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Lee MK, Cho YJ, Lee SK, Jung SK, Heo K. The effect of presymptomatic hypertension in posterior reversible encephalopathy syndrome. Brain Behav 2018; 8:e01061. [PMID: 29995307 PMCID: PMC6085895 DOI: 10.1002/brb3.1061] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 05/03/2018] [Accepted: 06/13/2018] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE The effect of blood pressure (BP) on the lesion distribution of posterior reversible encephalopathy syndrome (PRES) is controversial. The aim of this study was to identify the relationship between brain lesion distribution patterns and BP. METHODS Sixty-five patients with PRES were selected from the database. Data regarding brain MRI findings, clinical symptoms, medical conditions, and BP at the presymptomatic period (24 hr before the symptom onset) and at the symptom onset were collected. The brain lesion distribution degree was numerically calculated (lesion scoring point [LSP]) and compared with BP and medical conditions. RESULTS Mean onset-MAP was higher than mean pre-MAP. Pre-MAP correlated with onset-MAP. The LSP was significantly correlated with pre-MAP (p = 0.009, correlation coefficient [cc] = 0.323), whereas no significant correlation was found between LSP and onset-MAP (p = 0.159, cc = 0.177). Similarly, when patients were grouped by mean MAP values, LSP was significantly higher in the patients with high MAP at the presymptomatic period (p = 0.004), whereas no difference was found in the LSP value between patients with low MAP and high MAP at the symptom onset (p = 0.272). CONCLUSION The patient with PRES who has relatively higher BP in the presymptomatic period would be more likely to have wider lesion distribution than the patient with lower BP. BP elevation during presymptomatic period may be a heralding sign of impending PRES and a factor affecting the severity of PRES although BP was not investigated at earlier time points.
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Affiliation(s)
- Moon Kyu Lee
- Department of Neurology, Gangneung Asan Hospital, Gangneung, Korea
| | - Yang-Je Cho
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Seung-Koo Lee
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Ku Jung
- Department of Emergency Medicine, Gangneung Asan Hospital, Gangneung, Korea
| | - Kyoung Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
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202
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Potter CA, Hsu L. Emergent Neuroimaging in the Oncologic and Immunosuppressed Patient. Neuroimaging Clin N Am 2018; 28:397-417. [DOI: 10.1016/j.nic.2018.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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203
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Sesar A, Cavar I, Sesar AP, Sesar I. Transient cortical blindness in posterior reversible encephalopathy syndrome after postpartum eclampsia. Taiwan J Ophthalmol 2018; 8:111-114. [PMID: 30038892 PMCID: PMC6055316 DOI: 10.4103/tjo.tjo_5_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinical condition that can cause different ophthalmological and neurological symptoms. Preeclampsia toxemia or eclampsia is one of the leading causes of PRES. Herein, we present a study of a 35-year old woman who gave birth to healthy twins at 35 weeks of gestation by cesarean section because of threatened preterm delivery. On the 1st postoperative day, the woman developed a severe headache, arterial hypertension, tachycardia, generalized tonic-clonic seizures, and loss of consciousness that persisted for about 2 min. A provisional diagnosis of eclampsia was made, and the woman was then quickly transferred to the intensive care unit where she was treated with antihypertensive therapy, magnesium sulphate, and diazepam. Following stabilization of the general condition, the patient noticed sudden bilateral blindness. An ophthalmological examination revealed significant bilateral loss of vision at the level of insecured light perception, normal pupillary responses to a light stimulus, and normal fundus findings. On this basis, an ophthalmologist made the diagnosis to cortical blindness. Radiographic analysis showed an edematous change in the occipital and parietal brain regions, thus suggesting a diagnosis of PRES. In conclusion, cortical blindness is a clinically striking ophthalmic disorder that may occur in PRES associated with postpartum eclampsia.
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Affiliation(s)
- Antonio Sesar
- Department of Ophthalmology, University Clinical Hospital Mostar, Mostar, Bosnia and Herzegovina
| | - Ivan Cavar
- Department of Ophthalmology, University Clinical Hospital Mostar, Mostar, Bosnia and Herzegovina.,Department of Physiology, School of Medicine, University of Mostar, Mostar, Bosnia and Herzegovina
| | - Anita Pusic Sesar
- Department of Ophthalmology, University Clinical Hospital Mostar, Mostar, Bosnia and Herzegovina
| | - Irena Sesar
- Department of Ophthalmology, University Clinical Hospital Mostar, Mostar, Bosnia and Herzegovina
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204
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Haber MA, Nunez D. Imaging neurological emergencies in pregnancy and puerperium. Emerg Radiol 2018; 25:673-684. [PMID: 30030690 DOI: 10.1007/s10140-018-1625-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 07/06/2018] [Indexed: 12/13/2022]
Abstract
The altered physiologic state of female patients during and just after pregnancy places them at an increased risk for several potentially life-threatening neurologic disorders. Swift diagnosis of such pathology and related complications is critical in order to reduce risk of morbidity and mortality to both the mother and the fetus. Neuroimaging plays an important role in the emergent diagnosis of pathology associated with pregnancy and puerperium, and it is critical for the radiologist to be cognizant of correlative imaging findings. Furthermore, given concerns regarding risks of neuroimaging to the fetus, it is important for the radiologist to act as an informed consultant regarding balancing fetal risks and the mother's health. The purpose of this review is to elucidate the underlying pathophysiology and neuroimaging findings associated with diagnoses that are unique to or highly associated with pregnancy and puerperium, as well as to understand the role that CT and MR play in diagnosis during and just after pregnancy, and their respective risks to the fetus.
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Affiliation(s)
- Matthew A Haber
- Department of Radiology, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Diego Nunez
- Department of Radiology, Division of Neuroradiology, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, PBB RAD, 3rd Floor, Room 357, Boston, MA, 02115, USA.
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205
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Sudulagunta SR, Kumbhat M, Sodalagunta MB, Bangalore Raja SK. Paradoxical hypertension. Oxf Med Case Reports 2018; 2018:omy037. [PMID: 30087781 PMCID: PMC6059163 DOI: 10.1093/omcr/omy037] [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: 01/30/2018] [Revised: 04/21/2018] [Accepted: 05/09/2018] [Indexed: 11/24/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiological syndrome characterized by white matter vasogenic edema affecting the posterior occipital and parietal lobes of the brain predominantly. A 48-year-old female patient presented to ER with complaints of breathlessness and developed sudden painless loss of vision while eliciting history. The patient had a heart rate of 104/min and accelerated hypertension (BP of 220/120 mm of Hg). MRI Brain showed subcortical white matter T2/Fluid-attenuated inversion recovery hyperintensities, suggestive of PRES. The patient regained vision completely over 5 days after nitroglycerin infusion and calcium channel blockers. Beta blocker was started in view of increased BP and anxiety. Blood pressure paradoxically increased from 170/90 mm of Hg to 200/100 mm of Hg. Urine and plasma metanephrines were elevated. Contrast-enhanced computerized tomography abdomen showed locally infiltrative, retroperitoneal mass in left para-aortic prevertebral region diagnosed as paraganglioma. The patient improved with alpha blockers and surgical removal of paraganglioma. 0.1% of hypertensive patients harbor a pheochromocytoma or paraganglioma and its presentation as PRES is very rare.
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206
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207
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Whiting AC, Fanarjian MP, Hlubek RJ, Godzik J, Kakarla UK, Theodore N. Posterior Reversible Encephalopathic Syndrome in the Setting of Induced Elevated Mean Arterial Pressure in Patients With Spinal Cord Injury. Neurosurgery 2018; 83:16-21. [PMID: 28973505 DOI: 10.1093/neuros/nyx373] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 06/06/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Acute spinal cord injury (SCI) is managed by avoiding hypotension and elevating mean arterial pressure (MAP) to attain optimal perfusion of the spinal cord. Few studies have been published regarding complications related to this treatment paradigm. CLINICAL PRESENTATION Three patients with SCI developed posterior reversible encephalopathic syndrome (PRES) during treatment with intravenous fluids and vasopressors administered to maintain elevated MAPs. All of them experienced temporary elevations well above the standard blood pressure goals for acute SCI and deterioration of neurological status. CONCLUSION PRES is a potential complication of elevated MAPs in patients with SCI, particularly if the blood pressure rises above the goals of standard treatment paradigms. The neurosurgical staff should be suspicious of possible PRES early in the course of acute SCI in patients with unexplained neurological decline. This case series is the first report of PRES in patients with acute SCI.
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Affiliation(s)
- Alexander C Whiting
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Manuel P Fanarjian
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Randall J Hlubek
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Jakub Godzik
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - U Kumar Kakarla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Nicholas Theodore
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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208
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Ramgopal A, Thavamani A, Ghori A. Association between Posterior Reversible Encephalopathy Syndrome and Mycoplasma pneumoniae infection. J Pediatr Neurosci 2018; 13:109-111. [PMID: 29899785 PMCID: PMC5982478 DOI: 10.4103/jpn.jpn_145_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Mycoplasma pneumoniae is a microbe known to affect numerous organ systems, and in particular, can cause neurological manifestations. We describe an otherwise healthy child who presented with acute onset intractable headache with magnetic resonance imaging (MRI) findings consistent with posterior reversible encephalopathy syndrome (PRES), a neurological manifestation that presents with headache, vision changes, altered mental status, or seizures. Our patient did not have any of the common etiologies for PRES reported but tested positive for acute M. pneumonia infection. The clinical course followed that expected in PRES with rapid resolution of symptoms and MRI findings in subsequent imaging. Literature review shows association between Mycoplasma infection with encephalitis and cerebellitis, but none with PRES in children. Evidence of recent mycoplasma infection in a healthy patient presenting with clinical/radiological findings consistent with PRES, especially in the absence of known predisposing factors, raises the question of M. pneumoniae infection being a trigger for PRES.
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Affiliation(s)
- Archana Ramgopal
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Aravind Thavamani
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Abdulla Ghori
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
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209
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Allen ML, Kulik T, Keyrouz SG, Dhar R. Posterior Reversible Encephalopathy Syndrome as a Complication of Induced Hypertension in Subarachnoid Hemorrhage: A Case-Control Study. Neurosurgery 2018; 85:223-230. [DOI: 10.1093/neuros/nyy240] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 05/10/2018] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Induced hypertension (IH) remains the mainstay of medical management for delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH). However, raising blood pressure above normal levels may be associated with systemic and neurological complications, of which posterior reversible encephalopathy syndrome (PRES) has been increasingly recognized.
OBJECTIVE
To ascertain the frequency and predisposing factors for PRES during IH therapy.
METHODS
We identified 68 patients treated with IH from 345 SAH patients over a 3-yr period. PRES was diagnosed based on clinical suspicion, confirmed by imaging. We extracted additional data on IH, including baseline and highest target mean arterial pressure (MAP), comparing PRES to IH-treated controls.
RESULTS
Five patients were diagnosed with PRES at median 6.6 d (range 1-8 d) from vasopressor initiation. All presented with lethargy, 3 had new focal deficits, and 1 had a seizure. Although baseline MAP (prior to DCI) did not differ between cases and controls, both MAP immediately prior to IH (112 vs 90) and highest MAP targeted were greater (140 vs 120 mm Hg, both P < .01). Magnitude of MAP elevation was greater (54 vs 34 above baseline, P = .004) while degree of IH was not (37 vs 38 above pre-IH MAP). All 4 surviving PRES patients had complete resolution with IH discontinuation.
CONCLUSION
PRES was diagnosed in 7% of SAH patients undergoing IH therapy, most often when MAP was raised well above baseline to levels that exceed traditional autoregulatory thresholds. High suspicion for this reversible disorder appears warranted in the face of unexplained neurological deterioration during aggressive IH.
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Affiliation(s)
- Michelle L Allen
- Department of Neurology (Division of Neurocritical Care), Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Tobias Kulik
- Department of Neurology (Division of Neurocritical Care), Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Salah G Keyrouz
- Department of Neurology (Division of Neurocritical Care), Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Rajat Dhar
- Department of Neurology (Division of Neurocritical Care), Washington University in St. Louis School of Medicine, St. Louis, Missouri
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210
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Delgado-López PD, Garcés-Pérez G, García-Carrasco J, Alonso-García E, Gómez-Menéndez AI, Martín-Alonso J. Posterior Reversible Encephalopathy Syndrome with Status Epilepticus Following Surgery for Lumbar Stenosis and Spondylolisthesis. World Neurosurg 2018; 116:309-315. [PMID: 29864559 DOI: 10.1016/j.wneu.2018.05.174] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 05/23/2018] [Accepted: 05/24/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiologic condition encountered in many different clinical settings; it generally occurs in the context of hypertensive crisis, immunosuppressive therapy, or autoimmune diseases. It is characterized by headache, stupor, seizures, and visual alterations. Magnetic resonance imaging findings include white matter changes preferentially in the parieto-occipital regions. Although pathogenesis is not fully elucidated, vasoconstriction and brain hypoperfusion seem to be the cause of brain ischemia and vasogenic edema. Cerebrospinal fluid hypotension is also a reported plausible pathogenic mechanism. CASE DESCRIPTION We present a case of PRES following laminectomy and fixation for L4-5 lumbar stenosis and spondylolisthesis. The patient presented with status epilepticus immediately after surgery that lasted 5 days. Brain magnetic resonance imaging showed fluid attenuated inversion recovery and T2 hyperintensities in the bilateral parietal and occipital lobes and external capsules. On the basis of postoperative lumbar images, we hypothesized that an unnoticed cerebrospinal fluid leak might have contributed to development of PRES. The patient developed multiple postoperative complications but ultimately recovered after treatment for severe hypertension and seizures. CONCLUSIONS Prompt recognition and treatment of this potentially life-threatening syndrome is necessary to increase the likelihood of favorable outcome. Spinal surgeons need to be aware of the possibility of neurologic deterioration after spinal surgery and be alert about the occurrence of a dural leak, either recognized or unnoticed, as the plausible mechanism triggering PRES.
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Affiliation(s)
| | - Gloria Garcés-Pérez
- Department of Anesthesiology, Hospital Universitario de Burgos, Burgos, Spain
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211
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Acar H, Acar K. Posterior reversible encephalopathy syndrome in a pregnant patient without eclampsia or preeclampsia. Am J Emerg Med 2018; 36:1721.e3-1721.e4. [PMID: 29880411 DOI: 10.1016/j.ajem.2018.05.074] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 05/29/2018] [Indexed: 11/25/2022] Open
Abstract
Posterior Reversible Encephalopathy syndrome (PRES) is a rare neurologic disorder characterised by vasogenic edema in occipital and parietal lobes on MR. Patients usually complain about headache, visual disturbance, seizure and altered mental status. We repot a case of PRES seen in a pregnant patient. Although pre-eclampsia and eclampsia are among the common causes of this syndrome in this case patient was normotensive and no proteinuria was present. To our knowledge this is the first PRES case presented of a pregnant patient without eclampsia or pre-eclampsia.
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Affiliation(s)
- Hüseyin Acar
- Atatürk Eğitim ve Araştırma Hastanesi Basın Sitesi, Izmir 35360, Emergency Department, Turkey.
| | - Kadriye Acar
- Sakarya Üniversitesi, Sağlık bilimleri enstitüsü, Kemalpaşa Mahallesi Üniversite Caddesi, 54050 Serdivan, Sakarya, Turkey
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212
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Schoucair R, Nicolas G, Ahdab R, Bejjani N, Abdalla EK. Posterior reversible encephalopathy syndrome (PRES) in mesenteric leiomyosarcoma: A case report. Int J Surg Case Rep 2018; 49:96-101. [PMID: 29980031 PMCID: PMC6031592 DOI: 10.1016/j.ijscr.2018.04.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 04/29/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a syndrome characterized by headache, confusion, visual loss and seizures. Many factors influence the appearance of this syndrome, predominantly eclampsia, certain medical treatments and malignant hypertension. Diagnosed by typical transient lesions on magnetic resonance imaging. CASE REPORT We present a case of mesenteric leiomyosarcoma in a 52 year old woman, who had severe headache, abdominal heaviness, and hypertension. Investigations revealed a mesenteric mass and a Posterior Reversible Encephalopathy Syndrome features on brain MRI, suggesting renin secretion by the tumor, causing the patient's symptoms. CONCLUSION Patient's symptoms disappeared after resection of the tumor, suggesting a renin production cessation.
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Affiliation(s)
- Ramy Schoucair
- Lebanese University, Beirut, Lebanon; LAUMRCH, Beirut, Lebanon
| | - Gregory Nicolas
- Lebanese University, Beirut, Lebanon; LAUMRCH, Beirut, Lebanon.
| | - Rechdi Ahdab
- Lebanese University, Beirut, Lebanon; LAUMRCH, Beirut, Lebanon
| | - Noha Bejjani
- Lebanese University, Beirut, Lebanon; LAUMRCH, Beirut, Lebanon
| | - Eddie K Abdalla
- Lebanese University, Beirut, Lebanon; LAUMRCH, Beirut, Lebanon
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213
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Lin SF, Wu TI, Fang CL, Lee JE. Intraabdominal and Pelvic actinomycosis in association with posterior reversible encephalopathy syndrome (PRES): A case report. J Neuroradiol 2018; 45:262-264. [PMID: 29758229 DOI: 10.1016/j.neurad.2018.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 02/08/2018] [Accepted: 04/21/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Sheng-Feng Lin
- School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Tzu-I Wu
- Department of Obstetrics and Gynecology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Department of Obstetrics and Gynecology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chia-Lang Fang
- Department of Pathology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Pathology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Jing-Er Lee
- Department of Neurology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
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214
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Davi CB, Moraes BPD, Lichtenfels BF, Castro Filho JBSD, Portal MM, Montenegro RM, Manfro RC. Posterior reversible leukoencephalopathy syndrome (PRES) after kidney transplantation: a case report. ACTA ACUST UNITED AC 2018; 40:91-94. [PMID: 29796585 PMCID: PMC6533973 DOI: 10.1590/1678-4685-jbn-3825] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 08/06/2017] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Posterior reversible leukoencephalopathy syndrome (PRES) was first described by Hinchey in 1996. The syndrome is characterized by altered level of consciousness, headache, visual changes, and seizures associated with a vasogenic edema of the white matter that occurs predominantly in the occipital and parietal lobes. Imaging tests such as computed tomography (CT) and especially magnetic resonance imaging (MRI) support the diagnosis. CASE REPORT We report a case of a 48-year-old female patient who underwent a deceased donor kidney transplant and received tacrolimus as a part of the immunosuppressive regimen. Five weeks after transplantation she was admitted to the emergency due to sudden onset of confusion, disorientation, visual disturbances, and major headache. PRES was suspected and the diagnosis confirmed by brain MRI. Tacrolimus was withdrawn and rapid improvement of the neurological signs occurred leading to the conclusion that this drug triggered the syndrome. CONCLUSION PRES is an unusual complication after organ transplantation and should be considered in the appropriate clinical setting. Physicians must be aware of this condition in order to provide early detection and appropriate treatment since delay in removing the cause may lead to permanent sequelae.
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Affiliation(s)
- Carla Beatriz Davi
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
| | - Bruna Pinheiro de Moraes
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
| | - Bruno Fontes Lichtenfels
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
| | | | - Marcelle Maria Portal
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
| | - Rosangela Munhoz Montenegro
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
| | - Roberto Ceratti Manfro
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
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215
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Chan PKJ, Tse KS, Fok WSE, Poon WL. First case of neurofibromatosis with posterior reversible encephalopathy syndrome showing spinal cord involvement. Indian J Radiol Imaging 2018; 28:161-164. [PMID: 30050237 PMCID: PMC6038224 DOI: 10.4103/ijri.ijri_320_17] [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: 11/04/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a well-documented pathology of the brain in systemic upsets. Majority of PRES cases present with edema in the cerebrum, most commonly in the territory of posterior circulation. It has been reported to show spinal cord involvement in a rare subgroup known as PRES with spinal cord involvement (PRES-SCI), with very limited existing literature even in adult patients. Our institution recently encountered a pediatric case with neurofibromatosis type I (NF 1) showing PRES with extensive reversible spinal cord changes. This case illustrates the features of this rare entity in the pediatric group of patients, and is the first reported case in NF 1 patients.
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Affiliation(s)
- Pui Kwan Joyce Chan
- Department of Radiology and Imaging, Queen Elizabeth Hospital, Kowloon, Hong Kong (SAR), People's Republic of China
| | - Kin Sun Tse
- Department of Radiology and Imaging, Queen Elizabeth Hospital, Kowloon, Hong Kong (SAR), People's Republic of China
| | - Wing Shan Elaine Fok
- Department of Radiology and Imaging, Queen Elizabeth Hospital, Kowloon, Hong Kong (SAR), People's Republic of China
| | - Wai Lun Poon
- Department of Radiology and Imaging, Queen Elizabeth Hospital, Kowloon, Hong Kong (SAR), People's Republic of China
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216
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Magnesium Sulfate Treatment Correlates With Improved Neurological Function in Posterior Reversible Encephalopathy Syndrome (PRES): Report of a Case. Neurologist 2018; 23:65-66. [PMID: 29494439 DOI: 10.1097/nrl.0000000000000174] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a potentially reversible failure of cerebral autoregulation managed by correction of hypertension or underlying medical condition. Nonresponding cases progress to irreversible brain damage. There is some evidence of association of hypomagnesemia with PRES. We describe a case of nonresolving PRES where use of magnesium sulfate led to improvement in neurological function and eventual recovery. Our case highlights the need for a randomized controlled trial to test the efficacy of magnesium in PRES.
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217
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Miller JB, Suchdev K, Jayaprakash N, Hrabec D, Sood A, Sharma S, Levy PD. New Developments in Hypertensive Encephalopathy. Curr Hypertens Rep 2018; 20:13. [PMID: 29480370 DOI: 10.1007/s11906-018-0813-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW This review summarizes the latest science on hypertensive encephalopathy and posterior reversible encephalopathy syndrome (PRES). We review the epidemiology and pathophysiology of these overlapping syndromes and discuss best practices for diagnosis and management. RECENT FINDINGS Diagnosis of hypertensive encephalopathy largely relies on exclusion of other neurological emergencies. We review the extensive causes of PRES and its imaging characteristics. Management strategies have not changed substantially in the past decade, though newer calcium channel blockers simplify the approach to blood pressure reduction. While this alone may be sufficient for treatment of hypertensive encephalopathy in most cases, management of PRES also depends on modification of other precipitating factors. Hypertensive encephalopathy and PRES are overlapping disorders for which intensive blood pressure lowering is critical. Further research is indicated to both in diagnosis and additional management strategies for these critical conditions.
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Affiliation(s)
- Joseph B Miller
- Department of Emergency Medicine, Department of Internal Medicine, Henry Ford Hospital and Wayne State University, 2799 W Grand Blvd, Detroit, MI, 48202, USA.
| | - Kushak Suchdev
- Department of Neurology, Division of Neurocritical Care, Wayne State University, Detroit, MI, USA
| | - Namita Jayaprakash
- Department of Emergency Medicine, Division of Pulmonary Critical Care Medicine, Henry Ford Hospital and Wayne State University, Detroit, MI, USA
| | - Daniel Hrabec
- Department of Emergency Medicine, Department of Internal Medicine, Henry Ford Hospital and Wayne State University, 2799 W Grand Blvd, Detroit, MI, 48202, USA
| | - Aditya Sood
- Department of Internal Medicine, Division of Cardiology, Wayne State University, Detroit, MI, USA
| | - Snigdha Sharma
- Department of Internal Medicine, Division of Pulmonary Critical Care, Wayne State University, Detroit, MI, USA
| | - Phillip D Levy
- Department of Emergency Medicine, Wayne State University, Detroit, MI, USA
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218
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Farooq S, Garlanger K, Cox JA, Waring W. Acute visual loss in a patient with spinal cord injury. Spinal Cord Ser Cases 2018; 3:17080. [PMID: 29423286 DOI: 10.1038/s41394-017-0010-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Revised: 08/03/2017] [Accepted: 09/07/2017] [Indexed: 11/09/2022] Open
Abstract
Introduction Patients with spinal cord injury (SCI), especially those with injury at and above T6, are prone to transient episodes of hypertension induced by noxious triggers below the level of SCI, known as autonomic dysreflexia (AD). An uncommonly reported presentation of AD is posterior reversible encephalopathy syndrome (PRES). Case Presentation A 50-year-old male with the history of paraplegia from SCI presented with sepsis secondary to baclofen pump and urinary tract infections. On hospital day 4, he developed acute bilateral vision loss. The next morning he had a generalized-tonic-clonic seizure followed by cardiac arrest, with return of spontaneous circulation following resuscitation. Magnetic resonance imaging brain demonstrated multifocal areas of hyperintensity on T2 fluid-attenuated inversion recovery sequence, most pronounced in the occipital lobes. Systolic blood pressures (SBP) were under 180 mmHg throughout hospital stay but above his baseline (SBP 90 mmHg). PRES was diagnosed on the basis of clinical and radiologic evidence. With strict blood pressure (BP) control, there was resolution of visual abnormalities, headaches, encephalopathy, and seizures. Discussion Although PRES has been most commonly described in malignant hypertension, it can be seen in patients with normotension or moderate hypertension who have low baseline BPs, such as patients with SCI. These patients are prone to AD due to imbalanced sympathetic outflow to vasculature below the level of injury caused by noxious stimulus. This results in massive regional vasoconstriction leading to an uncontrolled rise in BP above baseline. This episode of PRES could have been prevented by identifying patient's risk, recognizing early signs and potential triggers of AD, and implementing aggressive treatment of the underlying noxious stimuli.
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Affiliation(s)
- Salman Farooq
- 1Department of Neurology, Medical College of Wisconsin, Milwaukee, WI USA
| | - Kristin Garlanger
- 2Department of Physical Medicine and Rehabilitation, Medical College of Wisconsin, Milwaukee, WI USA
| | - John-Andrew Cox
- 1Department of Neurology, Medical College of Wisconsin, Milwaukee, WI USA
| | - William Waring
- 2Department of Physical Medicine and Rehabilitation, Medical College of Wisconsin, Milwaukee, WI USA
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219
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Komori A, Mizu D, Ariyoshi K. Posterior Reversible Encephalopathy Syndrome: A Rare Childhood Case with Unconsciousness. J Emerg Med 2018; 54:540-543. [PMID: 29338905 DOI: 10.1016/j.jemermed.2017.12.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 11/10/2017] [Accepted: 12/01/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a condition characterized by seizures, altered consciousness, visual disturbances, and headache. Characteristic findings on neuroimaging include cerebral edema, typically involving the parieto-occipital white matter. PRES has been associated with hypertension, autoimmune disease, and Henoch-Schölein purpura (HSP), but few cases have been reported, and fewer cases of PRES have been reported in children. CASE REPORT We report the case of a 4-year-old girl who presented with blindness and semi-consciousness. The patient had no significant medical history and no abnormalities on physical examination or laboratory testing, although she had slightly elevated blood pressure. After hospitalization, the patient showed some characteristic signs of HSP and cranial magnetic resonance imaging revealed PRES as the cause of semi-consciousness. In our discussion, we examine the clinical features of PRES and remarkable points for the clinical diagnosis and management of this rare but important disease. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although reports of PRES in children are rare, PRES should be considered in the differential diagnosis of children presenting with disturbance of consciousness. Emergency physicians should consult with pediatric physicians to confirm diagnoses of PRES and determine an appropriate treatment plan, given its variable etiology. Measurements of blood pressure, which are often missing in pediatric cases, can help physicians to arrive at a correct diagnosis.
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Affiliation(s)
- Akira Komori
- Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Daisuke Mizu
- Kobe City Medical Center General Hospital, Hyogo, Japan
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220
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Stârcea M, Gavrilovici C, Munteanu M, Miron I. Focal segmental glomerulosclerosis in children complicated by posterior reversible encephalopathy syndrome. J Int Med Res 2018; 46:1172-1177. [PMID: 29310486 PMCID: PMC5972267 DOI: 10.1177/0300060517746559] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
An uncommon side effect of cyclosporine A (CsA) use is posterior reversible encephalopathy syndrome (PRES). PRES usually develops because of disturbed capacity of posterior cerebral blood flow to autoregulate an acute rise in blood pressure. We present the case of a 10-year-old girl who was previously diagnosed in our department with focal segmental glomerulosclerosis. She was treated with CsA and developed seizures, progressive loss of consciousness, and visual disturbance on the 7th day of treatment. Brain magnetic resonance imaging showed degeneration of white matter with diffuse demyelination in the parietal and posterior occipital lobes, consistent with the diagnosis of PRES. Cases of PRES reported in children are usually secondary to immunosuppressive therapy in oncological and haematological diseases. Our case is the fifth reported case of focal segmental glomerulosclerosis in children treated with CsA and complicated by PRES. Rapid recognition of PRES and stopping neurotoxic therapy early are essential for a good prognosis.
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Affiliation(s)
- Magdalena Stârcea
- Department of Pediatrics, St. Maria Children's Hospital, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, România
| | - Cristina Gavrilovici
- Department of Pediatrics, St. Maria Children's Hospital, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, România
| | - Mihaela Munteanu
- Department of Pediatrics, St. Maria Children's Hospital, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, România
| | - Ingrith Miron
- Department of Pediatrics, St. Maria Children's Hospital, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, România
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221
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Potchen MJ, Kampondeni SD, Seydel KB, Haacke EM, Sinyangwe SS, Mwenechanya M, Glover SJ, Milner DA, Zeli E, Hammond CA, Utriainen D, Lishimpi K, Taylor TE, Birbeck GL. 1.5 Tesla Magnetic Resonance Imaging to Investigate Potential Etiologies of Brain Swelling in Pediatric Cerebral Malaria. Am J Trop Med Hyg 2018; 98:497-504. [PMID: 29313473 DOI: 10.4269/ajtmh.17-0309] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The hallmark of pediatric cerebral malaria (CM) is sequestration of parasitized red blood cells in the cerebral microvasculature. Malawi-based research using 0.35 Tesla (T) magnetic resonance imaging (MRI) established that severe brain swelling is associated with fatal CM, but swelling etiology remains unclear. Autopsy and clinical studies suggest several potential etiologies, but limitations of 0.35 T MRI precluded optimal investigations into swelling pathophysiology. A 1.5 T MRI in Zambia allowed for further investigations including susceptibility-weighted imaging (SWI). SWI is an ideal sequence for identifying regions of sequestration and microhemorrhages given the ferromagnetic properties of hemozoin and blood. Using 1.5 T MRI, Zambian children with retinopathy-confirmed CM underwent imaging with SWI, T2, T1 pre- and post-gadolinium, diffusion-weighted imaging (DWI) with apparent diffusion coefficients and T2/fluid attenuated inversion recovery sequences. Sixteen children including two with moderate/severe edema were imaged; all survived. Gadolinium extravasation was not seen. DWI abnormalities spared the gray matter suggesting vasogenic edema with viable tissue rather than cytotoxic edema. SWI findings consistent with microhemorrhages and parasite sequestration co-occurred in white matter regions where DWI changes consistent with vascular congestion were seen. Imaging findings consistent with posterior reversible encephalopathy syndrome were seen in children who subsequently had a rapid clinical recovery. High field MRI indicates that vascular congestion associated with parasite sequestration, local inflammation from microhemorrhages and autoregulatory dysfunction likely contribute to brain swelling in CM. No gross radiological blood brain barrier breakdown or focal cortical DWI abnormalities were evident in these children with nonfatal CM.
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Affiliation(s)
- Michael J Potchen
- Faculty of Medical Radiation Sciences, Lusaka Apex Medical University, Lusaka, Zambia.,Department of Imaging Sciences, Neuroradiology Division, University of Rochester, Rochester, New York
| | - Samuel D Kampondeni
- Malawi MRI Center, Queen Elizabeth Central Hospital, Blantyre, Malawi.,Department of Imaging Sciences, Neuroradiology Division, University of Rochester, Rochester, New York
| | - Karl B Seydel
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi.,Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan
| | - E Mark Haacke
- Department of Radiology, Wayne State University, Detroit, Michigan
| | - Sylvester S Sinyangwe
- Department of Paediatric and Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Musaku Mwenechanya
- Department of Paediatric and Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Simon J Glover
- Medical and Biological Sciences, School of Medicine, University of St Andrews, St Andrews, Scotland
| | - Danny A Milner
- American Society for Clinical Pathologists, Washington, DC
| | - Eric Zeli
- Radiology Division, Cancer Diseases Hospital, Lusaka, Zambia
| | - Colleen A Hammond
- Radiology Department, Michigan State University, East Lansing, Michigan
| | | | - Kennedy Lishimpi
- Radiology Division, Cancer Diseases Hospital, Lusaka, Zambia.,Faculty of Medical Radiation Sciences, Lusaka Apex Medical University, Lusaka, Zambia
| | - Terrie E Taylor
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi.,Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan
| | - Gretchen L Birbeck
- Epilepsy Care Team, Chikankata Hospital, Mazabuka, Zambia.,Department of Neurology, Strong Epilepsy Center, University of Rochester, Rochester, New York
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222
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GUNGOR S, KILIC B, TABEL Y, SELIMOGLU A, OZGEN U, YILMAZ S. Clinical and Imaging Findings in Childhood Posterior Reversible Encephalopathy Syndrome. IRANIAN JOURNAL OF CHILD NEUROLOGY 2018; 12:16-25. [PMID: 29379559 PMCID: PMC5760670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 01/07/2017] [Accepted: 05/03/2017] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Posterior reversible encephalopathy syndrome (PRES) is characterized by typical radiologic findings in the posterior regions of the cerebral hemispheres and cerebellum. The symptoms include headache, nausea, vomiting, visual disturbances, focal neurologic deficits, and seizures. The aim of this study is to evaluate the clinical and radiological features of PRES in children and to emphasize the recognition of atypical features. MATERIALS & METHODS We retrospectively examined 23 children with PRES from Mar 2010-Apr 2015 in Inonu University Turgut Ozal Medical Center in Turkey. We compared the clinical features and cranial MRI findings between underlying diseases of PRES. RESULTS The most common precipitating factors were hypertension (78.2%) and medications, namely immunosuppressive and antineoplastic agents (60.8%). Manifestations included mental changes (100%), seizures (95.6%), headache (60.8%), and visual disturbances (21.7%) of mean 3.6 (range 1-10) days' duration. Cranial magnetic resonance imaging (MRI) showed bilateral occipital lesions in all patients, associated in 82.6% with less typical distribution of lesions in frontal, temporal or parietal lobes, cerebellum, corpus callosum, basal ganglia, thalamus, and brain stem. Frontal involvement was predominant, observed in 56.5% of patients. Clinical recovery was followed by radiologic resolution in all patients. CONCLUSION PRES is often unsuspected by the clinician, thus radiologists may be the first to suggest this diagnosis on an MRI obtained for seizures or encephalopathy. Atypical MRI finding is seen quite often. Rapid diagnosis and treatment are required to avoid a devastating outcome.
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Affiliation(s)
- Serdal GUNGOR
- Department of Pediatric Neurology, Faculty of Medicine, Inonu University, Malatya, Turkey
| | - Betul KILIC
- Department of Pediatric Neurology, Faculty of Medicine, Inonu University, Malatya, Turkey
| | - Yilmaz TABEL
- Department of Pediatric Neurology, Faculty of Medicine, Inonu University, Malatya, Turkey
| | - Ayse SELIMOGLU
- Department of Pediatric Neurology, Faculty of Medicine, Inonu University, Malatya, Turkey
| | - Unsal OZGEN
- Department of Pediatric Neurology, Faculty of Medicine, Inonu University, Malatya, Turkey
| | - Sezai YILMAZ
- Department of Surgery, Faculty of Medicine, Inonu University, Malatya, Turkey
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223
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Gao B, Lyu C, Lerner A, McKinney AM. Controversy of posterior reversible encephalopathy syndrome: what have we learnt in the last 20 years? J Neurol Neurosurg Psychiatry 2018; 89:14-20. [PMID: 28794149 DOI: 10.1136/jnnp-2017-316225] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 07/03/2017] [Accepted: 07/03/2017] [Indexed: 11/03/2022]
Abstract
Over two decades have passed since posterior reversible encephalopathy syndrome (PRES) was first described in 1996. It has becoming increasingly recognised because of improved and more readily available imaging modality. The exact pathophysiological mechanism is not completely understood and remains controversial at present. Precise diagnosis is essential to guide prompt, proper management. Our ability of differentiating it from other acute neurological disorders is likely to improve as we learnt more about the spectrum of this entity in the last 20 years. We emphasise the importance of recognising its diagnostic criteria and biomarker, which would be of great relevance to either outcome evaluation or study design. PRES has a favourable prognosis generally, but neurological sequelae and even fatalities can occur, especially in severe forms that might cause substantial morbidity and even mortality, particularly when the syndrome is complicated by intracranial haemorrhage or brain infarction. In this review, the pathophysiology, approach to diagnosis, some controversies as to the prognosis, as well as the future research direction of PRES are described.
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Affiliation(s)
- Bo Gao
- Department of Radiology, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Cui Lyu
- Department of Neurology, Yantaishan Hospital of Yantai City, Yantai, Shandong, China
| | - Alexander Lerner
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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224
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Godi C, Falini A. Posterior Reversible Encephalopathy Syndrome (PRES). Clin Neuroradiol 2018. [DOI: 10.1007/978-3-319-61423-6_83-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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225
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Gokhale A, Kimona A, Kantor S, Prakash S, Manhas Y. Posterior Reversible Leukoencephalopathy Syndrome (PRES) in Intensive Care Unit - Case series. Indian J Crit Care Med 2017; 21:772-778. [PMID: 29279639 PMCID: PMC5699006 DOI: 10.4103/ijccm.ijccm_235_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Introduction: Posterior reversible encephalopathy syndrome (PRES) is characterized by a range of clinico neuro radiological manifestation along with hypertension due to varied etiology. Contrary to its name, a small number of patients have residual neurological deficits. Patients with severe manifestation of PRES may get admitted to the Intensive Care Unit (ICU) due to coma or status epilepticus. Small case series and large multicenter studies have been reported. Materials and Methods: We report a single center series of ten cases admitted to ICU over a 5 year period in a tertiary care centre. We retrospectively analyzed patients, admitted to adult ICU with different etiologies, and diagnosed to have PRES. Outcome at discharge and at 90 days after ICU admission was noted. Result: The most common etiologies were medications. ICU admissions were mainly for uncontrolled hypertension, seizures, and low level of consciousness. All except one patient were ventilated. Four patients had residual neurological damage. Conclusion: Irrespective of the etiology, early control of blood pressure, and removal of precipitating factors is of paramount importance to prevent morbidity and mortality. Awareness about PRES among the intensivist is necessary to ensure early recognition and treatment.
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Affiliation(s)
- Antara Gokhale
- Department of Anesthesia and Adult ICU, Royal Hospital, Muscat, Oman
| | - Atheel Kimona
- Department of Radiology, Royal Hospital, Muscat, Oman
| | - Sandeep Kantor
- Department of Anesthesia and Adult ICU, Royal Hospital, Muscat, Oman
| | - S Prakash
- Department of Anesthesia and Adult ICU, Royal Hospital, Muscat, Oman
| | - Yogesh Manhas
- Department of Anesthesia and Adult ICU, Royal Hospital, Muscat, Oman
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226
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Shah RR. Anti-Angiogenic Tyrosine Kinase Inhibitors and Reversible Posterior Leukoencephalopathy Syndrome: Could Hypomagnesaemia Be the Trigger? Drug Saf 2017; 40:373-386. [PMID: 28181126 DOI: 10.1007/s40264-017-0508-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Reversible posterior leukoencephalopathy syndrome (RPLS), also known frequently as posterior reversible encephalopathy syndrome (PRES), is a characteristic acute neuro-radiology syndrome with clinical presentation that typically includes acute hypertension, seizures and other neurological symptoms and signs. Many patients with RPLS have (a history of) pre-existing hypertension and in receipt of diuretics. It is being diagnosed more frequently and in association with an increasing number of morbidities and medications. Drugs most frequently implicated are immunosuppressant drugs and anticancer agents, including a number of anti-angiogenic tyrosine kinase inhibitors (TKIs). Hypomagnesaemia is a frequent finding at presentation in RPLS patients, which is known to lead to or aggravate hypertension. Pre-eclampsia, a variant of RPLS, responds effectively to intravenous magnesium. Cyclosporin, tacrolimus and some TKIs that induce RPLS are also known to give rise to both hypertension and hypomagnesaemia. This raises an interesting hypothesis that hypomagnesaemia may play a contributory role in triggering RPLS in some patients by acutely raising the blood pressure further. Additional systematic studies are required to test this hypothesis. If the hypothesis is confirmed, hypomagnesaemia offers an effective target for risk mitigation and prevention of RPLS in patients identified at risk.
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Affiliation(s)
- Rashmi R Shah
- Pharmaceutical Consultant, 8 Birchdale, Gerrards Cross, Buckinghamshire, UK.
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227
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Abstract
PURPOSE OF REVIEW This article reviews key principles in the identification of tumors of the central nervous system (CNS) using standard and advanced imaging modalities. This article highlights the pitfalls and pearls of the imaging evaluation of patients with cancer at time of diagnosis and during cancer therapy and discusses the challenges of the imaging evaluation of treatment-related toxicities. RECENT FINDINGS Treatment of CNS tumors with surgery, chemotherapy, or radiation alters the imaging appearance of the tumor and can be associated with a variety of treatment-related toxicities. The clinician must be familiar with how to assess response to treatment and how to differentiate tumor progression from treatment-related effects. SUMMARY Management and follow-up of neuro-oncology patients is optimized by a comprehensive radiologic approach to CNS tumors and recognition of the challenges in the assessment of response to treatments.
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228
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Singh AK, Tantiwongkosi B, Moise AM, Altmeyer WB. Stroke-like migraine attacks after radiation therapy syndrome: Case report and review of the literature. Neuroradiol J 2017; 30:568-573. [PMID: 28643603 PMCID: PMC5703131 DOI: 10.1177/1971400917690009] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A 26-year-old female presented with vision loss accompanied by migraine-like headaches. A contrast-enhanced magnetic resonance imaging of the brain was performed which revealed findings suggestive of stroke-like migraine attacks after radiation therapy (SMART) syndrome. SMART syndrome is a delayed complication of brain radiation characterized by neurologic symptoms including migraine-like headaches, seizures, and hemispheric impairment. The purpose of this article is to make the readers aware of this rare complication of brain irradiation. Appropriate diagnosis of SMART syndrome is essential to avoid invasive tests.
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Affiliation(s)
- Achint K Singh
- Department of Radiology, University of Texas Health Science Center, San Antonio, USA
| | - Bundhit Tantiwongkosi
- Department of Radiology, University of Texas Health Science Center, San Antonio, USA
| | | | - Wilson B Altmeyer
- Department of Radiology, University of Texas Health Science Center, San Antonio, USA
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229
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Fan EP, Heiber G, Gerard EE, Schuele S. Stroke-like migraine attacks after radiation therapy: A misnomer? Epilepsia 2017; 59:259-268. [PMID: 29171011 DOI: 10.1111/epi.13963] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To understand the frequency of electrographic and clinical seizures in patients with stroke-like migraine attacks after radiation therapy (SMART), and determine whether SMART warrants comprehensive electroencephalographic (EEG) monitoring and aggressive seizure management. METHODS We searched our magnetic resonance brain imaging report database for all patients between January 2013 and December 2015 for suspected SMART syndrome. Clinical inclusion criteria were further applied as follows: inpatient adults (>18 years of age) with history of cranial radiation presenting with acute neurologic deficits as primary admission reason who lacked evidence of recurrent or new brain malignancy, stroke, or infectious agents in cerebrospinal fluid. Six patients were identified. All 6 patients underwent prolonged video EEG monitoring as part of our standard protocol. RESULTS All patients but 1 were found to have multiple or prolonged electrographic seizures consistent with status epilepticus during video EEG monitoring. Their neurological deficit and/or mental status change improved in parallel with resolution of the seizure activity. SIGNIFICANCE SMART is likely a misnomer that underestimates the significance of seizures and status epilepticus in the pathophysiology and clinical presentation of the syndrome. Systematic continuous EEG monitoring and appropriate seizure management is warranted to reduce symptom duration and optimize clinical outcome.
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Affiliation(s)
- Emily Peien Fan
- Department of Neurology, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Gabriel Heiber
- Department of Psychiatry, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Elizabeth E Gerard
- Department of Neurology, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Stephan Schuele
- Department of Neurology, Northwestern Memorial Hospital, Chicago, IL, USA
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230
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Cohen H, Rossignol M. [Maternal death by stroke. Results from the French enquiry into maternal deaths, 2010-2012]. ACTA ACUST UNITED AC 2017; 45:S65-S70. [PMID: 29153848 DOI: 10.1016/j.gofs.2017.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Indexed: 10/18/2022]
Abstract
Stroke is a rare event during pregnancy (10/100,000) and can be ischemic (24%), hemorrhagic (74%) or both (2%). Pregnancy probably increases the risk even if it is discussed for arteriovenous malformation (AVM), aneurismal subarachnoid hemorrhage (SAH) and cavernomas. Between 2010 and 2012, 31 maternal deaths were associated with stroke. In 22 cases, stroke was the direct cause of death giving a maternal mortality ratio of 0,9/100,000 witch is not different from the former report (2007-2009). There were 2 cerebral thrombophlebitis, 2 ischemic strokes and 18 hemorrhagic strokes (4 SAH, 2 AVM). These deaths occurred during ongoing pregnancy in 5 cases (25%), after miscarriage in 1 case (5%) and in the post-partum period in 14 cases (70%). In this last situation, stroke occurred before delivery in 4 cases and during the post-partum period in 9 cases (1 to 9 days) (1 unknown). There were 7 vaginal deliveries (50%) and 6 emergency cesarean sections (43%) (1 unknown). Most of those deaths were considered to be unavoidable (13/17, 76%). Four deaths were considered by the experts as being possibly avoidable (delay diagnosis, diagnostic error, inadequate treatment, lake of interruption of the pregnancy). Analyzing those deaths remind that any sudden, severe and unusual headache must be explored and that pregnancy does not contraindicate any of the diagnostic examinations (TDM, angio-TDM, MRI) or invasive treatments (surgery, arterio-embolization, fibrinolysis) necessary for its management. Furthermore, the diagnosis of postdural puncture headache should not be establishedwithout imaging when the symptomatology is not absolutely typical.
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Affiliation(s)
- H Cohen
- Service de gynécologie-obstétrique, institut mutualiste Montsouris, 42, boulevard Jourdan, 75014 Paris, France
| | - M Rossignol
- Département d'anesthésie-réanimation-SMUR, hôpital Lariboisière, Assistance publique-Hôpitaux de Paris, 2, rue Ambroise-Paré, 75010 Paris, France.
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231
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Hadjipanayis A, Efstathiou E, Theophilou L, Chrousos G. Reversible brain lesion following growth hormone replacement therapy in an adolescent. BMJ Case Rep 2017; 2017:bcr-2017-221885. [PMID: 29141928 DOI: 10.1136/bcr-2017-221885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 12.6-year-old girl presented with a 2-month history of headache, recurrent vomiting and 5 kg weight loss. She had been receiving recombinant human growth hormone (rhGH) replacement therapy at a dose of 0.035 mg/kg for the past 10 months, due to short stature. Investigations before initiating rhGH, including brain MRI, had been normal. Physical examination revealed a nystagmus and a mildly elevated arterial blood pressure. Brain MRI revealed a lesion in the posterior aspect of the medulla oblongata, adjacent to the foramen of Magendie. rhGH therapy was discontinued, followed by a gradual resolution of the symptoms. At follow-up 3 months later, she was asymptomatic and physical examination was unremarkable. A subsequent repeat brain MRI showed complete resolution of the lesion, supporting the diagnosis of a variant of reversible posterior leucoencephalopathy syndrome. This is the first case report of a reversible brain lesion linked to rhGH replacement therapy.
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Affiliation(s)
- Adamos Hadjipanayis
- School of Medicine, Larnaca General Hospital, European University Cyprus, Larnaca, Cyprus
| | | | - Leda Theophilou
- St George's University of London, University of Nicosia, Nicosia, Cyprus
| | - George Chrousos
- Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
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232
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Neurologic complications after allogeneic hematopoietic stem cell transplantation: risk factors and impact. Bone Marrow Transplant 2017; 53:199-206. [PMID: 29131150 DOI: 10.1038/bmt.2017.239] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 09/08/2017] [Accepted: 09/12/2017] [Indexed: 01/16/2023]
Abstract
Neurologic complications (NCs) may be a significant source of morbidity and mortality after hematopoietic cell transplantation (HCT). We performed a retrospective study of 263 consecutive patients undergoing allogeneic HCT for hematological malignancies to determine the incidence, risk factors and clinical impact of NCs in the first 5 years after HCT. We determined the incidence of central nervous system (CNS) infection, intracranial hemorrhage, ischemic stroke, metabolic encephalopathy, posterior reversal encephalopathy syndrome, seizure and peripheral neuropathy. In all, 50 patients experienced 63 NCs-37 early (⩽day +100), 21 late (day +101 to 2 years) and 5 very late (2 to 5 years). The 1- and 5-year cumulative incidences of all NCs were 15.6% and 19.2%, respectively, and of CNS complication (CNSC; all of the above complications except peripheral neuropathy) were 12.2 and 14.5%. Risk factors for CNSC were age (hazard ratio (HR)=1.06 per year, P=0.0034), development of acute GvHD grade III-IV (HR=2.78, P=0.041), transfusion-dependent thrombocytopenia (HR=3.07, P=0.025) and delayed platelet engraftment (>90th centile; HR=2.77, P=0.043). CNSCs negatively impacted progression-free survival (HR=2.29, P=0.0001), overall survival (HR=2.63, P<0.0001) and non-relapse mortality (HR=8.51, P<0.0001). NCs after HCT are associated with poor outcomes, and usually occur early after HCT.
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Shkalim-Zemer V, Konen O, Levinsky Y, Michaeli O, Yahel A, Krauss A, Yaniv I, Stein J. Calcineurin inhibitor-free strategies for prophylaxis and treatment of GVHD in children with posterior reversible encephalopathy syndrome after stem cell transplantation. Pediatr Blood Cancer 2017; 64. [PMID: 28417553 DOI: 10.1002/pbc.26531] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 02/20/2017] [Accepted: 02/23/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a distinct clinico-radiologic entity that can occur following allogeneic hematopoietic stem cell transplantation, often in the context of treatment with calcineurin inhibitors (CNIs). PROCEDURE We describe the results of CNI-free management of 14 children with PRES and review the clinical and radiologic manifestations of their presentation. RESULTS Discontinuation of CNIs usually resulted in remission of PRES, but patients with established graft versus host disease (GVHD) at the time when treatment was changed often experienced progressive GVHD despite administration of immune suppressive and modulating treatments. All but three patients experienced full neurologic recovery. Nine children died as a result of either GVHD, disease relapse, or severe infection. CONCLUSIONS Discontinuation of CNIs results in neurologic improvement in most cases, but superior alternative immune modulatory treatment is needed to prevent progression of established GVHD.
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Affiliation(s)
- Vered Shkalim-Zemer
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Osnat Konen
- Department of Imaging, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoel Levinsky
- Department of Pediatrics B, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Orli Michaeli
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Anat Yahel
- Bone Marrow Transplant Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Aviva Krauss
- Bone Marrow Transplant Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Isaac Yaniv
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jerry Stein
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Bone Marrow Transplant Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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234
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Vilela P. Acute stroke differential diagnosis: Stroke mimics. Eur J Radiol 2017; 96:133-144. [DOI: 10.1016/j.ejrad.2017.05.008] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 05/04/2017] [Indexed: 01/09/2023]
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235
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Reversible cerebral vasoconstriction syndrome and posterior reversible encephalopathy syndrome associated with intracranial hypotension. Neurocrit Care 2017; 26:103-108. [PMID: 27848124 DOI: 10.1007/s12028-016-0320-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Reversible cerebral vasoconstriction syndrome (RCVS) and posterior reversible encephalopathy syndrome (PRES) are both rare disorders. The pathophysiology of both diseases is not yet fully understood. METHODS We report the unique case of a 19-year-old comatose woman who was brought to the ER after a series of generalized tonic-clonic seizures 6 days post peridural anesthesia for cesarean section. Vital signs and initial laboratory testing including urine analysis and drug screening were unremarkable. Initial cranial CT scan showed an acute small subdural hematoma (17 mm length × 6 mm width × 30 mm height), cerebral edema with slit ventricles, and slight cerebellar tonsillar herniation as signs of intracranial hypotension. CT angiography depicted narrowing of the proximal intracranial vessels consistent with RCVS. MR imaging was also suggestive of both intracranial hypotension and RCVS and showed, in addition, vasogenic edema consistent with PRES. An extensive CSF leakage involving T1 to L2/L3 was confirmed by spinal MRI. RESULTS The patient underwent conservative therapy for intracranial hypotension (e.g., head-down position) as well as epidural blood patch, which led to regression of the clinical symptoms within a few days. Follow-up MRI showed complete resolution of all radiological changes. CONCLUSIONS In summary, our patient developed clinical and neuroradiological signs of intracranial hypotension and a combination of PRES and RCVS associated with a CSF leakage caused by peridural anesthesia; by treating the intracranial hypotension, the other syndromes resolved. From a clinical point of view, it is important to look for CSF leakage as a treatable possible cause of PRES and/or RCVS triggered by intracranial hypotension as in our patient postpartum. Moreover, it is vital to obtain a good history as, in cases of suspected CSF leakage with classic postural headache, a recent spinal/cranial procedure is typically present.
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236
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Bazuaye-Ekwuyasi E, Chow RD, Schmalzle S. An atypical subacute presentation of posterior reversible encephalopathy syndrome. J Community Hosp Intern Med Perspect 2017; 7:269-274. [PMID: 29046760 PMCID: PMC5637638 DOI: 10.1080/20009666.2017.1369381] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 08/07/2017] [Indexed: 01/15/2023] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) characteristically presents with rapid onset of headache, seizure, encephalopathy, and visual changes, along with evidence of parieto-occipital vasogenic edema on magnetic resonance imaging. We describe the case of a 41-year-old female with a protracted presentation of two of the four classic PRES symptoms, which were not immediately recognized as PRES due to the presence of multiple other comorbidities and reasons for encephalopathy. This case highlights the possibility of atypical presentations of PRES and the diagnostic challenges in making this clinical diagnosis when competing diagnoses are present.
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Affiliation(s)
- Eseosa Bazuaye-Ekwuyasi
- Department of Internal Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, MD, USA.,Department of Radiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Robert Dobbin Chow
- Department of Internal Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, MD, USA
| | - Sarah Schmalzle
- Department of Internal Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, MD, USA.,Division of Infectious Disease, University of Maryland School of Medicine, Baltimore, MD, USA.,Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
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237
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Lincoln CM, Fata P, Sotardi S, Pohlen M, Uribe T, Bello JA. Imaging spectrum of immunomodulating, chemotherapeutic and radiation therapy-related intracranial effects. Br J Radiol 2017; 91:20170553. [PMID: 29039692 DOI: 10.1259/bjr.20170553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE A wide range of treatment-related side effects result in specific neurologic symptoms and signs and neuroimaging features. Even to the most seasoned neuroradiologist, elucidating therapy-related side effects from other common mimics can be challenging. We provide a pictorial survey of some common and uncommon medication-induced and therapy-related neuroimaging manifestations, discuss pathophysiology and common pitfalls in imaging and diagnosis. METHODS A case-based review is utilized to depict scenarios on a routine basis in a general radiology or neuroradiology practice such as medication-induced posterior reversible encephalopathy syndrome to the more challenging cases of pseudoprogression and pseudoregression in temozolmide and bevacizumab therapy in gliobastoma treatment protocols. CONCLUSION Knowledge of the treatment-induced imaging abnormalities is essential in the accurate interpretation and diagnosis from the most routine to most challenging of clinical situations. We provide a pictorial review for the radiologist to employ in order to be an invaluable provider to our clinical colleagues and patients.
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Affiliation(s)
- Christie M Lincoln
- 1 Department of Radiology, Baylor College of Medicine , Houston, TX , USA
| | - Peter Fata
- 2 Department of Radiology, Houston Methodist , Houston, TX , USA
| | - Susan Sotardi
- 3 Department of Neuroradiology, Massachusetts General Hospital , Boston, MA , USA
| | - Michael Pohlen
- 1 Department of Radiology, Baylor College of Medicine , Houston, TX , USA
| | - Tomas Uribe
- 1 Department of Radiology, Baylor College of Medicine , Houston, TX , USA
| | - Jacqueline A Bello
- 4 Albert Einstein College of Medicine, Montefiore Medical Center , Bronx, NY , USA
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238
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Chaudhary RK, Dhakal P, Aryal A, Bhatt VR. Central nervous system complications after allogeneic hematopoietic stem cell transplantation. Future Oncol 2017; 13:2297-2312. [PMID: 28984145 DOI: 10.2217/fon-2017-0274] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Allogenic hematopoietic stem cell transplant (alloSCT) is a potentially curative modality of treatment for patients with hematological malignancies. However, CNS complications following transplant pose a risk to survival of the patients. Early recognition and management of these complications are crucial to reduce morbidity and mortality of patients following transplant. Early CNS complications associated with alloSCT are infection, cerebrovascular events, chemotherapy and radiation-induced toxicities while late complications include post-transplant lymphoproliferative disorder, CNS relapse of underlying malignancy and viral and fungal infections. Development of graft-versus-host disease can further increase the risk of CNS complications and outcomes after alloSCT. Strategies aimed to reduce the risk of CNS complications and early management may ameliorate the morbidity and mortality in transplant recipients.
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Affiliation(s)
- Ranjit Kumar Chaudhary
- Department of Radiodiagnosis & Imaging, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Prajwal Dhakal
- Department of Medicine, Michigan State University, East Lansing, MI 48824, USA
| | - Aashrayata Aryal
- Department of Neurology, University of Nebraska Medical Center; Omaha, NE 68198, USA
| | - Vijaya Raj Bhatt
- Department of Internal Medicine, Division of Hematology & Oncology, University of Nebraska Medical Center; Omaha, NE 68198, USA
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239
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Godasi R, Rupareliya C, Bollu PC. Bilateral Occipital Lobe Hemorrhages Presenting as Denial of Blindness in Posterior Reversible Encephalopathy Syndrome- A Rare Combination of Anton Syndrome and Encephalopathy. Cureus 2017; 9:e1746. [PMID: 29218261 PMCID: PMC5714403 DOI: 10.7759/cureus.1746] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) or reversible posterior leukoencephalopathy (RPL) is an acute neurological syndrome characterized by the development of radiological abnormalities on brain imaging along with clinical manifestations, such as a headache, seizures, encephalopathy, etc. We report the case of a middle-aged male who presented to the emergency department after he woke up with complete blindness and was found to have hemorrhagic PRES. Intracranial hemorrhages were seen in around 15% of patients who presented with this condition. In this article, we review the different types of hemorrhages seen in the setting of PRES and their associations.
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Affiliation(s)
- Raja Godasi
- Department of Neurology, University of Missouri, Columbia, Missouri
| | | | - Pradeep C Bollu
- Department of Neurology, University of Missouri, Columbia, Missouri
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240
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Janjua TK, Hassan M, Afridi HK, Zahid NA. Oxaliplatin-induced posterior reversible encephalopathy syndrome (PRES). BMJ Case Rep 2017; 2017:bcr-2017-221571. [PMID: 28978604 DOI: 10.1136/bcr-2017-221571] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES), first introduced in 1996, is a neurotoxic state characterised by seizures, headache, vision change, paresis, nausea and altered mental status. Risk factors include hypertension, eclampsia/pre-eclampsia, infection/sepsis and cancer chemotherapy. Although exposure to toxic agents is a common occurrence in patients who develop PRES, oxaliplatin has rarely been associated with it, with only 10 cases reported worldwide. We present the case of an oxaliplatin-induced PRES in a 23-year-old male patient who was started on oxaliplatin/capecitabine as adjuvant chemotherapy for anal canal adenocarcinoma. The patient developed symptoms of headache, slurred speech and left-sided facial weakness on the ninth day after the first dose of oxaliplatin that lasted for 6-8 hours. The patient experienced another episode next day with similar symptoms that lasted for 8 hours. Oxaliplatin was withheld and the patient was discharged on capecitabine only. The patient had no new episodes since discharge on follow-up.
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Affiliation(s)
- Taimoor Khalid Janjua
- Department of Oncology, Liaquat National Hospital and Medical College, Karachi, Pakistan
| | - Muhammad Hassan
- Department of Medicine, Jinnah Post Graduate Medical Centre, Karachi, Pakistan
| | - Hira Khan Afridi
- Department of Oncology, Liaquat National Hospital and Medical College, Karachi, Pakistan
| | - Naila Anjum Zahid
- Department of Oncology, Liaquat National Hospital and Medical College, Karachi, Pakistan
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241
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Fortini A, Cincotta M, Faraone A, Baruffi C, Carrieri G, Limbucci N, Boccadori C, Nenci G. Headache and visual impairment after twin birth: a challenging diagnosis. Intern Emerg Med 2017; 12:975-980. [PMID: 28710712 DOI: 10.1007/s11739-017-1712-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 07/08/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Alberto Fortini
- Department of Internal Medicine, San Giovanni di Dio Hospital, Florence, Italy.
| | - Massimo Cincotta
- Department of Neurology, San Giovanni di Dio Hospital, Florence, Italy
| | - Antonio Faraone
- Department of Internal Medicine, San Giovanni di Dio Hospital, Florence, Italy
| | - Cristina Baruffi
- Department of Internal Medicine, San Giovanni di Dio Hospital, Florence, Italy
| | - Giovanni Carrieri
- Department of Radiology, San Giovanni di Dio Hospital, Florence, Italy
| | - Nicola Limbucci
- Department of Neuro-vascular Radiology, AOU Careggi, Florence, Italy
| | - Costanza Boccadori
- Department of Internal Medicine, San Giovanni di Dio Hospital, Florence, Italy
| | - Gabriele Nenci
- Department of Internal Medicine, San Giovanni di Dio Hospital, Florence, Italy
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242
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Verma AK, Garg RK, Pradeep Y, Malhotra HS, Rizvi I, Kumar N, Kohli N, Pandey S. Posterior encephalopathy syndrome in women with eclampsia: Predictors and outcome. Pregnancy Hypertens 2017; 10:74-82. [DOI: 10.1016/j.preghy.2017.06.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 05/16/2017] [Accepted: 06/07/2017] [Indexed: 12/01/2022]
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243
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Dong X, Bai C, Nao J. Clinical and radiological features of posterior reversible encephalopathy syndrome in patients with pre-eclampsia and eclampsia. Clin Radiol 2017; 72:887-895. [DOI: 10.1016/j.crad.2017.06.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 05/26/2017] [Accepted: 06/06/2017] [Indexed: 12/19/2022]
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244
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Abstract
Perioperative vision loss (POVL) may cause devastating visual morbidity. A prompt anatomical and etiologic diagnosis is paramount to guide management and assess prognosis. Where possible, steps should be undertaken to minimize risk of POVL for vulnerable patients undergoing high-risk procedures. We review the specific risk factors, pathophysiology, and management and prevention strategies for various etiologies of POVL.
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Affiliation(s)
- Bart Chwalisz
- a Department of Neuro-Ophthalmology , Massachusetts Eye and Ear and Harvard Medical School , Boston , MA , USA
| | - Aubrey L Gilbert
- a Department of Neuro-Ophthalmology , Massachusetts Eye and Ear and Harvard Medical School , Boston , MA , USA
| | - John W Gittinger
- a Department of Neuro-Ophthalmology , Massachusetts Eye and Ear and Harvard Medical School , Boston , MA , USA
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245
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Hiremath SB, Anantrao Gautam A, Anil S, Thomas R, Benjamin G. Susceptibility-weighted angiography and diffusion-weighted imaging in posterior reversible encephalopathy syndrome – Is there an association between hemorrhage, cytotoxic edema, blood pressure and imaging severity? J Neuroradiol 2017; 44:319-325. [DOI: 10.1016/j.neurad.2017.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 04/03/2017] [Accepted: 05/03/2017] [Indexed: 12/01/2022]
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246
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Brady E, Parikh NS, Navi BB, Gupta A, Schweitzer AD. The imaging spectrum of posterior reversible encephalopathy syndrome: A pictorial review. Clin Imaging 2017; 47:80-89. [PMID: 28910681 DOI: 10.1016/j.clinimag.2017.08.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 08/09/2017] [Accepted: 08/22/2017] [Indexed: 12/11/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is characterized by the acute onset of neurologic symptoms (headache, altered mental status, visual changes, seizures) with accompanying vasogenic edema on brain imaging. Risk factors for PRES include infection, uremia, malignancy, autoimmune disorders, the peripartum state and hypertension. PRES is classically described as being posterior (i.e. parieto-occipital) but radiologic variants are increasingly recognized. This pictorial review demonstrates the heterogeneity of the different radiologic presentations of PRES in reference to lesion distribution, hemorrhage, diffusion restriction, contrast enhancement, and other associated findings.
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Affiliation(s)
- Emily Brady
- Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, United States; Department of Radiology, Weill Cornell Medicine, 525 E. 68th Street, New York, NY 10065, United States.
| | - Neal S Parikh
- Department of Neurology, Weill Cornell Medicine, 525 E. 68th Street, New York, NY 10065, United States; Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, 525 E. 68th Street, New York, NY 10065, United States
| | - Babak B Navi
- Department of Neurology, Weill Cornell Medicine, 525 E. 68th Street, New York, NY 10065, United States; Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, 525 E. 68th Street, New York, NY 10065, United States
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, 525 E. 68th Street, New York, NY 10065, United States; Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, 525 E. 68th Street, New York, NY 10065, United States
| | - Andrew D Schweitzer
- Department of Radiology, Weill Cornell Medicine, 525 E. 68th Street, New York, NY 10065, United States
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247
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Posterior reversible encephalopathy syndrome in children with kidney disease. Int Urol Nephrol 2017; 49:1793-1800. [DOI: 10.1007/s11255-017-1684-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 08/17/2017] [Indexed: 01/13/2023]
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248
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A Case of Familial Hemophagocytic Lymphohistiocytosis Type 4 With Involvement of the Central Nervous System Complicated With Infarct. J Pediatr Hematol Oncol 2017; 39:e321-e324. [PMID: 28692549 DOI: 10.1097/mph.0000000000000886] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Familial hemophagocytic lymphohistiocytosis (HLH) is a fatal disease affecting infants and very young children. Central nervous system involvement of HLH can cause catastrophic results. METHOD We present a case with cranial involvement of familial HLH type 4 who showed diffuse infiltration of white matter complicated with intracranial thrombosis. A 5-year-old girl from a consanguineous couple presented with fever and pancytopenia, and was referred to our hematology unit. Examination revealed fever, lymphadenopathy, and hepatosplenomegaly. Ultrasound examination revealed hepatosplenomegaly and free intra-abdominal fluid. HLH was revealed on bone marrow aspiration biopsy. Defective natural killer and T lymphocyte cytotoxicity using degranulation tests was determined. In the genetic analysis, syntaxin gene mutation was found. On T2-weighted and T2-fluid-attenuated inversion recovery magnetic resonance imaging (MRI), diffuse hyperintense signal changes of cerebral white matter, indicating white matter demyelination, were observed. A second brain MRI showed an acute infarct involving the left temporooccipital region. Immunosuppressive therapy according to the HLH 2004 protocol was started. The infarct resolved but white matter lesions were stable on the brain MRI that was performed 1 month later. Brain MRI taken 4 months after the first examination showed stable cerebral white matter lesions, but hyperintense signal changes appeared in the cerebellar white matter and were regarded as progression. The patient died because of infection despite immunosuppressive therapy. CONCLUSIONS Physicians managing patients with HLH must be vigilant about the possibility of central nervous system involvement including stroke.
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249
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Garg RK, Malhotra HS, Jain A, Kumar N. Dengue encephalopathy: very unusual neuroimaging findings. J Neurovirol 2017; 23:779-782. [PMID: 28718068 DOI: 10.1007/s13365-017-0547-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 05/17/2017] [Accepted: 06/13/2017] [Indexed: 10/19/2022]
Abstract
Neuroimaging, in many patients with dengue encephalopathy, may reveal periventricular signal changes. We report a 25-year-old man, who presented with altered sensorium. Dengue-IgM test in serum was positive. Cerebrospinal fluid examination was normal. MRI brain revealed presence of bilateral parieto-occipital intraparenchymal bleed with mass effect. Neuroimaging was consistent with posterior reversible encephalopathy syndrome. We report posterior reversible encephalopathy syndrome in a normotensive patient with dengue encephalopathy and systemic metabolic alterations.
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Affiliation(s)
- Ravindra Kumar Garg
- Department of Neurology, King George's Medical University, UP, Lucknow, 226003, India.
| | | | - Amita Jain
- Department of Microbiology, King George's Medical University, UP, Lucknow, 226003, India
| | - Neeraj Kumar
- Department of Neurology, King George's Medical University, UP, Lucknow, 226003, India
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250
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Batra U, Koyyala VPB, Jain A, Agrawal C, Maheswari U. Folfox encephalopathy: A rare case series. South Asian J Cancer 2017; 6:86-87. [PMID: 28702417 PMCID: PMC5506820 DOI: 10.4103/2278-330x.208850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Ullas Batra
- Department of Medical Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | | | - Akhil Jain
- Department of Medical Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Chaturbhuj Agrawal
- Department of Medical Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Udip Maheswari
- Department of Medical Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
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