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Biswas HK, Ibu KTI, Biswas R, Ahmed MNU. Posterior reversible encephalopathy syndrome associated with dengue fever induced intrauterine death: A case report. Clin Case Rep 2024; 12:e8575. [PMID: 38444915 PMCID: PMC10912089 DOI: 10.1002/ccr3.8575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/17/2024] [Accepted: 02/21/2024] [Indexed: 03/07/2024] Open
Abstract
In recent years dengue fever has become a major health concern specifically due to its diverse presentation and adverse outcome. Progression from mild febrile illness to a severe systemic illness may occur in dengue fever including neurological disorder. Here, we report an unusual and rare case of a 20-year-old mother who developed posterior reversible encephalopathy syndrome (PRES) following dengue fever induced intrauterine death and septic shock.
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Affiliation(s)
| | | | - Rama Biswas
- Department of NeurologySquare HospitalDhakaBangladesh
| | - Md Nasir Uddin Ahmed
- Department of Critical Care MedicineAnwer Khan Modern Medical College HospitalDhakaBangladesh
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Li Y, Song J, Huq AM, Timilsina S, Gershwin ME. Posterior reversible encephalopathy syndrome and autoimmunity. Autoimmun Rev 2023; 22:103239. [PMID: 36464226 DOI: 10.1016/j.autrev.2022.103239] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 11/27/2022] [Indexed: 12/03/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinical syndrome characterized by acute or subacute onset of neurological symptoms (e.g., headache, seizure, confusion, vomiting, and diminished eyesight) and impaired endothelial barrier function of the cerebral circulation that leads to bilateral subcortical vasogenic edema, while exhibiting a "reversible" feature in most cases. Clinically, various predisposing or precipitating conditions have been identified, such as hypertension, autoimmune diseases, renal dysfunction/failure, preeclampsia/eclampsia, post-transplantation conditions, and certain therapeutic agents. Among several putative mechanisms, the immune activation hypothesis prevails, as up to 50% of patients with PRES harbor abnormalities related to autoimmunity, such as concurrent systemic lupus erythematosus. In this Review, we summarize the clinical and laboratory evidence that places PRES in the context of autoimmunity.
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Affiliation(s)
- Yang Li
- Department of Critical Care Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, PR China
| | - Junmin Song
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, PR China.
| | - Ahm M Huq
- Department of Pediatrics, Central Michigan University, Detroit, MI 48201, USA
| | - Suraj Timilsina
- Division of Rheumatology/Allergy and Clinical Immunology, School of Medicine, University of California, Davis, CA 95616, USA
| | - M Eric Gershwin
- Division of Rheumatology/Allergy and Clinical Immunology, School of Medicine, University of California, Davis, CA 95616, USA
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Sanghan N, Lin S, Tartrakoon G, Setthawatcharawanich S, Amornpojnimman T, Sathirapanya P, Khumtong R, Leelawattana R, Korathanakhun P. Factors associated with acute symptomatic seizure occurrence among patients with posterior reversible encephalopathy syndrome. Epilepsy Behav 2022; 134:108834. [PMID: 35834860 DOI: 10.1016/j.yebeh.2022.108834] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/23/2022] [Accepted: 06/27/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES We aimed to define the factors associated with acute symptomatic seizure occurrence in posterior reversible encephalopathy syndrome (PRES) in the Thai-Asian population. MATERIALS AND METHODS We conducted a retrospective cohort study enrolling patients with PRES admitted to the hospital between 2006 and 2019. In addition to seizure characteristics, baseline characteristics, clinical presentations, precipitating factors, neuroimaging characteristics, hospital complications, and hospital outcomes were compared between the seizure and non-seizure groups. Factors with p-value <0.05 in the univariate analysis were entered into the first model of multivariate logistic regression analysis to determine the factors associated with seizure occurrence if the p-value <0.05. The interaction of associated factors was also analyzed in the final multiple logistic regression analysis model. RESULTS Acute symptomatic seizure, which is mainly based on the clinical documentation without electroencephalography, occurred in 50.0% of 136 patients with PRES. Of these, early seizures within 14 days of PRES occurred in 98.5% which mostly developed at presentation (82.4%) with a single seizure attack (55.9%). Convulsive seizures (77.9%) were the most common seizure semiology. The seizure group was significantly younger (median [interquartile range: IQR] 36.00 years old (21.75-48.50) vs 46.50 years old (31.25-61.00), p = 0.003). In univariate analysis, the seizure group had a higher prevalence of consciousness impairment (61.76% vs 26.47%, p < 0.001), Glasgow coma scale (GCS) score of 0-13 (42.46% vs 13.23%, p < 0.001), preeclampsia (20.58% vs 4.41%, p = 0.004), autoimmune disease (17.65% vs 5.88%, p = 0.033), and frontal lesions (25.00% vs 11.76%, p = 0.046) than those in the non-seizure group. In contrast, the seizure group had a lower prevalence of headache (27.94% vs 61.76%, p < 0.001). In the final multivariate logistic regression analysis which included the interaction terms, the acute symptomatic seizure occurrence directly associated with preeclampsia (adjusted odds ratio (aOR) 6.426, 95% confidence interval (CI) 1.450-27.031, p = 0.016) and autoimmune disease (aOR 4.962, 95% CI 1.283-18.642, p = 0.025), while headache showed a reverse association (aOR 0.310, 95% CI = 0.158-0.721, p = 0.008). CONCLUSIONS Acute symptomatic seizure occurred in a half of patients with PRES in this cohort. Preeclampsia and autoimmune disease were directly associated with seizure occurrence, while headache showed a reverse association.
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Affiliation(s)
- Nattha Sanghan
- Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Siriporn Lin
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Gawinnart Tartrakoon
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Suwanna Setthawatcharawanich
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Thanyalak Amornpojnimman
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Pornchai Sathirapanya
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Rujimas Khumtong
- Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Rattana Leelawattana
- Division of Endocrinology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Pat Korathanakhun
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand.
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Amornpojnimman T, Suwanwong P, Setthawatcharawanich S, Sathirapanya P, Leelawattana R, Korathanakhun P. Predictors of hospital outcomes among patients with posterior reversible encephalopathy syndrome. J Stroke Cerebrovasc Dis 2022; 31:106579. [PMID: 35738219 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 05/04/2022] [Accepted: 05/15/2022] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES We aimed to identify independent predictors of the clinical outcomes of posterior reversible encephalopathy syndrome (PRES) in the Thai-Asian population. MATERIALS AND METHODS This retrospective cohort study recruited PRES patients admitted in the hospital between 2006 and 2019. The baseline characteristics, clinical presentations, precipitating factors, neuroimaging characteristics, hospital complications, and hospital outcomes were compared between the groups with favourable (modified Rankin scale [mRS] score, 0-2) and unfavourable (mRS score, 3-6) clinical outcomes. Factors presenting with p-values < 0.5 in univariate analysis were analysed in the multiple logistic regression model to determine independent predictors of outcome. RESULTS Among 136 PRES patients, 22.80% experienced unfavourable outcomes (mRS score, 3-6), and the mortality rate was 7.35%. The common presenting symptoms in the unfavourable clinical outcome group were impairment of consciousness (90.32%) and seizures (67.74%). Sepsis as a hospital complication (adjusted odds ratio [aOR], 32.95; 95% confidence interval [CI], 4.44-244.22, p = 0.001), acute kidney injury as a hospital complication (aOR, 9.94; 95% CI, 1.71-57.66; p = 0.010), and impairment of consciousness (aOR, 10.85; 95% CI, 1.72-68.53, p = 0.011) were independent predictors of unfavourable outcomes. On the other hand, headache was an independent protective factor (aOR, 0.164; 95% CI, 0.03-0.91; p = 0.039). CONCLUSIONS Impairment of consciousness, sepsis as a hospital complication, and acute kidney injury were independent predictors of unfavourable clinical outcomes, whereas headache showed a preventive effect.
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Affiliation(s)
- Thanyalak Amornpojnimman
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Pachara Suwanwong
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Suwanna Setthawatcharawanich
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Pornchai Sathirapanya
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Rattana Leelawattana
- Division of Endocrinology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Pat Korathanakhun
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand.
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Balu R, Fischer M. Posterior Reversible Encephalopathy Syndrome. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00038-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Gag K, Müller J, Süße M, Fleischmann R, Schroeder HWS. Acute disseminated encephalomyelitis following endonasal resection of a craniopharyngioma: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE21293. [PMID: 35855278 PMCID: PMC9281492 DOI: 10.3171/case21293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 05/27/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND Acute disseminated encephalomyelitis (ADEM) is a rare, acquired demyelination syndrome that causes cognitive impairment and focal neurological deficits and may be fatal. The potentially reversible disease mainly affects children, often after vaccination or viral infection, but may be seen rarely in adults. OBSERVATIONS A 50-year-old woman presented with loss of visual acuity of the left eye. Magnetic resonance imaging (MRI) revealed an intra- and suprasellar mass, which was removed successfully. On postoperative day 1, MRI showed gross total resection of the lesion and no surgery-related complications. On postoperative day 2, the patient presented with a progressive left-sided hemiparesis, hemineglect, and decline of cognitive performance. MRI showed white matter edema in both hemispheres. Cerebrospinal fluid analysis revealed mixed pleocytosis (355/µL) without further evidence of infection. In synopsis of the findings, ADEM was diagnosed and treated with intravenous immunoglobulins. Shortly thereafter, the patient recovered, and no sensorimotor deficits were detected in the follow-up examination. LESSONS Pituitary gland pathologies are commonly treated by transsphenoidal surgery, with only minor risks for complications. A case of ADEM after craniopharyngioma resection has not been published before and should be considered in case of progressive neurological deterioration with multiple white matter lesions.
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Affiliation(s)
| | - Jonas Müller
- Neurosurgery, University Medicine Greifswald, Greifswald, Germany
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Ismail FS, van de Nes J, Kleffner I. A broad spectrum of posterior reversible encephalopathy syndrome - a case series with clinical and paraclinical characterisation, and histopathological findings. BMC Neurol 2021; 21:386. [PMID: 34615476 PMCID: PMC8492815 DOI: 10.1186/s12883-021-02408-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 09/14/2021] [Indexed: 12/03/2022] Open
Abstract
Background Posterior reversible encephalopathy syndrome (PRES) is clinical-neuroradiologically defined and potentially reversible, so there are limited data about histopathological findings. We aimed to describe the clinical and paraclinical features of patients with PRES with regard to its reversibility. Methods This retrospective case series encompasses 15 PRES cases out of 1300 evaluated patients from a single German center between January 1, 2010, and June 15, 2020. PRES was established according to the diagnostic criteria as proposed by the Berlin PRES Study 2012. One of the cases studied was subject to brain autopsy. Results From the 15 patients studied (median age 53 years, range 17–73; 11 female), 67 % presented with epileptic seizures, 40 % suffered from encephalopathy with reduced consciousness and 53 % developed delirium, while 47 % had headache and visual disturbances. Subcortical brain MRI abnormalities related to PRES were observed in all patients. One patient developed spinal ischemia and another Guillain-Barré syndrome in addition to PRES. Hypertensive blood pressure was the main underlying/trigger condition in all patients. Clinical symptoms and MRI changes were not reversible in 42 %, even progressive in 3 out of these 5 patients. Median time from symptom onset to diagnosis in these non-reversible cases was 7 days (range 0–13), while the median delay in diagnosis in the reversible group was 1 day (range 0–3). Cerebellar/brain stem involvement and status epilepticus were more frequently in patients with non-reversible disease course. Mortality due to PRES occurred in 13 % of these patients. Neuropathological examination of the brain of a 57-year-old female patient revealed major leukencephalopathic changes, fibrinoid necrosis of endothelial cells and fresh petechial hemorrhages in accordance with PRES. Conclusions Our case series demonstrates that PRES was not reversible in 42 % of the studied patients. Delay in diagnosis seems to contribute to limited reversibility and poor outcome.
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Affiliation(s)
- Fatme Seval Ismail
- Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, In der Schornau 23-25, 44892, Bochum, Germany.
| | | | - Ilka Kleffner
- Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, In der Schornau 23-25, 44892, Bochum, Germany
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Fang X, Liang Y, Zhang W, Wang Q, Chen J, Chen J, Lin Y, Chen Y, Yu L, Wang H, Chen D. Serum Neurofilament Light: a Potential Diagnostic and Prognostic Biomarker in Obstetric Posterior Reversible Encephalopathy Syndrome. Mol Neurobiol 2021; 58:6460-6470. [PMID: 34550542 DOI: 10.1007/s12035-021-02562-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 09/10/2021] [Indexed: 12/17/2022]
Abstract
Obstetric posterior reversible encephalopathy syndrome (PRES), caused by preeclampsia (PE) or eclampsia, is a clinical imaging syndrome and a critical maternal complication, with vasogenic edema in white matter as a typical imaging characteristic. Serum neurofilament light (NFL) is a marker of neuroaxonal injury. Therefore, we performed this study to explore the diagnostic and prognostic role of NFL in obstetric PRES. We used stored serum samples and clinical data obtained from 2148 PE or eclampsia patients from the Guangzhou Medical Centre for Critical Pregnant Women from January 2015 to January 2020. The serum NFL concentration was measured by Simoa assay. Patients without complete data and MRI examinations were excluded. All patients were grouped into the PRES and non-PRES groups based on the PRES diagnostic criteria. In total, 222 patients met the inclusion criteria and were grouped into the PRES (n = 123) and non-PRES (n = 99) groups. The NFL level was significantly higher in the PRES group than in the non-PRES group (p < 0.0001). The discriminatory accuracy of diagnostic panels (headaches + NFL, NFL) in receiver operating characteristic curve analysis (area under the curve) was 0.9338 and 0.7664. Importantly, the NFL level was significantly correlated with edema severity (Spearman's correlation, p < 0.0001), and a poorer pregnancy outcome was observed in the PRES group. In conclusion, an increased NFL level can add predictive value for diagnosing obstetric PRES, and its level is associated with both clinical severity and pregnancy outcome, suggesting that NFL could serve as a diagnostic and prognostic biomarker for obstetric PRES.
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Affiliation(s)
- Xiaobo Fang
- Department of Neurology, The Third Affiliated Hospital of Guangzhou Medical University, Key Laboratory for Major Obstetric Diseases of Guangdong Province, Guangzhou, 510150, Guangdong, China.,Department of Obstetrics, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical Center for Critical Pregnant Women, No. 63, Duobao Road, Guangzhou, 510150, Guangdong, China
| | - Yanling Liang
- Department of Neurology, The Third Affiliated Hospital of Guangzhou Medical University, Key Laboratory for Major Obstetric Diseases of Guangdong Province, Guangzhou, 510150, Guangdong, China
| | - Weixi Zhang
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases of Guangdong Province, Guangzhou, 510080, Guangdong, China
| | - Qiong Wang
- Department of Neurology, The Third Affiliated Hospital of Guangzhou Medical University, Key Laboratory for Major Obstetric Diseases of Guangdong Province, Guangzhou, 510150, Guangdong, China
| | - Jingsi Chen
- Department of Obstetrics, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical Center for Critical Pregnant Women, No. 63, Duobao Road, Guangzhou, 510150, Guangdong, China
| | - Jia Chen
- Department of Neurology, The Third Affiliated Hospital of Guangzhou Medical University, Key Laboratory for Major Obstetric Diseases of Guangdong Province, Guangzhou, 510150, Guangdong, China
| | - Yongqiang Lin
- Department of Neurology, The Third Affiliated Hospital of Guangzhou Medical University, Key Laboratory for Major Obstetric Diseases of Guangdong Province, Guangzhou, 510150, Guangdong, China
| | - Yanli Chen
- Department of Neurology, The Third Affiliated Hospital of Guangzhou Medical University, Key Laboratory for Major Obstetric Diseases of Guangdong Province, Guangzhou, 510150, Guangdong, China
| | - Li Yu
- Department of Obstetrics, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical Center for Critical Pregnant Women, No. 63, Duobao Road, Guangzhou, 510150, Guangdong, China
| | - Haibin Wang
- Department of Obstetrics, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical Center for Critical Pregnant Women, No. 63, Duobao Road, Guangzhou, 510150, Guangdong, China.
| | - Dunjin Chen
- Department of Obstetrics, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical Center for Critical Pregnant Women, No. 63, Duobao Road, Guangzhou, 510150, Guangdong, China.
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Nelke C, Schulte-Mecklenbeck A, Pawlitzki M, Rolfes L, Räuber S, Gross CC, Minnerup J, Meuth SG, Wiendl H, Ruck T. The Innate Immune Response Characterizes Posterior Reversible Encephalopathy Syndrome. J Clin Immunol 2021; 41:1229-1240. [PMID: 33844127 PMCID: PMC8310851 DOI: 10.1007/s10875-021-01033-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/30/2021] [Indexed: 12/12/2022]
Abstract
While posterior reversible encephalopathy syndrome (PRES) is often characterized by an inflammatory cerebrospinal-fluid (CSF) profile, knowledge of immune cell patterns in PRES is lacking. Thus, we retrospectively characterized CSF and peripheral blood (PB) from 15 PRES patients, which we analyzed by multidimensional flow cytometry (FC). Results were compared to 72 controls, as well as to 9 patients with progressive multifocal leukoencephalopathy (PML, as a relevant differential diagnosis) and 15 multiple sclerosis patients (MS, as a classical neuroinflammatory disorder), respectively. Total protein level in CSF from PRES patients was elevated compared to that in controls, but not to MS and PML. In-depth FC analysis revealed no differences for adaptive immune cells (B cells, plasma cells, CD4+, and CD8+ T cells) in PB or CSF of PRES compared to controls. In contrast, we observed alterations of the adaptive immune response in CSF of PML and MS compared to PRES, indicating that the adaptive immune response is not a driver of disease in PRES. Indeed, PRES was characterized by an innate immune response with CD14++/CD16+ (intermediate) monocytes elevated in PB and CSF, while CD14++/CD16- (classical) monocytes were decreased in PB from PRES patients as compared to controls. Levels of CD14++/CD16+ monocytes correlated with the duration of hospital stay as a surrogate marker for disease severity in PRES patients. Our findings argue for a role of innate rather than adaptive immunity in the pathophysiology of PRES. The observed shift in monocyte subsets might provide valuable diagnostic clues for the clinical management of these patients.
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Affiliation(s)
- Christopher Nelke
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, D-48149, Münster, Germany.
| | - Andreas Schulte-Mecklenbeck
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, D-48149, Münster, Germany
| | - Marc Pawlitzki
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, D-48149, Münster, Germany
| | - Leoni Rolfes
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, D-48149, Münster, Germany
| | - Saskia Räuber
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, D-48149, Münster, Germany
| | - Catharina C Gross
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, D-48149, Münster, Germany
| | - Jens Minnerup
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, D-48149, Münster, Germany
| | - Sven G Meuth
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, D-48149, Münster, Germany
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, D-48149, Münster, Germany
| | - Tobias Ruck
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, D-48149, Münster, Germany
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
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Cerebrovascular events during pregnancy and puerperium. Rev Neurol (Paris) 2021; 177:203-214. [PMID: 33642057 DOI: 10.1016/j.neurol.2021.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 02/05/2021] [Indexed: 11/20/2022]
Abstract
Though cerebrovascular complications of pregnancy remain relatively rare, they represent a potentially devastating event that necessitates prompt identification and treatment. Eighteen percent of strokes occurring in young women are linked to pregnancy. They occur mostly in the third trimester or during the post-partum period. Their biggest risk factors are hypertension, preeclampsia/eclampsia and migraine. Cerebrovascular events occurring during this period may involve specific pathophysiological processes that include embolic phenomena or endothelial dysfunction, but can also have common etiologies that are simply favored by the context of pregnancy. Thus, posterior encephalopathy and vasoconstriction cerebral syndrome are relatively frequently involved in cerebrovascular complications of pregnancy. Other very specific causes like amniotic fluid embolism or postpartum cardiomyopathy can also be responsible for such events. The management of stroke during pregnancy must be multidisciplinary and include a neurovascular expertise. Some conditions can lead to a long-life follow-up and modify the management of a future pregnancy.
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Fang X, Liang Y, Chen D, Liu Y, Xie M, Zhang W. Contribution of excess inflammation to a possible rat model of eclamptic reversible posterior leukoencephalopathy syndrome induced by lipopolysaccharide and pentylenetetrazol: A preliminary study. Cytokine 2020; 135:155212. [DOI: 10.1016/j.cyto.2020.155212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 06/15/2020] [Accepted: 07/13/2020] [Indexed: 12/01/2022]
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Kaur G, Ashraf I, Peck MM, Maram R, Mohamed A, Ochoa Crespo D, Malik BH. Chemotherapy and Immunosuppressant Therapy-Induced Posterior Reversible Encephalopathy Syndrome. Cureus 2020; 12:e11163. [PMID: 33251070 PMCID: PMC7688184 DOI: 10.7759/cureus.11163] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 10/25/2020] [Indexed: 11/25/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is an entity which is characterized by acute to subacute onset of neurological symptoms like altered mental status, seizures, headaches and other focal neurological deficits. It is diagnosed with the help of MRI findings which typically involve the subcortical white matter of parieto-occipital lobes. In this review, we will discuss the various etiologies and risk factors including some of the most common chemotherapeutic agents and immunosuppressant agents associated with this disorder. We will discuss the mechanism of actions and side effect profiles of a few drugs and their role in causation of PRES. This review article discusses if there is any difference in presentation and imaging findings of PRES caused by cytotoxic agents versus caused by other etiologies. It also highlights the difficulty in management of PRES caused by cytotoxic agents as the discontinuation of these drugs could be life-threatening due to graft rejections or graft versus host disease.
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Affiliation(s)
- Gurleen Kaur
- Neurology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ibtisam Ashraf
- Internal Medicine, Shalamar Institute of Health Sciences, Lahore, PAK
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Mercedes Maria Peck
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ruchira Maram
- Internal Medicine, Arogyasri Healthcare Trust, Hyderabad, IND
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Alaa Mohamed
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Internal Medicine, Memorial Hermann Texas Medical Center, Houston, USA
| | - Diego Ochoa Crespo
- Internal Medicine, Clinica San Martin, Azogues, ECU
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Bilal Haider Malik
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Gudkova VV, Shanina TV, Kimelfeld EI, Salimov KA, Orekhova MA, Fedotov EV, Stakhovskaya LV. [Posterior reversible encephalopathy syndrome as a presentation of acute intermittent porphyria]. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 120:60-66. [PMID: 32323945 DOI: 10.17116/jnevro202012003160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The authors describe a clinical case of posterior reversible encephalopathy syndrome (PRES) in a 36-year-old female patient due to the first onset of not previously diagnosed acute intermittent porphyria. Only 22 clinical and radiological cases of the combination of PRES and acute porphyria were reported in the literature by 2018. This is the first report of a similar association confirmed by magnetic resonance imaging (MRI) in the Russian literature. The article describes the dynamics of the disease from unexplained abdominal pain to repeated epileptic paroxysms and subsequent formation of a detailed picture of encephalo- and polyneuropathy. The particularities of neurological presentations, the significance of epileptic paroxysms and MRI in the diagnosis of the abovementioned combined pathology are shown. Possible mechanisms causing both pathological processes are considered.
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Affiliation(s)
- V V Gudkova
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - T V Shanina
- Eramishantsev City Clinical Hospital, Moscow, Russia
| | - E I Kimelfeld
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - K A Salimov
- Eramishantsev City Clinical Hospital, Moscow, Russia
| | - M A Orekhova
- Eramishantsev City Clinical Hospital, Moscow, Russia
| | - E V Fedotov
- Eramishantsev City Clinical Hospital, Moscow, Russia
| | - L V Stakhovskaya
- Pirogov Russian National Research Medical University, Moscow, Russia
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14
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Unsal Bilgin YO, Eskut N, Koskderelioglu A, Gedizlioglu M. Atypical posterior reversible encephalopathy syndrome with albuminocytological dissociation and late emerging neuroradiological findings: A case report. Postgrad Med 2020; 133:108-111. [PMID: 32880496 DOI: 10.1080/00325481.2020.1816359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a central nervous system disorder accompanied by vasogenic edema in white matter that is usually located in temporo-parieto-occipital area. Typically, PRES is presented with headaches, seizures, and change of consciousness. The most common etiologic factor is fluctuations in blood pressure. An eighty-eight-year-old female patient was evaluated because of her acute confused state. Medical history revealed hypertension. Blood pressure was 190/100 mmHg. The initial examination showed impaired consciousness. Radiological investigations of brain showed chronic ischemic lesions. Albuminocytological dissociation was detected in CSF examination. On the 6th day of admission, cranial MRI was repeated. Radiological findings were typical for PRES. The cranial MRI is a valuable diagnostic tool for the diagnosis of the PRES but, as in our case, despite the subtle clinical and radiological findings presented during admission, repeated MRI and CSF examination may contribute to a definite diagnosis. This case is remarkable for severe protein elevation in CSF, irreversible fatal course and radiographic evidence of vasogenic edema occurred subsequently.
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Affiliation(s)
- Yaprak Ozum Unsal Bilgin
- Department of Neurology, University of Health Sciences, Izmir Bozyaka Education and Research Hospital , Izmir, Turkey
| | - Neslihan Eskut
- Department of Neurology, University of Health Sciences, Izmir Bozyaka Education and Research Hospital , Izmir, Turkey
| | - Asli Koskderelioglu
- Department of Neurology, University of Health Sciences, Izmir Bozyaka Education and Research Hospital , Izmir, Turkey
| | - Muhtesem Gedizlioglu
- Department of Neurology, University of Health Sciences, Izmir Bozyaka Education and Research Hospital , Izmir, Turkey
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15
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Xiromerisiou G, Kalampokini S, Rikos D, Provatas A, Tsouris Z, Markou K, Ralli S, Dardiotis E. Posterior reversible encephalopathy in a GT1a positive oculopharyngeal variant of Guillain-Barré syndrome: A case-report and review of the literature. Clin Neurol Neurosurg 2020; 196:106037. [DOI: 10.1016/j.clineuro.2020.106037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/18/2020] [Accepted: 06/19/2020] [Indexed: 11/16/2022]
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16
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D'Angelo R, Boschetti E, Amore G, Costa R, Pugliese A, Caporali L, Gramegna LL, Papa V, Vizioli L, Capristo M, Contin M, Mohamed S, Cenacchi G, Lodi R, Morelli MC, Fasano L, Pisani L, Cescon M, Tonon C, Pinna AD, Dotti MT, Sicurelli F, Scarpelli M, Filosto M, Casali C, Pironi L, Carelli V, De Giorgio R, Rinaldi R. Liver transplantation in mitochondrial neurogastrointestinal encephalomyopathy (MNGIE): clinical long-term follow-up and pathogenic implications. J Neurol 2020; 267:3702-3710. [PMID: 32683607 DOI: 10.1007/s00415-020-10051-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/30/2020] [Accepted: 07/02/2020] [Indexed: 01/21/2023]
Abstract
We report the longest follow-up of clinical and biochemical features of two previously reported adult mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) patients treated with liver transplantation (LT), adding information on a third, recently transplanted, patient. All three patients overcame the early post-operative period and tolerated immunosuppressive therapy. Plasma nucleoside levels dramatically decreased, with evidence of clinical improvement of ambulation and neuropathy. Conversely, other features of MNGIE, as gastrointestinal dysmotility, low weight, ophthalmoparesis, and leukoencephalopathy were essentially unchanged. A similar picture characterized two patients treated with allogenic hematopoietic stem cell transplantation (AHSCT). In conclusion, LT promptly and stably normalizes nucleoside imbalance in MNGIE, stabilizing or improving some clinical parameters with marginal periprocedural mortality rate as compared to AHSCT. Nevertheless, restoring thymidine phosphorylase (TP) activity, achieved by both LT and AHSCT, does not allow a full clinical recovery, probably due to consolidated cellular damage and/or incomplete enzymatic tissue replacement.
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Affiliation(s)
- Roberto D'Angelo
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Interaziendale Clinica Neurologica Rete Metropolitana (NeuroMet), Neurologia AOU S. Orsola-Malpighi, Policlinico Sant'Orsola-Malpighi, Building #2, Via Albertoni, 15, 40138, Bologna, Italy.
| | - Elisa Boschetti
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Giulia Amore
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Roberta Costa
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Alessia Pugliese
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Leonardo Caporali
- UOC Clinica Neurologica, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Laura Ludovica Gramegna
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.,Functional and Molecular Neuroimaging Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Valentina Papa
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Luca Vizioli
- Department of Organ Insufficiency and Transplantation, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Mariantonietta Capristo
- UOC Clinica Neurologica, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Manuela Contin
- UOC Clinica Neurologica, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Susan Mohamed
- UOC Clinica Neurologica, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Giovanna Cenacchi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Raffaele Lodi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Maria Cristina Morelli
- Department of Organ Insufficiency and Transplantation, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Luca Fasano
- Respiratory and Critical Care Unit, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Lara Pisani
- Respiratory and Critical Care Unit, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Matteo Cescon
- Department of Organ Insufficiency and Transplantation, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Caterina Tonon
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.,Functional and Molecular Neuroimaging Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Antonio Daniele Pinna
- Department of Organ Insufficiency and Transplantation, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Maria Teresa Dotti
- Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy
| | - Francesco Sicurelli
- Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy
| | | | - Massimiliano Filosto
- Center for Neuromuscular Diseases, Unit of Neurology, ASST "Spedali Civili", Brescia, Italy
| | - Carlo Casali
- Department of Medico-Surgical Sciences and Biotechnologies, University 'La Sapienza', Roma, Italy
| | - Loris Pironi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Valerio Carelli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,UOC Clinica Neurologica, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Roberto De Giorgio
- Department of Morphology, Surgery and Experimental Medicine, St. Anna Hospital, University of Ferrara, Ferrara, Italy
| | - Rita Rinaldi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Interaziendale Clinica Neurologica Rete Metropolitana (NeuroMet), Neurologia AOU S. Orsola-Malpighi, Policlinico Sant'Orsola-Malpighi, Building #2, Via Albertoni, 15, 40138, Bologna, Italy
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17
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Hwang SK, Lee YJ, Lee SM, Kwon S. Clinical Spectrum of Posterior Reversible Encephalopathy Syndrome in Children. ANNALS OF CHILD NEUROLOGY 2020. [DOI: 10.26815/acn.2020.00031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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18
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Tetsuka S, Ogawa T. Posterior reversible encephalopathy syndrome: A review with emphasis on neuroimaging characteristics. J Neurol Sci 2019; 404:72-79. [DOI: 10.1016/j.jns.2019.07.018] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 06/25/2019] [Accepted: 07/16/2019] [Indexed: 01/24/2023]
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Abstract
PURPOSE OF REVIEW Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological syndrome characterized by acute cerebral endotheliopathy with consecutive disruption of the blood-brain barrier and vasogenic edema. Since its first description in 1996, PRES is increasingly recognized. However, many aspects of this syndrome with its wide spectrum of clinical and radiological features are still incompletely understood. In this review, possible pathophysiological mechanisms, approaches to diagnosis, recent study results on outcome, and future directions of research are described. RECENT FINDINGS Clinical manifestations of PRES include seizures, headache, visual disturbances, altered mental state, and more rarely hemiparesis or aphasia. Vasogenic edema predominantly occurs in the parieto-occipital region, but lesions affecting formerly called 'atypical' regions such as frontal lobe, cerebellum, or basal ganglia are common. If treated early and adequately, that is by removal of the underlying cause, PRES has a favorable prognosis, but neurological residual symptoms and even mortality can occur, particularly in patients with complications such as intracranial hemorrhage. SUMMARY In summary, validated diagnostic criteria and algorithms are warranted to standardize the diagnosis of PRES. This is essential for further research and future prospective studies that should investigate risk factors for unfavorable outcome and identify the roles of imaging features, clinical symptoms, and other biomarkers in predicting outcome.
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20
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Ellis CA, Balu R. Authors’ Reply to Drs Bourque and Breiner, Re: Cerebrospinal Fluid in Posterior Reversible Encephalopathy Syndrome. Neurohospitalist 2019; 9:126. [DOI: 10.1177/1941874419847356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Colin A. Ellis
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ramani Balu
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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21
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Hebant B, Guegan-Massardier E, Triquenot-Bagan A, Ozkul-Wermester O. Atypical MRI presentation of posterior reversible encephalopathy syndrome with predominant brainstem involvement. Acta Neurol Belg 2019; 119:123-125. [PMID: 30498887 DOI: 10.1007/s13760-018-1055-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 11/26/2018] [Indexed: 11/27/2022]
Abstract
We report here the case of a 80-year-old woman for the assessment of an acute confusional state since 2 days asssociated with diffuse and gradual headache. Brain MRI disclosed isolated hyperintense signal on fluid-attenuated inversion recovery sequence involving the medulla and the right inferior cerebellar peduncle with moderate swelling, consistent with vasogenic oedema, without abnormalities on diffusion-weighted imaging sequence. PRES diagnosis was suspected and antihypertensive therapy was introduced to achieve a blood pressure goal < 140/90 mmHg, allowing a quickly favourable clinical course. Three months later, brain MRI demonstrated a complete clearance of the abnormalities, confirming the PRES diagnosis. Atypical MRI findings are possible with involvement of basal ganglia, brainstem or cerebellum, but in these cases, oedema is most of the time accompanied by the classical parieto-occipital region involvement. Vasogenic oedema strictly unilateral or involving exclusively the brainstem or the cerebellum are very rare and should prompt suspicion for an alternative diagnosis. That constitutes a crucial diagnosis challenge in neurology.
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Affiliation(s)
- Benjamin Hebant
- Department of Neurology, Rouen University Hospital and University of Rouen, 76031, Rouen Cedex, France.
| | - Evelyne Guegan-Massardier
- Department of Neurology, Rouen University Hospital and University of Rouen, 76031, Rouen Cedex, France
| | - Aude Triquenot-Bagan
- Department of Neurology, Rouen University Hospital and University of Rouen, 76031, Rouen Cedex, France
| | - Ozlem Ozkul-Wermester
- Department of Neurology, Rouen University Hospital and University of Rouen, 76031, Rouen Cedex, France
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22
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Gowan JM, Liu A. Isolated pan-pontine posterior reversible encephalopathy syndrome in a patient with uncontrolled hypertension. Clin Case Rep 2019; 7:32-36. [PMID: 30656003 PMCID: PMC6332822 DOI: 10.1002/ccr3.1888] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 09/26/2018] [Accepted: 10/05/2018] [Indexed: 11/11/2022] Open
Abstract
Recognition of central variant PRES is key to avoiding detrimental treatment. The pons may be the most vulnerable area in central PRES, and delayed presentation may result in greater damage. CSF reporting may lead to eventual recognition of a common profile, and possible aid in future diagnosis.
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Affiliation(s)
| | - Antonio Liu
- Department of NeurologyCalifornia Hospital Medical CenterLos AngelesCalifornia
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23
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Ayesh Haj Yousef MH, Eyadeh A, Rawashdeh RA, Khasawneh R, Saleh JA, Jibreel MJ. Vinblastine-induced posterior reversible encephalopathy syndrome. J Oncol Pharm Pract 2018; 25:2019-2022. [PMID: 30537916 DOI: 10.1177/1078155218816776] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Posterior reversible encephalopathy syndrome has recently been recognized as an entity characterized by central neurological and radiological manifestations. There are increasing reports of posterior reversible encephalopathy syndrome associated with the use of chemotherapeutic agents. We herein present a case of posterior reversible encephalopathy syndrome occurring in a patient with Hodgkin's lymphoma after taking two courses of adriamycin, bleomycin, vinblastine, dacarbazine chemotherapy. A prompt recognition of posterior reversible encephalopathy syndrome associated with vinblastine and discontinuation of this drug is paramount to prevent severe neurological damage.
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Affiliation(s)
- Mahmoud H Ayesh Haj Yousef
- Department of Internal Medicine, Faculty of Medicine, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan
| | - Ahmed Eyadeh
- Department of Internal Medicine, Faculty of Medicine, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan
| | - Rand Al Rawashdeh
- Department of Internal Medicine, Faculty of Medicine, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan
| | - Ruba Khasawneh
- Department of Radiology, Faculty of Medicine, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan
| | | | - Malak J Jibreel
- Department of Clinical Pharmacy, Faculty of Pharmacy, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan
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24
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Ellis CA, McClelland AC, Mohan S, Kuo E, Kasner SE, Zhang C, Khankhanian P, Balu R. Cerebrospinal Fluid in Posterior Reversible Encephalopathy Syndrome: Implications of Elevated Protein and Pleocytosis. Neurohospitalist 2018; 9:58-64. [PMID: 30915182 DOI: 10.1177/1941874418802061] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background and Purpose Patients with posterior reversible encephalopathy syndrome (PRES) sometimes undergo analysis of cerebrospinal fluid (CSF) to exclude alternative diagnoses. This study's objectives were to describe the CSF characteristics in patients with PRES and to identify clinical and radiologic findings associated with distinct CSF abnormalities. Methods We identified a retrospective cohort of patients with PRES. We compared clinical and radiographic characteristics of those who did versus did not undergo lumbar puncture, described the observed range of CSF findings, and analyzed clinical and radiographic features associated with specific CSF abnormalities. Results A total of 188 patients were included. Patients with (n = 77) and without (n = 111) CSF analysis had similar clinical and radiographic characteristics. Cerebrospinal fluid protein was elevated in 46 (60%) of 77, with median CSF protein 53 mg/dL (upper limit of normal 45 mg/dL). Protein elevation was significantly associated with radiographic severity (P = .0058) but not with seizure, time from symptom onset, radiographic evidence of diffusion restriction, or contrast enhancement. Five (7%) patients had elevated CSF white blood cells, all of whom had infarction and/or hemorrhage on neuroimaging, and 4 of whom had eclampsia. Conclusion The CSF of most patients with PRES shows a mild protein elevation commensurate with radiographic severity. Cerebrospinal fluid pleocytosis may mark a distinct subtype of PRES with predisposition toward infarction and/or hemorrhage. These findings help clinicians interpret CSF findings in these patients and generate new hypotheses about the pathophysiology of this syndrome.
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Affiliation(s)
- Colin A Ellis
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew C McClelland
- Division of Neuroradiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Suyash Mohan
- Division of Neuroradiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Emory Kuo
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Scott E Kasner
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Cen Zhang
- Department of Neurology, New York University Medical Center, NY, USA
| | - Pouya Khankhanian
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Ramani Balu
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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25
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Hebant B, Bennani O. Unusual Aspect of Posterior Reversible Encephalopathy Syndrome in an Elderly Adult. J Emerg Med 2018; 55:e9-e13. [PMID: 29748058 DOI: 10.1016/j.jemermed.2018.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 01/01/2018] [Accepted: 04/10/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) classically occurs in patients presenting with a sudden increase of arterial pressure or eclampsia, but the range of etiologies is very wide. Although the mechanisms underlying PRES remain unclear, research suggests that when the extent of hypertension exceeds the threshold of cerebral blood flow autoregulation, this induces blood-brain barrier disruption that leads to brain edema. Unusual presentations on magnetic resonance imaging (MRI) are possible, including the involvement of frontal or temporal lobes, cerebellar hemispheres, basal ganglia, brainstem, or deep white matter. However, in these atypical locations, edema is mostly accompanied by the classical parieto-occipital region involvement. CASE REPORT We report the case of an elderly adult presenting with an unusual presentation of PRES with exclusive involvement of the frontal lobes, associated with severe hypertension. In our case, computed tomography and MRI abnormalities were exclusively localized in the frontal regions without involvement of the classical parieto-occipital regions. A favorable clinical course after hypertension management and complete clearance on an MRI scan at 3 months' follow-up confirmed the diagnosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: PRES is a condition potentially encountered by many doctors, especially in the emergency department. However, atypical clinical or imaging presentations are possible and could delay the diagnosis. These must be known to begin adequate treatment as quickly as possible.
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Affiliation(s)
| | - Omar Bennani
- Department of Neurology, Le Havre General Hospital, Le Havre, France
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26
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Lee SW, Lee SJ. Central-Variant Posterior Reversible Encephalopathy Syndrome with Albuminocytologic Dissociation. Case Rep Neurol 2018. [PMID: 29515421 PMCID: PMC5836266 DOI: 10.1159/000486444] [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: 11/19/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a disorder of reversible vasogenic brain edema which mainly involves the parieto-occipital lobes in various clinical settings. The main mechanism is known to be cerebral autoregulation failure and endothelial dysfunction leading to the disruption of the blood-brain barrier. We report the case of a 47-year-old woman with PRES which involved the brain stem and thalami, sparing the cerebral hemispheres. She was admitted to the emergency room because of acute-onset confusion. Her initial blood pressure was 270/220 mm Hg. Routine blood lab tests showed pleocytosis, hyperglycemia, and azotemia. Brain magnetic resonance imaging (MRI) showed a lesion of vasogenic edema involving nearly the whole area of pons, the left side of the midbrain, and the bilateral medial thalami. Cerebrospinal fluid (CSF) examination revealed an increased level of protein with normal white blood cell count. With conservative care, the patient markedly recovered 3 days after symptom onset, and a follow-up MRI confirmed complete resolution of the vasogenic edema. This case suggests that PRES can rarely involve the "central zone" only, sparing the cerebral hemispheres, which may be confused with other neurological diseases. Besides, the CSF albuminocytologic dissociation may suggest the disruption of the blood-brain barrier in patients with PRES.
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Affiliation(s)
- Sang-Woo Lee
- Department of Neurology, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Seung-Jae Lee
- Department of Neurology, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
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27
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Mai NTH, Phu NH, Nghia HDT, Phuong TM, Duc DT, Chau NVV, Wills B, Lim CCT, Thwaites G, Simmons CP, Yacoub S. Dengue-Associated Posterior Reversible Encephalopathy Syndrome, Vietnam. Emerg Infect Dis 2018; 24:402-404. [PMID: 29350156 PMCID: PMC5782880 DOI: 10.3201/eid2402.171634] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Dengue can cause neurologic complications in addition to the more common manifestations of plasma leakage and coagulopathy. Posterior reversible encephalopathy syndrome has rarely been described in dengue, although the pathophysiology of endothelial dysfunction likely underlies both. We describe a case of dengue-associated posterior reversible encephalopathy syndrome and discuss diagnosis and management.
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28
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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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29
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Ninomiya I, Kanazawa M, Akaiwa Y, Shimohata T, Okamoto K, Onodera O, Nishizawa M. Apparent diffusion coefficient reduction might be a predictor of poor outcome in patients with posterior reversible encephalopathy syndrome. J Neurol Sci 2017; 381:1-3. [PMID: 28991655 DOI: 10.1016/j.jns.2017.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 08/01/2017] [Accepted: 08/02/2017] [Indexed: 10/19/2022]
Abstract
It is thought that posterior reversible encephalopathy syndrome (PRES) is both clinically and radiologically reversible. However, its reversible nature has been challenged based on reports of permanent neurological impairments. The factors that predict the development of irreversible neurological impairment are still unclear. In the present study, we investigated clinical manifestations, laboratory findings, and neuroradiological images to identify predictors of functional outcomes in PRES. We investigated 23 PRES patients. Apparent diffusion coefficient (ADC) reduction was observed in 4 patients in the poor outcome group, whereas no patients presented ADC reduction in the favourable outcome group (p<0.01). Further studies are warranted to evaluate the association between ADC reduction and functional outcome after PRES.
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Affiliation(s)
- Itaru Ninomiya
- Department of Neurology, Brain Research Institute, Niigata University, 1-757 Asahimachi-dori, Niigata 951-8585, Japan
| | - Masato Kanazawa
- Department of Neurology, Brain Research Institute, Niigata University, 1-757 Asahimachi-dori, Niigata 951-8585, Japan.
| | - Yasuhisa Akaiwa
- Department of Neurology, Brain Research Institute, Niigata University, 1-757 Asahimachi-dori, Niigata 951-8585, Japan
| | - Takayoshi Shimohata
- Department of Neurology, Brain Research Institute, Niigata University, 1-757 Asahimachi-dori, Niigata 951-8585, Japan
| | - Kouichirou Okamoto
- Department of Neurosurgery, Brain Research Institute, Niigata University, 1-757 Asahimachi-dori, Niigata 951-8585, Japan
| | - Osamu Onodera
- Department of Neurology, Brain Research Institute, Niigata University, 1-757 Asahimachi-dori, Niigata 951-8585, Japan
| | - Masatoyo Nishizawa
- Department of Neurology, Brain Research Institute, Niigata University, 1-757 Asahimachi-dori, Niigata 951-8585, Japan
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30
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Fischer M, Schmutzhard E. Posterior reversible encephalopathy syndrome. J Neurol 2017; 264:1608-1616. [PMID: 28054130 PMCID: PMC5533845 DOI: 10.1007/s00415-016-8377-8] [Citation(s) in RCA: 268] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 12/16/2016] [Accepted: 12/19/2016] [Indexed: 12/02/2022]
Abstract
The posterior reversible encephalopathy syndrome (PRES) is a neurological disorder of (sub)acute onset characterized by varied neurological symptoms, which may include headache, impaired visual acuity or visual field deficits, disorders of consciousness, confusion, seizures, and focal neurological deficits. In a majority of patients the clinical presentation includes elevated arterial blood pressure up to hypertensive emergencies. Neuroimaging, in particular magnetic resonance imaging, frequently shows a distinctive parieto-occipital pattern with a symmetric distribution of changes reflecting vasogenic edema. PRES frequently develops in the context of cytotoxic medication, (pre)eclampsia, sepsis, renal disease or autoimmune disorders. The treatment is symptomatic and is determined by the underlying condition. The overall prognosis is favorable, since clinical symptoms as well as imaging lesions are reversible in most patients. However, neurological sequelae including long-term epilepsy may persist in individual cases.
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Affiliation(s)
- Marlene Fischer
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Erich Schmutzhard
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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31
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Chen TH, Lin WC, Kao WT, Tseng CM, Tseng YH. Posterior Reversible Encephalopathy Syndrome With Spinal Cord Involvement in Children. J Child Neurol 2017; 32:112-119. [PMID: 28257278 DOI: 10.1177/0883073816671237] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
We characterized a cohort of patients with posterior reversible encephalopathy syndrome with spinal cord involvement. We encountered 2 children and identified an additional 19 patients from the internet databases. Of the 21 patients analyzed, 8 were children. The mean peak systolic blood pressure in adults was significantly higher than in children (221.8 ± 14.3 vs 191.4 ± 31.3 mm Hg; P < .01). Regardless of age, the most common clinical symptom was headache (90%) and the least common clinical symptom was seizures (28%). Atypical neuroimaging was more common in children (63%) than in adults (8%). Abnormal cerebrospinal fluid results were frequently found in children (83%). All children recovered uneventfully, but 3 adults had sequelae. A broader clinicoradiologic spectrum makes the diagnosis of children more complex than in adults. Awareness of the atypical features with a meticulous management of hypertension is imperative to avoid unnecessary invasive workups and to achieve an uneventful recovery.
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Affiliation(s)
- Tai-Heng Chen
- 1 Division of Pediatric Neurology, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wei-Chen Lin
- 2 Department of Medical Imaging, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wei-Tsun Kao
- 3 Division of Pediatric Emergency, Department of Emergency, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chien-Ming Tseng
- 3 Division of Pediatric Emergency, Department of Emergency, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yong-Hao Tseng
- 3 Division of Pediatric Emergency, Department of Emergency, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
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32
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Siebert E, Bohner G, Liebig T, Endres M, Liman TG. Factors associated with fatal outcome in posterior reversible encephalopathy syndrome: a retrospective analysis of the Berlin PRES study. J Neurol 2016; 264:237-242. [PMID: 27815684 DOI: 10.1007/s00415-016-8328-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 10/25/2016] [Accepted: 10/25/2016] [Indexed: 01/23/2023]
Abstract
Although often reversible, fatal outcome in posterior reversible encephalopathy syndrome (PRES) is well known. However, data on predictors of PRES-associated in-hospital death are scarce. In this study, we aimed to investigate predictors of in-hospital death in a large cohort. Radiological report databases between January 1999 and February 2015 were retrospectively searched for patients with PRES. Patients were included if they met criteria for PRES after detailed investigation of clinical charts and imaging studies. Various clinical, paraclinical and brain MRI data as well as data on in-hospital mortality were analyzed. 151 patients were included into the study, 64% were female. Seventeen (11.2%) patients died during hospital stay. In univariate analyses, higher age (p = 0.04), higher levels of C-reactive protein (p < 0.001), etiology of PRES (sepsis and chemotherapy; p = 0.02), altered coagulation (p = 0.002), altered mental state at onset (p = 0.03), and subarachnoid hemorrhage (SAH; p = 0.01) were related to in-hospital death. In multivariate analyses adjusted for age and sex, elevated CRP levels (OR 1.1 95% CI 1.1-1.2), altered coagulation (OR 5.1 95% CI 1.8-14.7), subarachnoid hemorrhage (OR 10.1 95% CI 2.2-46.1) and altered mental state (OR 3.3; 95% CI 1.1-9.4) were independently associated with in-hospital death. Altered mental state, subarachnoid hemorrhage as well as the higher levels of CRP and altered coagulation were significantly more frequent in patients who died in hospital. However, prospective studies are warranted to establish predictors of fatality in patients with PRES.
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Affiliation(s)
- Eberhard Siebert
- Institut für Neuroradiologie, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - G Bohner
- Institut für Neuroradiologie, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - T Liebig
- Institut für Neuroradiologie, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - M Endres
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Klinik für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Disease (DZNE), Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - T G Liman
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Klinik für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
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