de Versailles, Le Chesnay cedex, France (e-mail: )
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102
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Liu J, Qin J. [Research advances of posterior reversible encephalopathy syndrome in children]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2016; 18:787-91. [PMID: 27530801 PMCID: PMC7399525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Accepted: 07/01/2016] [Indexed: 11/12/2023]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinico-neuroradiological entity affecting the posterior brain, i.e. occipital and parietal lobes. The syndrome are characterized by headaches, altered mental status, seizures, and visual disturbances. Although the pathogenesis remains unclear, endothelial dysfunction may be a key factor. The basic disease may play a crucial role in the incidence of PRES. In most cases, PRES resolves spontaneously and patients show both clinical and radiological improvements. In severe forms, PRES might cause substantial morbidity with sequel and even mortality, as a result of acute hemorrhage or massive posterior fossa edema causing obstructive hydrocephalus or brainstem compression. Early identification, active and appropriate treatment is very important.
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Affiliation(s)
- Jing Liu
- Department of Pediatrics, Peking University People's Hospital, Beijing 100044, China.
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103
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Liu J, Qin J. [Research advances of posterior reversible encephalopathy syndrome in children]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2016; 18:787-791. [PMID: 27530801 PMCID: PMC7399525 DOI: 10.7499/j.issn.1008-8830.2016.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Accepted: 07/01/2016] [Indexed: 06/06/2023]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinico-neuroradiological entity affecting the posterior brain, i.e. occipital and parietal lobes. The syndrome are characterized by headaches, altered mental status, seizures, and visual disturbances. Although the pathogenesis remains unclear, endothelial dysfunction may be a key factor. The basic disease may play a crucial role in the incidence of PRES. In most cases, PRES resolves spontaneously and patients show both clinical and radiological improvements. In severe forms, PRES might cause substantial morbidity with sequel and even mortality, as a result of acute hemorrhage or massive posterior fossa edema causing obstructive hydrocephalus or brainstem compression. Early identification, active and appropriate treatment is very important.
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Affiliation(s)
- Jing Liu
- Department of Pediatrics, Peking University People's Hospital, Beijing 100044, China.
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104
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Predictors of seizures in patients with posterior reversible encephalopathy syndrome. Epilepsy Behav 2016; 61:97-101. [PMID: 27337161 DOI: 10.1016/j.yebeh.2016.05.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 04/12/2016] [Accepted: 05/03/2016] [Indexed: 01/25/2023]
Abstract
PURPOSE Although seizures are common in patients with posterior reversible encephalopathy syndrome (PRES), epilepsy is rare. Our objective was to identify predictors and impact of seizures in patients with PRES. METHODS A retrospective review of the clinical and radiological parameters of all patients diagnosed with PRES from 2007 to 2014 was performed. Patients were divided into two groups based on the occurrence of PRES-related seizures at presentation or during their hospital course. Univariate and multivariate analyses were performed to determine factors associated with the occurrence of PRES-related seizures. RESULTS Of 100 patients, 70% experienced at least one seizure from PRES. On univariate analysis, the factors associated with seizures were the following: high Charlson comorbidity index (4.16±2.89 vs. 2.87±2.20, p=0.03), systemic malignancy (41.4% vs. 16.7%, p=0.02), occipital lobe involvement (97.1% vs. 83.3%, p=0.02), more lobes involved (4.6±1.48 vs. 3.9±1.32, p=0.03) but less likely in patients with visual disturbances (15.7% vs. 46.7%, p=0.005), and facial droop (12.9% vs. 16.7%, p=0.002). On multivariate analysis, only occipital lobe involvement was significantly (odds ratio: 9.63, 95% CI: 1.45-64.10, p=0.02) associated with the occurrence of PRES-related seizures. Despite the occurrence of seizures, they were less likely to require a nursing home placement upon hospital discharge (odds ratio: 0.17, 95% CI: 0.03-0.91, p=0.04). CONCLUSION We conclude that seizures are common in patients with occipital lobe involvement from PRES.
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105
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Gao B, Lerner A, Law M. The Clinical Outcome of Posterior Reversible Encephalopathy Syndrome. AJNR Am J Neuroradiol 2016; 37:E55-6. [PMID: 27365328 DOI: 10.3174/ajnr.a4853] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- B Gao
- Department of Radiology Yantai Yuhuangding Hospital Qingdao University Yantai, Shandong, China Department of Radiology Keck School of Medicine University of Southern California Los Angeles, California
| | - A Lerner
- Department of Radiology Keck School of Medicine University of Southern California Los Angeles, California
| | - M Law
- Department of Radiology Keck School of Medicine University of Southern California Los Angeles, California
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106
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Fisher N, Saraf S, Egbert N, Homel P, Stein EG, Minkoff H. Clinical Correlates of Posterior Reversible Encephalopathy Syndrome in Pregnancy. J Clin Hypertens (Greenwich) 2016; 18:522-7. [PMID: 26293622 PMCID: PMC8031836 DOI: 10.1111/jch.12656] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 07/06/2015] [Accepted: 07/12/2015] [Indexed: 10/23/2022]
Abstract
The authors aimed to determine whether clinical findings of preeclampsia predict magnetic resonance imaging (MRI) diagnosis of posterior reversible encephalopathy syndrome (PRES). The course among preeclamptics/eclamptics with clinically suspected PRES with vs without MRI diagnosis of PRES was compared. Of 46 patients who underwent MRI (eight eclamptics, 38 preeclamptics), five eclamptics (62.5%) and four preeclamptics (10.5%) had confirmed PRES (P=.004). Patients with PRES were younger (26 years vs 31 years, P=.008) and had a higher prevalence of thrombocytopenia (33% vs 8%, P=.04), a greater prevalence of proteinuria (100% vs 61%, P=.04), and higher peak systolic and diastolic blood pressures (P<.05). As opposed to findings from previous reports, PRES was not seen uniformly among eclamptic women and was found in 10.5% of preeclamptics with clinical suspicion of PRES in this study. Given that no single or set of findings were reliable predictors of PRES, consideration for rigorous management of hypertension should be applied to all patients with preeclampsia and eclampsia.
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Affiliation(s)
- Nelli Fisher
- Department of Obstetrics and GynecologyMaimonides Medical CenterBrooklynNY
| | - Sumit Saraf
- Department of Obstetrics and GynecologyMaimonides Medical CenterBrooklynNY
| | - Neha Egbert
- Department of Obstetrics and GynecologyMaimonides Medical CenterBrooklynNY
| | - Peter Homel
- Department of MedicineAlbert Einstein College of MedicineMaimonides Medical CenterBrooklynNY
- Maimonides Research FoundationMaimonides Medical CenterBrooklynNY
| | - Evan G. Stein
- Department of RadiologyMaimonides Medical CenterBrooklynNY
| | - Howard Minkoff
- Department of Obstetrics and GynecologyMaimonides Medical CenterBrooklynNY
- Department of Obstetrics and GynecologySUNY DownstateBrooklynNY
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107
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Critically ill allogeneic hematopoietic stem cell transplantation patients in the intensive care unit: reappraisal of actual prognosis. Bone Marrow Transplant 2016; 51:1050-61. [PMID: 27042832 DOI: 10.1038/bmt.2016.72] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 02/14/2016] [Accepted: 02/17/2016] [Indexed: 12/16/2022]
Abstract
The outcome of allogeneic hematopoietic stem cell transplantation (allo-HSCT) patients has significantly improved over the past decade. Still, a significant number of patients require intensive care unit (ICU) management because of life-threatening complications. Literature from the 1990s reported extremely poor prognosis for critically ill allo-HSCT patients requiring ICU management. Recent data justify the use of ICU resources in hematologic patients. Yet, allo-HSCT remains an independent variable associated with mortality. However, outcomes in allo-HSCT patients have improved over time and many classic determinants of mortality have become irrelevant. The main actual prognostic factors are the need for mechanical ventilation, the presence of GvHD and the number of organ failures at ICU admission. Recently, the development of reduced-intensity conditioning regimens, early ICU admission and the increased use of noninvasive ventilation, combined with time effect and general advances in hematology, in allo-HSCT procedures and in ICU management have contributed to improve general outcome. A rational policy of ICU admission triage in these patients is very hard to define, as each decision for ICU admission is a case-by-case decision at patient bedside. The collaboration between hematologists and intensivists is crucial in this context.
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108
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Montelescaut E, Bailly P, Le Calloch R, Thill C, Aries P, Ben Salem D. Une cause rare d’hémorragie méningée. Presse Med 2016; 45:470-3. [DOI: 10.1016/j.lpm.2016.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 01/04/2016] [Accepted: 01/13/2016] [Indexed: 11/24/2022] Open
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109
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Merayo-Chalico J, Apodaca E, Barrera-Vargas A, Alcocer-Varela J, Colunga-Pedraza I, González-Patiño A, Arauz A, Abud-Mendoza C, Martínez-Martínez M, Gómez-Martín D. Clinical outcomes and risk factors for posterior reversible encephalopathy syndrome in systemic lupus erythematosus: a multicentric case-control study. J Neurol Neurosurg Psychiatry 2016; 87:287-94. [PMID: 25804426 DOI: 10.1136/jnnp-2014-310145] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 03/02/2015] [Indexed: 01/19/2023]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a well-known but rare complication in patients (<1%) with systemic lupus erythematosus (SLE). However, current epidemiological data are quite scant. The aim of the present study was to describe potentially unrecognised risk factors. PATIENTS AND METHODS We performed a multicentre, retrospective case-control study in Mexico between 1999 and 2014. We included a total of 168 patients who accounted for 77 episodes of PRES, as follows: SLE/PRES, 43 patients with 48 episodes; SLE without PRES, 96 patients; and PRES without SLE, 29 patients. SLE diagnosis was considered when patients fulfilled ≥4 American College of Rheumatology criteria. PRES was defined by reversible neurological manifestations and MRI changes. RESULTS Patients with SLE/PRES were younger, presented with seizures as the most common manifestation (81%) and 18% had the typical occipital MRI finding. Hypertension (OR=16.3, 95% CI 4.03 to 65.8), renal dysfunction (OR=6.65, 95% CI 1.24 to 35.6), lymphopenia (OR=5.76, 95% CI 1.36 to 24.4), Systemic Lupus Erythematosus Activity Index ≥ 6 points (OR=1.11, 95% CI 1.01 to 1.22) and younger age (OR=0.86, 95% CI 0.81 to 0.91, p<0.001) were independent risk factors for development of PRES in SLE. Furthermore, dyslipidemia also characterised the association between PRES and SLE (OR=10.6, 95% CI 1.17 to 96.4). CONCLUSIONS This is the largest reported series of patients with SLE and PRES. We were able to corroborate the known risk factors for of PRES, and found two previously undescribed factors (lymphopenia and dyslipidemia), which suggests that endothelial dysfunction is a key element in PRES pathogenesis in lupus patients.
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Affiliation(s)
- Javier Merayo-Chalico
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Elia Apodaca
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ana Barrera-Vargas
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Jorge Alcocer-Varela
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Iris Colunga-Pedraza
- Department of Rheumatology, Hospital Universitario Dr José E González, Monterrey, Nuevo León, Mexico
| | - Alejandra González-Patiño
- Stroke Clinic, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Antonio Arauz
- Stroke Clinic, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Carlos Abud-Mendoza
- Regional Unit of Rheumatology and Osteoporosis, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosí, Mexico
| | - Marco Martínez-Martínez
- Regional Unit of Rheumatology and Osteoporosis, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosí, Mexico
| | - Diana Gómez-Martín
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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110
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Hinduja A, Habetz K, Raina S, Ramakrishnaiah R, Fitzgerald RT. Predictors of poor outcome in patients with posterior reversible encephalopathy syndrome. Int J Neurosci 2016; 127:135-144. [PMID: 26892843 DOI: 10.3109/00207454.2016.1152966] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE Posterior reversible encephalopathy syndrome (PRES) is an acute neurotoxic syndrome that, although characteristically reversible, can be fatal or result in long-term disability in a subset of patients. Our aim was to identify factors associated with poor discharge outcome in PRES patients. MATERIALS AND METHODS We retrospectively reviewed the clinical and radiological records of all patients with PRES admitted at our tertiary care medical center from 2007 to 2014. They were divided based their modified Rankin Score at discharge and compared for their baseline variables, clinical, laboratory and imaging features. Poor outcome was defined by a modified Rankin scale 2-6 and was subdivided based on the primary mechanism that led to poor outcome. RESULTS Out of 100 PRES subjects, 36% had poor discharge outcomes. Factors associated with poor outcomes on univariate analysis were history of diabetes mellitus, coma, high Charlson comorbidity index, post-transplantation, autoimmune condition, lack of systolic or diastolic hypertension, elevated blood urea nitrogen and involvement of the corpus callosum. On multivariate analysis, only prior diabetes mellitus odd ratio (OR) = 6.8 (95% CI 1.1-42.1, p = 0.04), corpus callosum involvement (OR = 11.7; 95% CI 2.4-57.4, p = 0.00) were associated with poor outcome. Poor outcome also correlated with increased length of hospital stay (OR = 7.9; 95% CI 1.3-49.7, p = 0.03). CONCLUSION Large prospective studies incorporating serial blood glucose values and advanced imaging studies are required to validate these findings.
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Affiliation(s)
- Archana Hinduja
- a Department of Neurology , University of Arkansas for Medical Sciences , Little Rock , AR , US
| | - Kenneth Habetz
- b Department of Pediatric Neurology , Arkansas Children Hospital , Little Rock , AR , US
| | - Sunil Raina
- c Department of Community Medicine , Dr RP Government Medical College , Tanda , India
| | - Raghu Ramakrishnaiah
- d Department of Radiology , University of Arkansas for Medical Sciences , Little Rock , AR , US
| | - Ryan T Fitzgerald
- d Department of Radiology , University of Arkansas for Medical Sciences , Little Rock , AR , US
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111
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Christopoulou F, Rizos EC, Kosta P, Argyropoulou MI, Elisaf M. Does this patient have hypertensive encephalopathy? ACTA ACUST UNITED AC 2016; 10:399-403. [PMID: 26896240 DOI: 10.1016/j.jash.2016.01.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Revised: 09/03/2015] [Accepted: 01/13/2016] [Indexed: 11/25/2022]
Abstract
A 63-year-old man was admitted to our hospital for further investigation and management of brain metastases. The patient was initially presented with a 4-day history of confusion. On the day of admission, the patient was confused, agitated, disorientated in place and time, and had visual disturbances. His blood pressure was repeatedly recorded high, with levels of systolic blood pressure between 170-210 mm Hg. A brain magnetic resonance imaging showed areas of high signal on T2 and fluid-attenuated inversion recovery images, located bilaterally in the white matter of the occipital regions and unilateral in the left frontal lobe, suggestive of posterior reversible encephalopathy syndrome. Aggressive treatment of hypertension resulted in complete resolution of the clinical and radiologic features of the syndrome.
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Affiliation(s)
| | - Evangelos C Rizos
- Department of Internal Medicine, University Hospital of Ioannina, Ioannina, Greece
| | - Paraskevi Kosta
- Radiology Department, Medical School, University Hospital of Ioannina, Ioannina, Greece
| | - Maria I Argyropoulou
- Radiology Department, Medical School, University Hospital of Ioannina, Ioannina, Greece
| | - Moses Elisaf
- Department of Internal Medicine, University Hospital of Ioannina, Ioannina, Greece.
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112
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Iwafuchi Y, Okamoto K, Oyama Y, Narita I. Posterior Reversible Encephalopathy Syndrome in a Patient with Severe Uremia without Hypertension. Intern Med 2016; 55:63-8. [PMID: 26726088 DOI: 10.2169/internalmedicine.55.5563] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 28-year-old man was admitted to our hospital with nausea, headache and weakness of the left hand. He had severe uremia without hypertension due to recurrent/chronic pyelonephritis. Brain magnetic resonance imaging showed reversible vasogenic edema in the brainstem and bilateral frontal centrum semiovale. All of his neurological symptoms immediately improved after the introduction of hemodialysis. When a patient with uremia presents with neurological symptoms, posterior reversible encephalopathy syndrome should be considered in the differential diagnosis even if high blood pressure is not observed. Brain magnetic resonance imaging may be helpful in such a case, and an appropriate therapy could be subsequently initiated.
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Affiliation(s)
- Yoichi Iwafuchi
- Department of Internal Medicine, Koseiren Sanjo General Hospital, Japan
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113
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Fitzgerald RT, Samant RS, Kumar M, Van Hemert R, Angtuaco EJ. Features of infratentorial-predominant posterior reversible encephalopathy syndrome. Acta Neurol Belg 2015; 115:629-34. [PMID: 25605260 DOI: 10.1007/s13760-015-0431-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 01/12/2015] [Indexed: 01/02/2023]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a neurotoxic process that typically occurs in the setting of immune dysregulation. In contrast to the characteristic pattern involving parieto-occipital and posterior frontal regions, predominant involvement of the infratentorial brain occurs in a minority of PRES patients. We examined six patients with infratentorial predominant posterior reversible encephalopathy syndrome (IPPRES) relative to those with typical PRES in terms of clinical factors of toxicity and outcomes. We review the current understanding of PRES pathophysiology. An institutional database of PRES patients was created through an IRB-approved search of the electronic record from 2007 to 2012. MR images were reviewed and classified by two neuro radiologists. Clinical data including laboratory data, blood pressure, and discharge outcome were collected through review of existing electronic medical records. Characteristics of the two groups were compared. Six cases among 80 PRES patients displayed an atypical distribution of signal abnormality predominantly involving the infratentorial brain. In IPPRES patients, signal abnormalities within the supratentorial brain, when present, showed a predominantly central distribution rather than the typical peripheral distribution. IPPRES patients showed higher rates of extreme hypertension, renal dysfunction, abnormal serum calcium, and abnormal serum magnesium relative to typical PRES patients. Outcomes were similar between the two groups. In our small series, IPPRES differs from typical PRES patients not only in the distribution of imaging abnormalities but also in rates of extreme hypertension and several laboratory indices. Despite these differences, clinical outcome in the IPPRES group was similar to that of typical PRES.
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Affiliation(s)
- Ryan T Fitzgerald
- Department of Radiology, Neuroradiology Division Slot 556, University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, AR, 72205, USA.
| | - Rohan S Samant
- Department of Radiology, Neuroradiology Division Slot 556, University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, AR, 72205, USA
| | - Manoj Kumar
- Department of Radiology, Neuroradiology Division Slot 556, University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, AR, 72205, USA
| | - Rudy Van Hemert
- Department of Radiology, Neuroradiology Division Slot 556, University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, AR, 72205, USA
| | - Edgardo J Angtuaco
- Department of Radiology, Neuroradiology Division Slot 556, University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, AR, 72205, USA
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Yamamoto H, Natsume J, Kidokoro H, Ishihara N, Suzuki M, Tsuji T, Kubota T, Yamada A, Ozeki M, Kato Z, Kawamura Y, Yoshikawa T, Okumura A, Ando N, Saitoh S, Takahashi Y, Watanabe K, Kojima S. Clinical and neuroimaging findings in children with posterior reversible encephalopathy syndrome. Eur J Paediatr Neurol 2015; 19:672-8. [PMID: 26232050 DOI: 10.1016/j.ejpn.2015.07.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2014] [Revised: 06/16/2015] [Accepted: 07/13/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To clarify the clinical and radiological spectrum of posterior reversible encephalopathy syndrome (PRES) in children, and to identify the prognostic factors. METHODS The records of 40 children with PRES were reviewed. Acute clinical symptoms, MRI including apparent diffusion coefficient (ADC) maps in the acute and follow-up periods and neurological sequelae, including epilepsy, were noted. RESULTS Age at onset ranged from 2 to 16 years. Underlying disorders were hematological or neoplastic disorders (n = 20), renal diseases (n = 14) and others (n = 6). In the acute period, 31 patients had seizures, 25 had altered consciousness, 11 had visual disturbances and 10 had headache. Of 29 patients who had ADC maps in the acute period, 13 had reduced diffusivity as shown by ADC within PRES lesions. Of 26 patients with follow-up MRI, 13 had focal gliosis or cortical atrophy. No patients had motor impairment, and four patients had focal epilepsy. No clinical variables were associated with focal gliosis or cortical atrophy on follow-up MRI, but lesional ADC reduction in the acute period was prognostic for focal gliosis or cortical atrophy on follow-up MRI (p = 0.005). CONCLUSIONS To the best of our knowledge, this is the largest cohort study to date involving PRES in children. Acute symptoms in pediatric patients are similar to those reported in adults, but altered consciousness was more frequent in children. Lesional ADC reduction in the acute period was common and was a good predictor of later, irreversible MRI lesions.
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Affiliation(s)
- Hiroyuki Yamamoto
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Jun Natsume
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroyuki Kidokoro
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naoko Ishihara
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Motomasa Suzuki
- Department of Neurology, Aichi Children's Health and Medical Center, Obu, Japan
| | - Takeshi Tsuji
- Department of Pediatrics, Okazaki City Hospital, Okazaki, Japan
| | - Tetsuo Kubota
- Department of Pediatrics, Anjo Kosei Hospital, Anjo, Japan
| | - Akio Yamada
- Department of Pediatrics, Social Insurance Chukyo Hospital, Nagoya, Japan
| | - Michio Ozeki
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Zenichiro Kato
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Yoshiki Kawamura
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake, Japan
| | - Tetsushi Yoshikawa
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake, Japan
| | - Akihisa Okumura
- Department of Pediatrics, Aichi Medical University, Nagakute, Japan; Department of Pediatrics, Juntendo University School of Medicine, Tokyo, Japan
| | - Naoki Ando
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Shinji Saitoh
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yoshiyuki Takahashi
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuyoshi Watanabe
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Seiji Kojima
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
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115
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Zhou J, Zheng H, Zhong X, Wu D, Wang M, Tang X, Li Q. Reversible posterior encephalopathy syndrome in children with nephrotic syndrome. Nephrology (Carlton) 2015; 20:849-54. [DOI: 10.1111/nep.12518] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2015] [Indexed: 11/26/2022]
Affiliation(s)
- Juan Zhou
- Ministry of Education Key Laboratory of Child Development and Disorders; Key Laboratory of Pediatrics in Chongqing; Chongqing International Science and Technology Cooperation Center for Child Development and Disorders; Children's Hospital of Chongqing Medical University; Chongqing China
| | - Helin Zheng
- Ministry of Education Key Laboratory of Child Development and Disorders; Key Laboratory of Pediatrics in Chongqing; Chongqing International Science and Technology Cooperation Center for Child Development and Disorders; Children's Hospital of Chongqing Medical University; Chongqing China
| | - Xuefei Zhong
- Ministry of Education Key Laboratory of Child Development and Disorders; Key Laboratory of Pediatrics in Chongqing; Chongqing International Science and Technology Cooperation Center for Child Development and Disorders; Children's Hospital of Chongqing Medical University; Chongqing China
| | - Daoqi Wu
- Ministry of Education Key Laboratory of Child Development and Disorders; Key Laboratory of Pediatrics in Chongqing; Chongqing International Science and Technology Cooperation Center for Child Development and Disorders; Children's Hospital of Chongqing Medical University; Chongqing China
| | - Mo Wang
- Ministry of Education Key Laboratory of Child Development and Disorders; Key Laboratory of Pediatrics in Chongqing; Chongqing International Science and Technology Cooperation Center for Child Development and Disorders; Children's Hospital of Chongqing Medical University; Chongqing China
| | - Xuemei Tang
- Ministry of Education Key Laboratory of Child Development and Disorders; Key Laboratory of Pediatrics in Chongqing; Chongqing International Science and Technology Cooperation Center for Child Development and Disorders; Children's Hospital of Chongqing Medical University; Chongqing China
| | - Qiu Li
- Ministry of Education Key Laboratory of Child Development and Disorders; Key Laboratory of Pediatrics in Chongqing; Chongqing International Science and Technology Cooperation Center for Child Development and Disorders; Children's Hospital of Chongqing Medical University; Chongqing China
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Clinical Utility of Computed Tomography and Magnetic Resonance Imaging for Diagnosis of Posterior Reversible Encephalopathy Syndrome after Stem Cell Transplantation in Children and Adolescents. Biol Blood Marrow Transplant 2015; 21:2028-32. [PMID: 26226408 DOI: 10.1016/j.bbmt.2015.07.023] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 07/22/2015] [Indexed: 02/08/2023]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinical syndrome characterized by vision changes, altered mental status, and seizures, typically caused by an acute rise in blood pressure. PRES has been reported after hematopoietic stem cell transplantation (HSCT) in association with hypertension from calcineurin inhibitors and corticosteroids. The imaging evaluation of PRES after HSCT in children and young adults has not been well described. We performed a retrospective review of all HSCT recipients presenting to the intensive care unit with new neurologic symptoms. A neuroradiologist reviewed all radiologic images and compared computed tomography (CT) versus magnetic resonance imaging (MRI) findings indicative of diagnosis of PRES. Alternative imaging diagnoses explaining the patients' symptoms were also recorded. Fifty-four transplant recipients were admitted to the intensive care unit with new neurologic symptoms. Thirty-nine percent (21 of 54) of subjects had imaging findings consistent with PRES, 24% (13 of 54) had imaging findings consistent with an alternative diagnosis, 9% (5 of 54) had a nonspecific finding, and 28% (15 of 54) had no acute imaging findings. PRES was diagnosed at a median of 49 days (interquartile range, 29 to 94) after HSCT. The presenting symptom for the majority of patients with PRES was seizures (86%), whereas 14% presented with acute encephalopathy. Ninety-five percent of subjects diagnosed with PRES (20 of 21) underwent a head CT as their initial imaging evaluation. CT scan was diagnostic of PRES in 40% (8 of 20). Subsequently, 16 patients underwent brain MRI with 12 additional patients being diagnosed with PRES on MRI. The median time elapsed between negative CT and a positive MRI examination was 20 hours (range, 3.6 hours to 9 days). CT serves as an excellent screening test for acute pathology, such as intracranial hemorrhage; however, it lacks sensitivity for the diagnosis of PRES. Patients with clinical symptoms suggestive of PRES who have a negative CT should be treated appropriately for PRES and should undergo MRI of the brain as soon as clinically stable to confirm the diagnosis.
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Posterior reversible encephalopathy syndrome: clinical and radiological manifestations, pathophysiology, and outstanding questions. Lancet Neurol 2015; 14:914-925. [PMID: 26184985 DOI: 10.1016/s1474-4422(15)00111-8] [Citation(s) in RCA: 658] [Impact Index Per Article: 73.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 04/08/2015] [Accepted: 05/27/2015] [Indexed: 12/12/2022]
Abstract
Almost two decades have elapsed since posterior reversible encephalopathy syndrome (PRES) was described in an influential case series. This usually reversible clinical syndrome is becoming increasingly recognised, in large part because of improved and more readily available brain imaging. Although the pathophysiological changes underlying PRES are not fully understood, endothelial dysfunction is a key factor. A diagnosis of PRES should be considered in the setting of acute neurological symptoms in patients with renal failure, blood pressure fluctuations, use of cytotoxic drugs, autoimmune disorders, or eclampsia. Characteristic radiographic findings include bilateral regions of subcortical vasogenic oedema that resolve within days or weeks. The presence of haemorrhage, restricted diffusion, contrast enhancement, and vasoconstriction are all compatible with a diagnosis. In most cases, PRES resolves spontaneously and patients show both clinical and radiological improvements. The range of symptoms that can comprise the syndrome might be broader than usually thought. In its mild form, this disorder might cause only one clinical symptom (headache or seizure) and radiographically might show few areas of vasogenic oedema or even normal brain imaging in some rare cases. In severe forms, PRES might cause substantial morbidity and even mortality, most often as a result of acute haemorrhage or massive posterior fossa oedema causing obstructive hydrocephalus or brainstem compression.
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[Posterior reversible encephalopathy syndrome and cerebrovascular constriction syndrome in the differential diagnosis of post-partum headaches]. ACTA ACUST UNITED AC 2015; 63:116-21. [PMID: 26056067 DOI: 10.1016/j.redar.2015.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 04/26/2015] [Accepted: 04/27/2015] [Indexed: 11/22/2022]
Abstract
Postpartum headache can be due to many causes. In a patient with previous epidural analgesia, the headache can be attributed to post-dural puncture headache, even if the symptoms are not typical of this clinical entity. We report a case of a post-partum with accidental dural tap during the insertion of an epidural catheter for labour analgesia, and who referred to headaches in the third post-partum day. Initially, a post-dural puncture headache was suspected, but the subsequent onset of seizures and visual impairment meant that the diagnosis had to be reconsidered. In this case report, the clinical and pathophysiological features of posterior reversible encephalopathy syndrome and reversible cerebral vasoconstriction syndrome, as well as the differential diagnosis of post-partum headaches are described.
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Wagih A, Mohsen L, Rayan MM, Hasan MM, Al-Sherif AH. Posterior Reversible Encephalopathy Syndrome (PRES): Restricted Diffusion does not Necessarily Mean Irreversibility. Pol J Radiol 2015; 80:210-6. [PMID: 25960819 PMCID: PMC4418207 DOI: 10.12659/pjr.893460] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Accepted: 01/24/2015] [Indexed: 11/21/2022] Open
Abstract
Background Restricted diffusion is the second most common atypical presentation of PRES. This has a very important implication, as lesions with cytotoxic edema may progress to infarction. Several studies suggested the role of DWI in the prediction of development of infarctions in these cases. Other studies, however, suggested that PRES is reversible even with cytotoxic patterns. Our aim was to evaluate whether every restricted diffusion in PRES is reversible and what factors affect this reversibility. Material/Methods Thirty-six patients with acute neurological symptoms suggestive of PRES were included in our study. Inclusion criteria comprised imaging features of atypical PRES where DWI images and ADC maps show restricted diffusion. Patients were imaged with 0.2-T and 1.5-T machines. FLAIR images were evaluated for the severity of the disease and a FLAIR/DWI score was used. ADC values were selectively recorded from the areas of diffusion restriction. A follow-up MRI study was carried out in all patients after 2 weeks. Patients were classified according to reversibility into: Group 1 (reversible PRES; 32 patients) and Group 2 (irreversible changes; 4 patients). The study was approved by the University’s research ethics committee, which conforms to the declaration of Helsinki. Results The age and blood pressure did not vary significantly between both groups. The total number of regions involved and the FLAIR/DWI score did not vary significantly between both groups. Individual regions did not reveal any tendency for the development of irreversible lesions. Similarly, ADC values did not reveal any significant difference between both groups. Conclusions PRES is completely reversible in the majority of patients, even with restricted diffusion. None of the variables under study could predict the reversibility of PRES lesions. It seems that this process is individual-dependent.
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Affiliation(s)
- Alaa Wagih
- Department of Radiology, Minia University, Minia, Egypt
| | - Laila Mohsen
- Department of Radiology, Minia University, Minia, Egypt
| | | | - Mo'men M Hasan
- Department of Obstetrics and Gynecology, Minia University, Minia, Egypt
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Poullet-Brea AM, Salazar-Ramirez C, Garcia-Rodriguez FJ, Benitez Lozano JA. [Encephalopathy syndrome: A serius clinical case]. Med Intensiva 2015; 39:516-8. [PMID: 25687582 DOI: 10.1016/j.medin.2014.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 12/24/2014] [Accepted: 12/29/2014] [Indexed: 11/19/2022]
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Siebert E, Bohner G, Endres M, Liman TG. Clinical and radiological spectrum of posterior reversible encephalopathy syndrome: does age make a difference?--A retrospective comparison between adult and pediatric patients. PLoS One 2014; 9:e115073. [PMID: 25514795 PMCID: PMC4267732 DOI: 10.1371/journal.pone.0115073] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 11/18/2014] [Indexed: 11/19/2022] Open
Abstract
Background Posterior reversible encephalopathy syndrome (PRES) is a serious and increasingly recognized disorder, but data from observational studies on clinicoradiological differences between etiologies and age groups are limited. In this study, we aimed to investigate the clinical and imaging characteristics of PRES in children compared to adults in a large cohort. Methods We retrospectively reviewed the radiological report data bases between January 1999 and August 2012 for patients with PRES (total of 110 patients). Patients fulfilling the criteria for PRES after detailed investigation of clinical charts and imaging studies were separated into children (<18years) and adults (≥18years). Various imaging features at onset of symptoms and on follow-up as well as clinical and paraclinical data were analyzed. Results A total of 19 pediatric and 91 adult patients with PRES were included into the study. In pediatric PRES patients, seizures were significantly more frequent as initial PRES-related symptom (p = 0.01). In addition, in children the superior frontal sulcus topographic lesion pattern occurred as frequent as the parieto-occipital one and was significantly more prevalent than in adults (p = 0.02). In contrast, in adults visual disturbances tended to occur more frequently than in children (p = 0.05). Also, severity of edema tended to be greater in adults than in children (p = 0.07). Conclusion In our PRES cohort, we found relevant clinicoradiological differences between pediatric and adult PRES patients. However, prospective studies are warranted to establish factors that are specifically associated with pediatric PRES.
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Affiliation(s)
- Eberhard Siebert
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- * E-mail:
| | - Georg Bohner
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK) Partner Site, Charité - Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE) Partner Site, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas G. Liman
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
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A multi-disciplinary model of risk factors for fatal outcome in posterior reversible encephalopathy syndrome. J Neurol Sci 2014; 347:59-65. [DOI: 10.1016/j.jns.2014.09.019] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 08/19/2014] [Accepted: 09/03/2014] [Indexed: 11/18/2022]
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Akins PT, Axelrod Y, Silverthorn JW, Guppy K, Banerjee A, Hawk MW. Management and outcomes of malignant posterior reversible encephalopathy syndrome. Clin Neurol Neurosurg 2014; 125:52-7. [DOI: 10.1016/j.clineuro.2014.06.034] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 06/05/2014] [Accepted: 06/23/2014] [Indexed: 10/25/2022]
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Liman TG, Bohner G, Endres M, Siebert E. Discharge status and in-hospital mortality in posterior reversible encephalopathy syndrome. Acta Neurol Scand 2014; 130:34-9. [PMID: 24329761 DOI: 10.1111/ane.12213] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome is a serious and increasingly recognized disorder, but data from observational studies on outcome and mortality in posterior reversible encephalopathy syndrome (PRES) are scarce. We aimed to determine the frequency and associations of in-hospital death and discharge status in a large cohort of patients with PRES. METHOD We retrospectively reviewed the radiological report databases of our university hospitals between January 1999 and March 2011 for patients with PRES. Patients fulfilling the criteria for PRES after detailed investigation of clinical charts and imaging studies were included. Clinical charts, paraclinical and brain imaging data at onset as well as available data on in-hospital mortality and discharge status were analyzed. RESULTS A total of 103 patients were included. Five (4.8%) patients died during hospital stay, 27 (26.2%) remained hospitalized after discharge. In univariate analyses, significant differences were found between patients discharged home from hospital and patients referred to rehabilitation or who died in hospital for the following variables: severe edema (P = 0.013), etiology of PRES (P = 0.001), altered mental state at onset (P = 0.003), altered coagulation (P = 0.004), and length of hospital stay >30 days (P < 0.001). CONCLUSION Features of a severe course of PRES such as severe edema and altered mental state are significantly more frequent in patients who were referred to inpatient rehabilitation or died in hospital. Prospective studies are warranted to establish factors that are associated with unfavorable outcome in PRES.
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Affiliation(s)
- T. G. Liman
- Department of Neurology; Charité - Universitätsmedizin Berlin; Berlin Germany
- Center for Stroke Research Berlin; Charité - Universitätsmedizin Berlin; Berlin Germany
| | - G. Bohner
- Department of Neuroradiology; Charité - Universitätsmedizin Berlin; Berlin Germany
| | - M. Endres
- Department of Neurology; Charité - Universitätsmedizin Berlin; Berlin Germany
- Center for Stroke Research Berlin; Charité - Universitätsmedizin Berlin; Berlin Germany
| | - E. Siebert
- Department of Neuroradiology; Charité - Universitätsmedizin Berlin; Berlin Germany
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Zhang Y, Zhou J, Chen Y. Posterior reversible encephalopathy syndrome in a child with steroid-resistant nephrotic syndrome: a case report and review of literature. INTERNATIONAL JOURNAL OF CLINICAL AND EXPERIMENTAL PATHOLOGY 2014; 7:4433-4437. [PMID: 25120830 PMCID: PMC4129065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 06/28/2014] [Indexed: 06/03/2023]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a rare and serious syndrome of central nervous system that can develop in both adults and children. It is characterized by acute onset of headache, confusion, seizures or focal neurological deficits along with radiological findings of white matter abnormalities in the parietal and occipital lobes. In the past ten years, this syndrome has been described mainly in adults, rare in children. Here, we report a case of PRES presenting in a 12-year-old girl with steroid-resistant nephrotic syndrome. Her neurological symptom was rapidly recovered after control of hypertension without discontinuation of cyclosporine A.
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Affiliation(s)
- Yu Zhang
- Pediatric Intensive Care Unit, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology Wuhan, China
| | - Jianhua Zhou
- Pediatric Intensive Care Unit, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology Wuhan, China
| | - Yu Chen
- Pediatric Intensive Care Unit, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology Wuhan, China
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Long-term Consequences of the Posterior Reversible Encephalopathy Syndrome in Eclampsia and Preeclampsia. Obstet Gynecol Surv 2014; 69:287-300. [DOI: 10.1097/ogx.0000000000000069] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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