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Sharma S, Tiwari S, Yadav T, Saini L, Mittal A, Khera D, Garg PK, Khera PS. Magnetic resonance imaging patterns and perfusion changes of posterior reversible encephalopathy syndrome in children with clinical outcome correlation. Pediatr Radiol 2024:10.1007/s00247-024-06045-w. [PMID: 39249148 DOI: 10.1007/s00247-024-06045-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 08/21/2024] [Accepted: 08/22/2024] [Indexed: 09/10/2024]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) in children has a propensity towards atypical features on magnetic resonance (MR) imaging, with limited literature on perfusion changes and clinicoradiological correlation. OBJECTIVE We aimed to comprehensively study MR imaging patterns of pediatric PRES, including cerebral blood flow variations on arterial spin labeling, and looked for any MR biomarkers of poor clinical outcome. MATERIALS AND METHODS In this retrospective observational study conducted in a tertiary hospital setting, MR records over a 4-year period (May 2019 to May 2023) were systematically searched along with their clinical details. Patients with an age less than 18 years and a clinicoradiological constellation consistent with PRES were included. MR scans were analyzed by two neuroradiologists with 8 years' and 10 years' experience. Association was sought with poor clinical outcome (defined as modified Rankin Scale score at discharge of > 2). RESULTS A total of 45 patients (29 boys) were included in the study, with a mean age (± standard deviation) of 11.19 (± 4.53) years. On MR imaging, 95.6% of patients (n = 43) showed atypical features and/or atypical areas of involvement. The superior frontal sulcus (n = 18) was the most predominant MR pattern, and cerebellar involvement was not uncommon (n = 15). Unilateral involvement (n = 3), isolated central pattern (n = 1), and spinal cord involvement (PRES-SCI: n = 1) were also encountered. Brainstem involvement (n = 4) showed a characteristic "V-sign" of anterior medullary hyperintensity. Patchy restricted diffusion (46.6%), punctate hemorrhages (37.7%), and leptomeningeal contrast enhancement (36%) were not uncommon. Arterial spin labeling sequence (available in 24 patients) showed increased cerebral blood flow in the involved areas in 79.2% of patients. Univariate analysis showed a significant association of the presence of hemorrhage (P = 0.003), involvement of brainstem (P = 0.007), deep white matter (P = 0.008), and thalamus (P = 0.026) with poor clinical outcome. Multivariate regression analysis found that hemorrhage on MRI (P = 0.011, odds ratio 8) was an independent factor associated with poor clinical outcome. CONCLUSIONS The conventionally described atypical features in PRES are common in children and therefore may no longer be considered exceptions. Raised perfusion on arterial spin labeling sequence was seen in the majority of cases. Hemorrhage on MRI was an independent predictor of poor clinical outcome in pediatric PRES.
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Affiliation(s)
- Smily Sharma
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India, 342005
| | - Sarbesh Tiwari
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India, 342005.
| | - Taruna Yadav
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India, 342005
| | - Lokesh Saini
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Aliza Mittal
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Daisy Khera
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Pawan Kumar Garg
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India, 342005
| | - Pushpinder Singh Khera
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India, 342005
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Kumar M, Guin A, Singh A, Singh R, Tiwari A. Role of prazosin in patients with Guillain-Barré syndrome with sympathetic overactivity: A cohort study. Muscle Nerve 2024. [PMID: 39175215 DOI: 10.1002/mus.28236] [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: 02/22/2024] [Revised: 08/07/2024] [Accepted: 08/09/2024] [Indexed: 08/24/2024]
Abstract
INTRODUCTION/AIMS In Guillain-Barré syndrome (GBS), patients with dysautonomia demonstrate sympathetic overactivity (SO). This study assessed the role of prazosin (α1-blocker) in the management of SO. METHODS This cohort study was conducted from January 2022 to September 2023. Thirty-two GBS patients with SO received prazosin (2.5-10 mg three times a day) (prazosin group). For comparison, we included historical controls that included 33 GBS patients having SO with similar baseline characteristics, including median age and disability, who did not receive prazosin, from a GBS registry of patients admitted during February 2018-December 2021. The primary endpoint was days to resolution of SO. Secondary endpoints were daily fluctuations in the systolic (SBP) and diastolic blood pressure (DBP), duration of hospital stay, in-hospital mortality, and disability at 3 months. RESULTS The median ages of both the treatment and the control groups were 36 (IQR 25-49) years and 43 (66.2%) were males. The demographic and clinical parameters were comparable. Prazosin resulted in significantly earlier normalization of SO compared to the control group (median 15 vs. 20 days; p = .01). The mean fluctuations in the SBP and DBP at 15 days were significantly lower in the prazosin group. However, the duration of hospital stay and good recovery at 3 months were comparable. Three patients developed hypotension, while two patients died (ventilator-associated pneumonia) in the prazosin group. DISCUSSION This study provides new evidence supporting the role of prazosin in SO, and needs randomized trials to confirm our findings.
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Affiliation(s)
- Mritunjai Kumar
- Department of Neurology, All India Institute of Medical Sciences, Rishikesh, Uttrakhand, India
| | - Abhishek Guin
- Department of Neurology, All India Institute of Medical Sciences, Rishikesh, Uttrakhand, India
| | - Anu Singh
- Department of Neurology, All India Institute of Medical Sciences, Rishikesh, Uttrakhand, India
| | - Rajni Singh
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Rishikesh, Uttrakhand, India
| | - Ashutosh Tiwari
- Department of Neurology, All India Institute of Medical Sciences, Rishikesh, Uttrakhand, India
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Jeong DY, Shin YN, Ha SH, Chang JY, Kang DW, Kwon SU, Kim BJ. Association between renal insufficiency and lesion characteristics of posterior reversible encephalopathy syndrome. Neurol Sci 2024; 45:3907-3915. [PMID: 38480646 DOI: 10.1007/s10072-024-07446-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 03/03/2024] [Indexed: 07/18/2024]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is characterized by cerebral blood flow dysregulation and the blood-brain barrier (BBB) disruption. While renal insufficiency has been considered a factor in BBB fragility, the relationship between renal insufficiency and the PRES lesions volume remains unclear. METHODS This observational study was performed retrospectively. PRES patients were categorized into two groups with renal insufficiency, defined as an estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73m2 on the day of symptom occurrence. Lesion volume was measured using fluid-attenuated inversion recovery (FLAIR) imaging, and the brain was divided into nine regions. The volume of the parietal-occipital-temporal lobe was considered typical, while the other six regions were labeled as atypical. RESULTS The study included 200 patients, of whom 94 (47%) had renal insufficiency. Patients with renal insufficiency had a larger lesion volume (144.7 ± 125.2 cc) compared to those without renal insufficiency (110.5 ± 93.2 cc; p = 0.032); particularly in the atypical lesions volume (49.2 ± 65.0 vs. 29.2 ± 44.3 cc; p = 0.013). However, there was no difference in the reversibility of the lesions (35.2 ± 67.5 vs. 18.8 ± 33.4 cc; p = 0.129). Multiple regression analysis revealed that decreases in eGFR (β = -0.34, 95% CI -0.62-0.05, p = 0.020) were positively associated with total lesion volume. CONCLUSION Our findings suggest that PRES patients with renal insufficiency experience more severe lesion volumes, likely due to the atypical brain regions involvement. The lesions involving atypical regions may have a similar pathophysiology to typical lesions, as the PRES lesions reversibility was found to be similar between individuals with and without renal insufficiency.
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Affiliation(s)
- Dong Young Jeong
- School of Convergence Science and Technology, Pohang University of Science and Technology (POSTECH), Pohang, Republic of Korea
| | - Yea Na Shin
- Department of Family Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang Hee Ha
- Department of Neurology, Gil Medical Center, Gachon College of Medicine, Incheon, Republic of Korea
| | - Jun Young Chang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong-Wha Kang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sun U Kwon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Bum Joon Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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Takigawa K, Shima T, Kubara C, Akamine S, Utsumi S, Yoshino T, Minami M, Hayashi M, Matsuo Y, Kuriyama T, Yoneda R, Taniguchi S, Eto T. Fatal posterior reversible encephalopathy syndrome after blood transfusion in a patient with myelodysplastic syndromes. Transfusion 2024. [PMID: 39044568 DOI: 10.1111/trf.17968] [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: 05/30/2024] [Revised: 06/28/2024] [Accepted: 07/03/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is known as a transfusion-related complication with typically favorable prognosis and no report fatalities. Pathological evaluation of PRES is also scarce. CASE REPORT An 88-year-old female with myelodysplastic syndromes (MDS) attended our hospital because of a compression fracture and chronic heart failure with chronic anemia. While her hemoglobin levels improved from 4.6 to 8.0 g/dL and the pleural effusions substantially decreased following six units of red blood cell transfusion and diuretic therapy, a gradual decline in cognitive function and speech reduction was noted. PRES was diagnosed by magnetic resonance imaging of the head. Despite treatment of intensive supportive care, the patient fell into a coma by the 20th day and passed away on the 22nd day. Although the pathophysiological link between blood-transfusion-related PRES and its impact on survival is not fully understood, autopsy findings confirmed the diagnosis of PRES and revealed multiple cerebral hemorrhages that were not detected in earlier imaging studies. CONCLUSION This case highlights the importance of vigilant monitoring and management of PRES, especially in high-risk populations such as elderly patients with multiple comorbidities or those with thrombocytopenia. Further studies are needed to elucidate the mechanisms of PRES in patients with hematologic diseases.
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Affiliation(s)
- Ken Takigawa
- Department of Hematology, Hamanomachi Hospital, Fukuoka, Japan
| | - Takahiro Shima
- Department of Hematology, Hamanomachi Hospital, Fukuoka, Japan
- Department of Hematology, Kyushu University Hospital, Fukuoka, Japan
| | - Chiaki Kubara
- Department of Hematology, Hamanomachi Hospital, Fukuoka, Japan
| | - Shun Akamine
- Department of Pathology, Hamanomachi Hospital, Fukuoka, Japan
| | - Sae Utsumi
- Department of Hematology, Hamanomachi Hospital, Fukuoka, Japan
| | | | - Mariko Minami
- Department of Hematology, Hamanomachi Hospital, Fukuoka, Japan
| | | | - Yayoi Matsuo
- Department of Hematology, Hamanomachi Hospital, Fukuoka, Japan
| | - Takuro Kuriyama
- Department of Hematology, Hamanomachi Hospital, Fukuoka, Japan
| | - Reiko Yoneda
- Department of Pathology, Hamanomachi Hospital, Fukuoka, Japan
| | | | - Tetsuya Eto
- Department of Hematology, Hamanomachi Hospital, Fukuoka, Japan
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Largeau B, Bergeron S, Auger F, Salmon Gandonnière C, Jonville-Béra AP, Ehrmann S, Gautier S, Bordet R. Experimental Models of Posterior Reversible Encephalopathy Syndrome: A Review From Pathophysiology to Therapeutic Targets. Stroke 2024; 55:484-493. [PMID: 38126184 DOI: 10.1161/strokeaha.123.044533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiological entity characterized by nonspecific symptomatology (eg, headache, visual disturbances, encephalopathy, and seizures) and classically cortical and subcortical vasogenic edema predominantly affecting the parietooccipital region. PRES etiologies are usually dichotomized into toxic PRES (eg, antineoplastic drugs, illicit drugs) and clinical condition-associated PRES (eg, acute hypertension, dysimmune disorders). Although the pathophysiology of PRES remains elusive, 2 main pathogenic hypotheses have been suggested: cerebral hyperperfusion due to acute hypertension and cerebral hypoperfusion related to endothelial dysfunction. Research into the pathogenesis of PRES has emerged through the development of animal models in the last decade. The motivation for developing a suitable PRES model is 2-fold: to fill in knowledge gaps of the pathophysiological mechanisms involved, and to open new perspectives for clinical assessment of pharmacological targets to improve therapeutic management of PRES. All current models of PRES have a hypertensive background, on which other triggers (acute hypertension, inflammatory, drug toxicity) have been added to address specific facets of PRES (eg, seizures). The initial model consisted in inducing a reduced uterine perfusion pressure that mimics preeclampsia, a leading cause of PRES. More recently, a model of stroke-prone spontaneously hypertensive rats on high-salt diet, originally developed for hypertensive small vessel disease and vascular cognitive impairment, has been studied in PRES. This review aims to discuss, depending on the research objective, the benefits and limitations of current experimental approaches and thus to define the desirable characteristics for studying the pathophysiology of PRES and developing new therapies.
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Affiliation(s)
- Bérenger Largeau
- CHRU de Tours, Service de Pharmacosurveillance, Centre Régional de Pharmacovigilance Centre-Val de Loire, Tours, France (B.L.)
| | - Sandrine Bergeron
- Université de Lille, Institut National de la Santé et de la Recherche Médicale (INSERM), Lille Neuroscience & Cognition, Unité Mixte de Recherche (UMR) 1172, équipe Troubles Cognitifs Dégénératifs et Vasculaires, Centre Hospitalier Universitaire (CHU) de Lille, Service de Pharmacologie Médicale, Centre Régional de Pharmacovigilance, France (S.B., S.G., R.B.)
| | - Florent Auger
- Université de Lille, Centre National de la Recherche Scientifique (CNRS), INSERM, CHU Lille, Institut Pasteur de Lille, US 41, Unités Mixtes de Service 2014, Plateformes Lilloises en Biologie et Santé, Lille, France (F.A.)
| | - Charlotte Salmon Gandonnière
- CHRU de Tours, Service de Médecine Intensive Réanimation, réseau CRICS-TRIGGERSEP F-CRIN (Clinical Research in Intensive Care Sepsis Trial Group for Global Evaluation Research in Sepsis, a French Clinical Research Infrastructure Network) Research Network, Tours, France (C.S.G.)
| | - Annie-Pierre Jonville-Béra
- Université de Tours, Université de Nantes, INSERM, Methods in Patients-Centered Outcomes and Health Research (SPHERE), UMR 1246, CHRU de Tours, Service de Pharmacosurveillance, Centre Régional de Pharmacovigilance Centre-Val de Loire, Tours, France (A.-P.J.-B.)
| | - Stephan Ehrmann
- Université de Tours, INSERM, Centre d'étude des Pathologies Respiratoires (CEPR), UMR 1100, CHRU de Tours, Service de Médecine Intensive Réanimation, CIC 1415, réseau CRICS-TRIGGERSEP F-CRIN Research Network, Tours, France (S.E.)
| | - Sophie Gautier
- Université de Lille, Institut National de la Santé et de la Recherche Médicale (INSERM), Lille Neuroscience & Cognition, Unité Mixte de Recherche (UMR) 1172, équipe Troubles Cognitifs Dégénératifs et Vasculaires, Centre Hospitalier Universitaire (CHU) de Lille, Service de Pharmacologie Médicale, Centre Régional de Pharmacovigilance, France (S.B., S.G., R.B.)
| | - Régis Bordet
- Université de Lille, Institut National de la Santé et de la Recherche Médicale (INSERM), Lille Neuroscience & Cognition, Unité Mixte de Recherche (UMR) 1172, équipe Troubles Cognitifs Dégénératifs et Vasculaires, Centre Hospitalier Universitaire (CHU) de Lille, Service de Pharmacologie Médicale, Centre Régional de Pharmacovigilance, France (S.B., S.G., R.B.)
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Otite FO, Patel SD, Anikpezie N, Hoffman H, Beutler T, Akano EO, Aneni E, Lamikanra O, Osondu C, Wee C, Burke D, Albright KC, Latorre JG, Mejico L, Khandelwal P, Chaturvedi S. Demographic Disparities in the Incidence, Clinical Characteristics, and Outcome of Posterior Reversible Encephalopathy Syndrome in the United States. Neurology 2023; 101:e1554-e1559. [PMID: 37487751 PMCID: PMC10585693 DOI: 10.1212/wnl.0000000000207604] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 05/16/2023] [Indexed: 07/26/2023] Open
Abstract
OBJECTIVES To estimate age-specific, sex-specific, and race-specific incidence of posterior reversible encephalopathy syndrome (PRES) in the United States. METHODS We conducted a retrospective cohort study using the State Inpatient Database of Florida (2016-2019), Maryland (2016-2019), and New York (2016-2018). All new cases of PRES in adults (18 years or older) were combined with Census data to compute incidence. We evaluated the generalizability of incident estimates to the entire country using the 2016-2019 National Readmissions Database (NRD). RESULTS Across the study period, there were 3,716 incident hospitalizations for PRES in the selected states. The age-standardized and sex-standardized incidence of PRES was 2.7 (95% CI 2.5-2.8) cases/100,000/y. Incidence in female patients was >2 times that of male patients (3.7 vs 1.6 cases/100,000/y, p < 0.001). Incidence increased with age in both sexes (p-trend <0.001). Similar demographic distribution of first hospitalization for PRES was also noted in the entire country using the NRD. Age-standardized and sex-standardized PRES incidence in Black patients (4.2/100,000/y) was significantly greater than in Non-Hispanic White (2.7/100,000/y) and Hispanic patients (1.2/100,000/y) (p < 0.001 for pairwise comparisons). DISCUSSION The incidence of PRES in the United States is approximately 3/100,000/y, but incidence in female patients is >2 times that of male patients. PRES incidence is higher in Black compared with non-Hispanic White and Hispanic patients.
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Affiliation(s)
- Fadar Oliver Otite
- From the Department of Neurology (F.O.O., C.W., D.B., K.C.A., J.G.L., L.M.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurosurgery (S.D.P.), University of Connecticut, Hartford; Department of Population Health (N.A.), University of Mississippi Medical Center, Jackson, MS; Department of Neurosurgery (H.H., T.B.), SUNY Upstate Medical University, Syracuse, NY; Molecular Neuropharmacological Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Section of Cardiovascular Medicine (E.A.), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Department of Critical Care (O.L.), Springfield Clinic, IL; Baptist Health South Florida (C.O.), Miami; Departments of Neurology and Neurosurgery (P.K.), Rutgers University, Newark, NJ; and Department of Neurology (S.C.), University of Maryland, Baltimore.
| | - Smit D Patel
- From the Department of Neurology (F.O.O., C.W., D.B., K.C.A., J.G.L., L.M.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurosurgery (S.D.P.), University of Connecticut, Hartford; Department of Population Health (N.A.), University of Mississippi Medical Center, Jackson, MS; Department of Neurosurgery (H.H., T.B.), SUNY Upstate Medical University, Syracuse, NY; Molecular Neuropharmacological Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Section of Cardiovascular Medicine (E.A.), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Department of Critical Care (O.L.), Springfield Clinic, IL; Baptist Health South Florida (C.O.), Miami; Departments of Neurology and Neurosurgery (P.K.), Rutgers University, Newark, NJ; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Nnabuchi Anikpezie
- From the Department of Neurology (F.O.O., C.W., D.B., K.C.A., J.G.L., L.M.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurosurgery (S.D.P.), University of Connecticut, Hartford; Department of Population Health (N.A.), University of Mississippi Medical Center, Jackson, MS; Department of Neurosurgery (H.H., T.B.), SUNY Upstate Medical University, Syracuse, NY; Molecular Neuropharmacological Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Section of Cardiovascular Medicine (E.A.), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Department of Critical Care (O.L.), Springfield Clinic, IL; Baptist Health South Florida (C.O.), Miami; Departments of Neurology and Neurosurgery (P.K.), Rutgers University, Newark, NJ; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Haydn Hoffman
- From the Department of Neurology (F.O.O., C.W., D.B., K.C.A., J.G.L., L.M.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurosurgery (S.D.P.), University of Connecticut, Hartford; Department of Population Health (N.A.), University of Mississippi Medical Center, Jackson, MS; Department of Neurosurgery (H.H., T.B.), SUNY Upstate Medical University, Syracuse, NY; Molecular Neuropharmacological Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Section of Cardiovascular Medicine (E.A.), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Department of Critical Care (O.L.), Springfield Clinic, IL; Baptist Health South Florida (C.O.), Miami; Departments of Neurology and Neurosurgery (P.K.), Rutgers University, Newark, NJ; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Timothy Beutler
- From the Department of Neurology (F.O.O., C.W., D.B., K.C.A., J.G.L., L.M.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurosurgery (S.D.P.), University of Connecticut, Hartford; Department of Population Health (N.A.), University of Mississippi Medical Center, Jackson, MS; Department of Neurosurgery (H.H., T.B.), SUNY Upstate Medical University, Syracuse, NY; Molecular Neuropharmacological Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Section of Cardiovascular Medicine (E.A.), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Department of Critical Care (O.L.), Springfield Clinic, IL; Baptist Health South Florida (C.O.), Miami; Departments of Neurology and Neurosurgery (P.K.), Rutgers University, Newark, NJ; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Emmanuel Oladele Akano
- From the Department of Neurology (F.O.O., C.W., D.B., K.C.A., J.G.L., L.M.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurosurgery (S.D.P.), University of Connecticut, Hartford; Department of Population Health (N.A.), University of Mississippi Medical Center, Jackson, MS; Department of Neurosurgery (H.H., T.B.), SUNY Upstate Medical University, Syracuse, NY; Molecular Neuropharmacological Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Section of Cardiovascular Medicine (E.A.), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Department of Critical Care (O.L.), Springfield Clinic, IL; Baptist Health South Florida (C.O.), Miami; Departments of Neurology and Neurosurgery (P.K.), Rutgers University, Newark, NJ; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Ehimen Aneni
- From the Department of Neurology (F.O.O., C.W., D.B., K.C.A., J.G.L., L.M.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurosurgery (S.D.P.), University of Connecticut, Hartford; Department of Population Health (N.A.), University of Mississippi Medical Center, Jackson, MS; Department of Neurosurgery (H.H., T.B.), SUNY Upstate Medical University, Syracuse, NY; Molecular Neuropharmacological Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Section of Cardiovascular Medicine (E.A.), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Department of Critical Care (O.L.), Springfield Clinic, IL; Baptist Health South Florida (C.O.), Miami; Departments of Neurology and Neurosurgery (P.K.), Rutgers University, Newark, NJ; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Oluwatomi Lamikanra
- From the Department of Neurology (F.O.O., C.W., D.B., K.C.A., J.G.L., L.M.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurosurgery (S.D.P.), University of Connecticut, Hartford; Department of Population Health (N.A.), University of Mississippi Medical Center, Jackson, MS; Department of Neurosurgery (H.H., T.B.), SUNY Upstate Medical University, Syracuse, NY; Molecular Neuropharmacological Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Section of Cardiovascular Medicine (E.A.), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Department of Critical Care (O.L.), Springfield Clinic, IL; Baptist Health South Florida (C.O.), Miami; Departments of Neurology and Neurosurgery (P.K.), Rutgers University, Newark, NJ; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Chukwuemeka Osondu
- From the Department of Neurology (F.O.O., C.W., D.B., K.C.A., J.G.L., L.M.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurosurgery (S.D.P.), University of Connecticut, Hartford; Department of Population Health (N.A.), University of Mississippi Medical Center, Jackson, MS; Department of Neurosurgery (H.H., T.B.), SUNY Upstate Medical University, Syracuse, NY; Molecular Neuropharmacological Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Section of Cardiovascular Medicine (E.A.), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Department of Critical Care (O.L.), Springfield Clinic, IL; Baptist Health South Florida (C.O.), Miami; Departments of Neurology and Neurosurgery (P.K.), Rutgers University, Newark, NJ; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Claribel Wee
- From the Department of Neurology (F.O.O., C.W., D.B., K.C.A., J.G.L., L.M.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurosurgery (S.D.P.), University of Connecticut, Hartford; Department of Population Health (N.A.), University of Mississippi Medical Center, Jackson, MS; Department of Neurosurgery (H.H., T.B.), SUNY Upstate Medical University, Syracuse, NY; Molecular Neuropharmacological Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Section of Cardiovascular Medicine (E.A.), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Department of Critical Care (O.L.), Springfield Clinic, IL; Baptist Health South Florida (C.O.), Miami; Departments of Neurology and Neurosurgery (P.K.), Rutgers University, Newark, NJ; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Devin Burke
- From the Department of Neurology (F.O.O., C.W., D.B., K.C.A., J.G.L., L.M.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurosurgery (S.D.P.), University of Connecticut, Hartford; Department of Population Health (N.A.), University of Mississippi Medical Center, Jackson, MS; Department of Neurosurgery (H.H., T.B.), SUNY Upstate Medical University, Syracuse, NY; Molecular Neuropharmacological Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Section of Cardiovascular Medicine (E.A.), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Department of Critical Care (O.L.), Springfield Clinic, IL; Baptist Health South Florida (C.O.), Miami; Departments of Neurology and Neurosurgery (P.K.), Rutgers University, Newark, NJ; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Karen C Albright
- From the Department of Neurology (F.O.O., C.W., D.B., K.C.A., J.G.L., L.M.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurosurgery (S.D.P.), University of Connecticut, Hartford; Department of Population Health (N.A.), University of Mississippi Medical Center, Jackson, MS; Department of Neurosurgery (H.H., T.B.), SUNY Upstate Medical University, Syracuse, NY; Molecular Neuropharmacological Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Section of Cardiovascular Medicine (E.A.), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Department of Critical Care (O.L.), Springfield Clinic, IL; Baptist Health South Florida (C.O.), Miami; Departments of Neurology and Neurosurgery (P.K.), Rutgers University, Newark, NJ; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Julius G Latorre
- From the Department of Neurology (F.O.O., C.W., D.B., K.C.A., J.G.L., L.M.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurosurgery (S.D.P.), University of Connecticut, Hartford; Department of Population Health (N.A.), University of Mississippi Medical Center, Jackson, MS; Department of Neurosurgery (H.H., T.B.), SUNY Upstate Medical University, Syracuse, NY; Molecular Neuropharmacological Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Section of Cardiovascular Medicine (E.A.), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Department of Critical Care (O.L.), Springfield Clinic, IL; Baptist Health South Florida (C.O.), Miami; Departments of Neurology and Neurosurgery (P.K.), Rutgers University, Newark, NJ; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Luis Mejico
- From the Department of Neurology (F.O.O., C.W., D.B., K.C.A., J.G.L., L.M.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurosurgery (S.D.P.), University of Connecticut, Hartford; Department of Population Health (N.A.), University of Mississippi Medical Center, Jackson, MS; Department of Neurosurgery (H.H., T.B.), SUNY Upstate Medical University, Syracuse, NY; Molecular Neuropharmacological Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Section of Cardiovascular Medicine (E.A.), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Department of Critical Care (O.L.), Springfield Clinic, IL; Baptist Health South Florida (C.O.), Miami; Departments of Neurology and Neurosurgery (P.K.), Rutgers University, Newark, NJ; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Priyank Khandelwal
- From the Department of Neurology (F.O.O., C.W., D.B., K.C.A., J.G.L., L.M.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurosurgery (S.D.P.), University of Connecticut, Hartford; Department of Population Health (N.A.), University of Mississippi Medical Center, Jackson, MS; Department of Neurosurgery (H.H., T.B.), SUNY Upstate Medical University, Syracuse, NY; Molecular Neuropharmacological Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Section of Cardiovascular Medicine (E.A.), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Department of Critical Care (O.L.), Springfield Clinic, IL; Baptist Health South Florida (C.O.), Miami; Departments of Neurology and Neurosurgery (P.K.), Rutgers University, Newark, NJ; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Seemant Chaturvedi
- From the Department of Neurology (F.O.O., C.W., D.B., K.C.A., J.G.L., L.M.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurosurgery (S.D.P.), University of Connecticut, Hartford; Department of Population Health (N.A.), University of Mississippi Medical Center, Jackson, MS; Department of Neurosurgery (H.H., T.B.), SUNY Upstate Medical University, Syracuse, NY; Molecular Neuropharmacological Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Section of Cardiovascular Medicine (E.A.), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Department of Critical Care (O.L.), Springfield Clinic, IL; Baptist Health South Florida (C.O.), Miami; Departments of Neurology and Neurosurgery (P.K.), Rutgers University, Newark, NJ; and Department of Neurology (S.C.), University of Maryland, Baltimore
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7
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Schütze S, Drevets DA, Tauber SC, Nau R. Septic encephalopathy in the elderly - biomarkers of potential clinical utility. Front Cell Neurosci 2023; 17:1238149. [PMID: 37744876 PMCID: PMC10512712 DOI: 10.3389/fncel.2023.1238149] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 08/22/2023] [Indexed: 09/26/2023] Open
Abstract
Next to acute sickness behavior, septic encephalopathy is the most frequent involvement of the brain during infection. It is characterized by a cross-talk of pro-inflammatory cells across the blood-brain barrier, by microglial activation and leukocyte migration, but not by the entry of infecting organisms into the brain tissue. Septic encephalopathy is very frequent in older persons because of their limited cognitive reserve. The predominant clinical manifestation is delirium, whereas focal neurological signs and symptoms are absent. Electroencephalography is a very sensitive method to detect functional abnormalities, but these abnormalities are not specific for septic encephalopathy and of limited prognostic value. Routine cerebral imaging by computer tomography usually fails to visualize the subtle abnormalities produced by septic involvement of the brain. Magnetic resonance imaging is by far more sensitive to detect vasogenic edema, diffuse axonal injury or small ischemic lesions. Routine laboratory parameters most suitable to monitor sepsis, but not specific for septic encephalopathy, are C-reactive protein and procalcitonin. The additional measurement of interleukin (IL)-6, IL-8, IL-10 and tumor necrosis factor-α increases the accuracy to predict delirium and an unfavorable outcome. The most promising laboratory parameters to quantify neuronal and axonal injury caused by septic encephalopathy are neurofilament light chains (NfL) and S100B protein. Neuron-specific enolase (NSE) plasma concentrations are strongly influenced by hemolysis. We propose to determine NSE only in non-hemolytic plasma or serum samples for the estimation of outcome in septic encephalopathy.
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Affiliation(s)
- Sandra Schütze
- Department of Neuropathology, University Medicine Göttingen, Georg-August University Göttingen, Göttingen, Germany
- Department of Geriatrics, AGAPLESION Markus Krankenhaus, Frankfurt, Germany
| | - Douglas A. Drevets
- Infectious Diseases, Department of Internal Medicine, University of Oklahoma HSC, Oklahoma City, OK, United States
| | - Simone C. Tauber
- Department of Neurology, University Medicine Aachen, Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Roland Nau
- Department of Neuropathology, University Medicine Göttingen, Georg-August University Göttingen, Göttingen, Germany
- Department of Geriatrics Evangelisches Krankenhaus Göttingen-Weende, Göttingen, Germany
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Popa IL, Bălgrădean M, Costin M, Bobircă A, Bologa C, Armășelu T, Bobircă F, Croitoru A. Posterior Reversible Encephalopathy Syndrome in a Pediatric Patient with End-Stage Renal Disease. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10040731. [PMID: 37189980 DOI: 10.3390/children10040731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 04/03/2023] [Accepted: 04/13/2023] [Indexed: 05/17/2023]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinical and neuroimaging syndrome that can affect both children and adults and has variable etiology. It is clinically defined by headaches, consciousness disorders, seizures and visual disturbances. Early recognition (clinical and imaging) can lead to appropriate general measures to correct the underlying cause of PRES. In this paper, we report a case of PRES in an eight-year-old boy with bilateral renal hypoplasia and end-stage renal disease (ESRD).
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Affiliation(s)
- Ionela-Loredana Popa
- Department of Pediatric Nephrology, "M.S. Curie" Emergency Clinical Hospital for Children, 077120 Bucharest, Romania
| | - Mihaela Bălgrădean
- Department of Pediatric Nephrology, "M.S. Curie" Emergency Clinical Hospital for Children, 077120 Bucharest, Romania
- Department of Pediatrics, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Mariana Costin
- Department of Pediatric Nephrology, "M.S. Curie" Emergency Clinical Hospital for Children, 077120 Bucharest, Romania
- Department of Pediatrics, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Anca Bobircă
- Department of Internal Medicine and Rheumatology, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Internal Medicine and Rheumatology Department, Dr. Ion Cantacuzino Clinical Hospital, 011437 Bucharest, Romania
| | - Cristina Bologa
- Department of Pediatric Nephrology, "M.S. Curie" Emergency Clinical Hospital for Children, 077120 Bucharest, Romania
| | - Teodora Armășelu
- Department of Pediatric Nephrology, "M.S. Curie" Emergency Clinical Hospital for Children, 077120 Bucharest, Romania
| | - Florin Bobircă
- Department of Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Surgery Department, Dr. Ion Cantacuzino Clinical Hospital, 011437 Bucharest, Romania
| | - Anca Croitoru
- Department of Pediatric Nephrology, "M.S. Curie" Emergency Clinical Hospital for Children, 077120 Bucharest, Romania
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Bonura A, Iaccarino G, Rossi SS, Capone F, Motolese F, Calandrelli R, Di Lazzaro V, Pilato F. Posterior reversible encephalopathy syndrome and reversible cerebral vasoconstriction syndrome in patients with COVID-19 infection: is there a link? A systematic review and case report analysis. J Neurol 2023; 270:2826-2852. [PMID: 37014421 PMCID: PMC10071475 DOI: 10.1007/s00415-023-11684-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 02/26/2023] [Accepted: 03/21/2023] [Indexed: 04/05/2023]
Abstract
During the SARS-CoV2 pandemic, several cases of Posterior Reversible Encephalopathy Syndrome (PRES) and of Reversible Cerebral Vasoconstriction Syndrome (RCVS) in COVID-19 patients have been reported, but the link between these syndromes and COVID-19 is unclear. We performed a systematic review, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement to evaluate whether SARS-CoV2 infection or the drugs used to treat it could be deemed potential risk factors for PRES or RCVS. We performed a literature search. We found 70 articles (60 on PRES and 10 on RCVS) concerning n = 105 patients (n = 85 with PRES, n = 20 with RCVS). We analyzed the clinical characteristics of the two populations separately, then performed an inferential analysis to search for other independent risk factors. We found fewer than usual PRES-related (43.9%) and RCVS-related (45%) risk factors in patients with COVID-19. Such a low incidence of risk factors for PRES and RCVS might suggest the involvement of COVID-19 as an additional risk factor for both diseases due to its capability to cause endothelial dysfunction. We discuss the putative mechanisms of endothelial damage by SARS-CoV2 and antiviral drugs which may underlie the development of PRES and RCVS.
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Affiliation(s)
- Adriano Bonura
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
- Institute of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Gianmarco Iaccarino
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
- Institute of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Sergio Soeren Rossi
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
- Institute of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Fioravante Capone
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
- Institute of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Francesco Motolese
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
- Institute of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Rosalinda Calandrelli
- Institute of Radiology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 1, 00168, Rome, Italy
| | - Vincenzo Di Lazzaro
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
- Institute of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Fabio Pilato
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy.
- Institute of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy.
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10
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Clinical Features and Risk Factors of Mortality in Patients with Posterior Reversible Encephalopathy Syndrome. Behav Neurol 2022; 2022:9401661. [DOI: 10.1155/2022/9401661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 10/25/2022] [Indexed: 11/16/2022] Open
Abstract
Objective. Although the prognosis of posterior reversible encephalopathy syndrome (PRES) is usually favourable and most patients wholly recover, the disorder can result in death in some patients. To date, the data on clinical features and risk factors for death are still lacking; therefore, we aim to investigate the clinical features and long-term prognostic risk factors of PRES in the present study. Methods. The patients with PRES were identified from the First Affiliated Hospital of Zhengzhou University from June 2011 to June 2020. Clinical characteristics, laboratory tests, magnetic resonance imaging examinations, and treatment of all patients were analyzed retrospectively. All patients were followed up by telephone. Finally, the patients were divided into the survival group and death group for prognosis analysis. Results. A total of 92 patients with PRES were included; 84.8% of whom were female, with an average age of 25.4 (5–66) years at the onset of PRES. Epilepsy was the main clinical manifestation (72.8%). The in-hospital mortality rate was 2.17%. The 3-year all-cause survival rate for PRES patients was 86%. In univariate analysis, patients with systemic lupus erythematosus (
) and blood transfusion history within 1 month before onset (
), need for dialysis (
), nephritis (
), stroke (
), and heart failure (
) were associated with death. In multivariate analysis, we found that heart failure (
, 95% CI 0.020 to 0.441) and stroke (
, 95% CI 0.002 to 0.467) were independent risk factors for death in PRES patients, while pregnancy was a protective factor for death in PRES patients (
, 95% CI 1.446 to 44.006). Conclusions. Our results indicate that PRES could be considered as a sign of a very high-risk patient. We also demonstrated that heart failure and stroke were independent risk factors for death in patients with PRES; moreover, pregnancy was a protective factor.
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Garg A, Elmashala A, Roeder H. Early Readmissions After Hospitalization for Posterior Reversible Encephalopathy Syndrome. Neurology 2022; 99:e2072-e2080. [PMID: 35985829 DOI: 10.1212/wnl.0000000000201086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 06/24/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To evaluate the frequency, etiologies, and risk factors for 90-day readmissions after hospitalization for posterior reversible encephalopathy syndrome (PRES). METHODS Data were obtained from the Nationwide Readmissions Database 2016-2018. Patients with a primary diagnosis of PRES, survival to discharge, and known discharge disposition were included. The primary outcome was nonelective readmission within 90 days of discharge. Survival analysis was performed, and independent predictors of readmission were analyzed using multivariable Cox proportional hazards regression. RESULTS Based on the study inclusion criteria, 6,155 eligible patients were included (mean ± SD age: 55.9 ± 17.3 years, female: 71.0%). Nonelective readmission within 90 days of discharge occurred for 1,922 (31.2%) patients. Of these, 617 readmissions were due to PRES-related or neurologic etiologies and the remaining 1,305 readmissions were due to non-neurologic conditions. In multivariable analysis, age was inversely associated with the risk of readmission (hazards ratio [HR] 0.92 for every 10 years increase in age, 95% CI 0.88-0.97). Patients with diabetes (HR 1.21, 95% CI 1.04-1.42), systemic lupus erythematosus (HR 1.42, 95% CI 1.03-1.96), acute kidney injury (HR 1.28, 95% CI 1.11-1.47), and a higher Charlson comorbidity index score (HR 1.09, 95% CI 1.06-1.13) were more likely to be readmitted. Furthermore, patients admitted at large bed size hospitals (HR 1.19, 95% CI 1.03-1.39), those with a longer length of stay (HR 1.01, 95% CI: 1.00-1.02), and those not discharged to home (HR 1.33, 95% CI: 1.14-1.55) during the index hospitalization were also at a higher risk for readmission. DISCUSSION Nearly one-third of patients hospitalized because of PRES are readmitted within 90 days of discharge, and approximately one-third of these readmissions are due to PRES-related or neurologic etiologies. Younger age, a higher comorbidity burden, a longer length of hospital stay, and discharge disposition other than to home are independently associated with the risk of readmission.
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Affiliation(s)
- Aayushi Garg
- From the Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City.
| | - Amjad Elmashala
- From the Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City
| | - Hannah Roeder
- From the Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City
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Zhang Y, Liang B, Zhao C, Zhou Y, Yan C. Posterior reversible encephalopathy in a pregnant woman without preeclampsia or eclampsia: A case report. Medicine (Baltimore) 2022; 101:e30519. [PMID: 36086692 PMCID: PMC10980412 DOI: 10.1097/md.0000000000030519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/08/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND We report a case of a pregnant woman who presented posterior reversible encephalopathy syndrome (PRES) without pre-eclampsia, eclampsia, or any other common causes of PRES. METHODS A 32-year-old primigravida at 25 weeks and 4 days of gestation was admitted to neurology department because of suffering intermittent headache, hearing loss, memory loss with mental and behavioral disorder, and blurred vision for 1 month. She was healthy before without hypertension, migraine, or other medical or family history. Brain magnetic resonance imaging (MRI) revealed diffuse symmetrical high-signal intensity lesions in the white matter, medulla oblongata, without enhancement. After completely multidisciplinary discussion and with the family of the patient, she accepted termination of pregnancy. RESULTS After the operation, the patient improved symptomatically. The follow-up MRI showed a decrease of the white matter lesion after 3 months and complete recovery at postoperative 6 months. The patient returned to work without any neurological sequelae. CONCLUSION It might widen the cause spectrum of PRES that pregnancy itself without pre-eclampsia, eclampsia, or any other known risk factors could cause PRES. Pregnancy with acute or subacute leukoencephalopathy should be screened related causes and risk factors carefully. Hormonal fluctuations during the pregnancy might account for pregnancy-related PRES.
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Affiliation(s)
- Yi Zhang
- Department of Neurology, Rizhao Central Hospital, Shandong, China
| | - Bing Liang
- Department of Neurology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Cuiping Zhao
- Department of Neurology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Yi Zhou
- Department of Ultrasonic, Rizhao Hospital of Traditional Chinese Medicine, Rizhao, China
| | - Chuanzhu Yan
- Department of Neurology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
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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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14
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Hiremath SB, Massicotte-Tisluck K, Chakraborty S. Factors affecting hospitalization, imaging severity, and complications in posterior reversible encephalopathy syndrome. Neurol Sci 2022; 43:6461-6470. [DOI: 10.1007/s10072-022-06271-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 07/03/2022] [Indexed: 10/17/2022]
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15
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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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Belgrado E, Del Negro I, Bagatto D, Lorenzut S, Merlino G, Gigli GL, Valente M. Posterior Reversible Encephalopathy Syndrome in Guillain-Barré Syndrome: Just a Problem of Immunoglobulins? Controversy From Two Atypical Case Reports. Front Neurol 2022; 13:817295. [PMID: 35463144 PMCID: PMC9020620 DOI: 10.3389/fneur.2022.817295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background Posterior reversible encephalopathy syndrome (PRES), reversible cerebral vasoconstriction syndrome (RCVS), or the coexistence of these two entities shares similar risk factors and clinical features. For these conditions, a common origin has been supposed. Even if the majority of patients show a favorable course and a good prognosis, a small percentage of cases develop neurological complications. Up to date, only about 30 cases of PRES associated with Guillain-Barré syndrome (GBS) have been reported in the literature. Cases Here, we present two cases of a particularly aggressive PRES/RCVS overlap syndrome, associated with acute motor axonal neuropathy (AMAN) and acute inflammatory demyelinating polyneuropathy (AIDP) variants of GBS, respectively, presenting with similar initial clinical aspects and developing both an atypical and unfavorable outcome. On MRI examination, the first patient showed typical aspects of PRES, while, in the second case, radiological features were atypical and characterized by diffusion restriction on the apparent diffusion coefficient (ADC) map. The first patient demonstrated rapid worsening of clinical conditions until death; the second one manifested and maintained neurological deficits with a permanent disability. Conclusions We suggest that PRES may conceal RCVS aspects, especially in most severe cases or when associated with a dysimmune syndrome in which autoimmune system and endothelial dysfunction probably play a prominent role in the pathogenesis. Although the role of IVIg treatment in the pathogenesis of PRES has been proposed, we suggest that GBS itself should be considered an independent risk factor in developing PRES.
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Affiliation(s)
- Enrico Belgrado
- Neurology Unit, Azienda Sanitaria Universitaria Friuli Centrale, Udine University Hospital, Udine, Italy
| | - Ilaria Del Negro
- Clinical Neurology Unit, Azienda Sanitaria Universitaria Friuli Centrale, Udine University Hospital, Udine, Italy
- Department of Medicine (DAME), University of Udine, Udine, Italy
- *Correspondence: Ilaria Del Negro
| | - Daniele Bagatto
- Neuroradiology Unit, Department of Imaging, Azienda Sanitaria Universitaria Friuli Centrale, Udine University Hospital, Udine, Italy
| | - Simone Lorenzut
- Neurology Unit, Azienda Sanitaria Universitaria Friuli Centrale, Udine University Hospital, Udine, Italy
| | - Giovanni Merlino
- Clinical Neurology Unit, Azienda Sanitaria Universitaria Friuli Centrale, Udine University Hospital, Udine, Italy
| | - Gian L. Gigli
- Clinical Neurology Unit, Azienda Sanitaria Universitaria Friuli Centrale, Udine University Hospital, Udine, Italy
- Department of Medicine (DAME), University of Udine, Udine, Italy
| | - Mariarosaria Valente
- Clinical Neurology Unit, Azienda Sanitaria Universitaria Friuli Centrale, Udine University Hospital, Udine, Italy
- Department of Medicine (DAME), University of Udine, Udine, Italy
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17
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Deng T, Zhang X, Peng X, Peng H, He L, Hu Y. Clinical features and prognostic analysis of posterior reversible encephalopathy syndrome in children. Int J Dev Neurosci 2022; 82:349-360. [PMID: 35373858 DOI: 10.1002/jdn.10184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/05/2022] [Accepted: 04/01/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND We aimed to investigate the clinical features and prognosis of posterior reversible encephalopathy syndrome (PRES) in children. METHODS Clinical data of children with PRES diagnosed at the Children's Hospital of Chongqing Medical University from June 2015 to May 2019 were retrospectively analyzed. RESULTS The study enrolled 47 patients with a mean age at diagnosis of 8.79 ± 3.72 years (range, 2-15 years). PRES causes included renal disorder (29/47), hematological disease (13/47), and hypertension (5/47). PRES manifested as seizure (43/47), headache (28/47), visual impairment (18/47), dizziness (18/47), vomiting (18/47), and mental and behavioral abnormalities (17/47). Forty-six children had hypertension (46/47) at PRES onset. Magnetic resonance imaging (MRI) mainly involved the parietal and occipital lobes (42/47), 38 cases were mild (38/47), 7 were moderate (7/47), and 2 were severe (2/47). The clinical symptoms of 41 patients (41/47) were relieved within 1-2 weeks. Thirty-seven children were followed up for 7-54 months (modified Rankin Scale). Twenty-five children had favorable outcomes (25/37). Twelve children had adverse outcomes (12/37), including epilepsy, disorders of consciousness, visual impairment, and mental decline. Analysis of single factors revealed that severity on MRI, length of in-hospital stay, and mental and behavioral abnormalities were related to adverse outcomes after PRES. Analysis of multiple factors revealed that severity on MRI and length of in-hospital stay were independent risk factors for PRES. CONCLUSION Pediatric PRES is a clinical radiographic syndrome with multiple etiologies. Most patients have a good prognosis. Severity on MRI and length of in-hospital stay are independent risk factors.
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Affiliation(s)
- Ting Deng
- Department of Neurology Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders. Chongqing Key Laboratory of Pediatrics, China.,Xi'an Children's Hospital, China
| | - Xinyu Zhang
- Department of Neurology Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders. Chongqing Key Laboratory of Pediatrics, China
| | - Xiaoling Peng
- Division of Science and Technology, Beijing Normal University-Hongkong Baptist University United International College, China
| | - Hailun Peng
- Department of Neurology Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders. Chongqing Key Laboratory of Pediatrics, China.,Department of Radiology, Children's Hospital of Chongqing Medical University, China
| | - Ling He
- Department of Neurology Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders. Chongqing Key Laboratory of Pediatrics, China.,Department of Radiology, Children's Hospital of Chongqing Medical University, China
| | - Yue Hu
- Department of Neurology Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders. Chongqing Key Laboratory of Pediatrics, China
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18
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Posterior reversible encephalopathy syndrome: characteristics, diagnostic accuracy, prognostic factors and long-term outcome in a paediatric population. Acta Neurol Belg 2022; 122:485-495. [PMID: 34693510 DOI: 10.1007/s13760-021-01819-7] [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: 05/05/2021] [Accepted: 09/27/2021] [Indexed: 11/27/2022]
Abstract
Posterior reversible leukoencephalopathy syndrome (PRES) is a rare entity among children, characterised by acute neurological symptoms and radiological findings. The role of clinical symptoms and neuroimaging in predicting the prognosis of PRES have not been well-characterised. A retrospective descriptive study of children with PRES, admitted to a Paediatric Intensive Care Unit during a 10-year period, was performed to describe its characteristics, compare the accuracy of computed tomography (CT) scan and MRI on diagnosis and identify prognostic factors on paediatric population. Sixteen cases were identified. Most patients (13; 81%) presented underlying disorders, including malignancies (5; 31%), chronic kidney disease (3; 19%) and post-transplant status (3; 19%). Hypertension (15; 94%) was the most common trigger. All patients had seizures, 9 patients (56%) altered state of consciousness, 8 (50%) headache. CT scan was performed in 15 patients (94%) and MRI in 13 (81%); 1 patient underwent only MRI. MRI allows the identification of new areas of vasogenic oedema and a correct diagnosis of PRES when CT scan was inconclusive. Two patients (13%) remained with neurological sequelae and one died. In two patients (13%) cognitive disorders (specific learning disorder, intellectual disability, motor tic disorder) were diagnosed during follow-up period. Clinical presentation was not statistically associated with outcome. Also, atypical neuroimaging (haemorrhagic and unilateral lesions) were not statistically related with poor neurological or cognitive outcome. However, prospective studies with a larger cohort are needed to establish prognostic factors of PRES in the paediatric population.
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19
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Orhun G, Sencer S, Tüzün E, Bebek N, Ergin Özcan P, Barburoğlu M, Günver MG, Esen F. Posterior Reversible Encephalopathy in Sepsis-Associated Encephalopathy: Experience from a Single Center. Neurocrit Care 2022; 36:372-386. [PMID: 35133605 DOI: 10.1007/s12028-021-01433-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 12/29/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sepsis-associated encephalopathy (SAE) is frequently encountered in sepsis and is often accompanied by neuroimaging findings indicating ischemia, hemorrhage, and edema. Posterior reversible encephalopathy syndrome (PRES) has been vastly underrecognized in previously reported cohorts of patients with sepsis and SAE. Our aim was to determine the prevalence and distinguishing clinical, neuroimaging, and electroencephalography features of PRES in SAE. METHODS In this prospective observational study, patients with radiologically identified PRES were selected from a consecutively enrolled cohort of 156 patients with SAE and assessed for neurological outcome using the extended Glasgow Outcome Scale for 12 months. Patients with SAE and PRES and other types of brain lesions were compared in terms of clinical and diagnostic workup features. RESULTS Fourteen of 156 patients (8.9%) were determined to be radiologically compatible with PRES, whereas 48 patients displayed other types of acute brain lesions. Patients with PRES often showed lesions in atypical regions, including frontal lobes, the corpus callosum, and the basal ganglia. Source of infection was mostly gram-negative bacteria originating from pneumonia or intraabdominal infections. Patients with PRES were not different from other patients with SAE with brain lesions in terms of features of sepsis and neurological outcome. However, patients with PRES showed increased prevalence of seizures and intraabdominal source of infection. CONCLUSIONS PRES is highly prevalent in SAE, often encompasses unusual brain regions, and usually presents with generalized seizures. Patients with SAE and PRES do not appear to have distinguishing clinical and diagnostic workup features. However, generalized seizures may serve as warning signs for presence of PRES in patients with SAE.
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Affiliation(s)
- Günseli Orhun
- Department of Anesthesiology and Intensive Care, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
| | - Serra Sencer
- Department of Neuroradiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Erdem Tüzün
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Nerses Bebek
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Perihan Ergin Özcan
- Department of Anesthesiology and Intensive Care, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mehmet Barburoğlu
- Department of Neuroradiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | | | - Figen Esen
- Department of Anesthesiology and Intensive Care, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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20
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Triplett JD, Kutlubaev MA, Kermode AG, Hardy T. Posterior reversible encephalopathy syndrome (PRES): diagnosis and management. Pract Neurol 2022; 22:183-189. [PMID: 35046115 DOI: 10.1136/practneurol-2021-003194] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2021] [Indexed: 01/31/2023]
Abstract
Posterior reversible encephalopathy syndrome (PRES) may present with diverse clinical symptoms including visual disturbance, headache, seizures and impaired consciousness. MRI shows oedema, usually involving the posterior subcortical regions. Triggering factors include hypertension, pre-eclampsia/eclampsia, renal failure, cytotoxic agents and autoimmune conditions. The mechanism underlying PRES is not certain, but endothelial dysfunction is implicated. Treatment is supportive and involves correcting the underlying cause and managing associated complications, such as seizures. Although most patients recover, PRES is not always reversible and may be associated with considerable morbidity and even mortality.
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Affiliation(s)
- James D Triplett
- Neurology, Concord Hospital, Concord, New South Wales, Australia
| | | | - Allan G Kermode
- Perron Institute, University of Western Australia, Perth, Western Australia, Australia.,CMMIT, Murdoch University, Murdoch, Western Australia, Australia
| | - Todd Hardy
- Neurology, Concord Hospital, Concord, New South Wales, Australia.,Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
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21
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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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22
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Shiraishi W. Blood transfusion-induced posterior reversible encephalopathy syndrome presenting severe brain atrophy: A report of two cases. Clin Case Rep 2022; 10:e05286. [PMID: 35035968 PMCID: PMC8752457 DOI: 10.1002/ccr3.5286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 12/09/2021] [Accepted: 12/22/2021] [Indexed: 11/08/2022] Open
Abstract
Several cases of posterior reversible encephalopathy syndrome (PRES) after blood transfusion have been reported, but the long-term prognosis is unknown. Here, we report two cases of blood transfusion-associated PRES with severe brain atrophy at 1 year after onset. We report the case with a discussion of pathological mechanisms.
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Affiliation(s)
- Wataru Shiraishi
- Department of NeurologyKokura Memorial HospitalKitakyushu CityJapan
- Shiraishi Internal Medicine ClinicNogata CityJapan
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23
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Posterior reversible encephalopathy syndrome (PRES) due to acute hypertension in children: 12 years single-center experience. Acta Neurol Belg 2021; 121:1583-1589. [PMID: 32632712 DOI: 10.1007/s13760-020-01423-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 06/29/2020] [Indexed: 12/26/2022]
Abstract
The objective of the study is to evaluate the clinical and neuroradiological findings, the risk factors for recurrence and the prognosis in patients with posterior reversible encephalopathy syndrome developed secondary to acute hypertension in children. The study was conducted between 2008 and 2019 at Mersin University Faculty of Medicine. A total of 49 episodes were evaluated retrospectively in 38 patients with PRES secondary to acute hypertension. The demographic data, etiology, and clinical and neuroradiological findings were recorded. Twenty-one (55.3%) patients were female; the mean age was 11.8 years. The etiology of acute hypertension in 29 (76.3%) patients was end-stage renal disease (ESRD). The most common clinical findings were seizure (81.6%) and altered consciousness (79.6%). Status epilepticus developed in eight (16.3%) episodes. MRI lesions were atypical in 33 episodes (67.3%). In eight (21%) patients, PRES recurred. Irreversible brain damage was detected after PRES in three (7.8%) patients. C-reactive protein and erythrocyte sedimentation rate were elevated in 82.2% and 71.4% of the episodes, respectively. A statistically significant relationship was found between the recurrence, the duration of hospitalization at the PICU, SE and the occurrence of irreversible lesion (p = 0.013, p = 0.015, p = 0.001 respectively). Also, there were statistically significant relationships between recurrence and ESRD; epilepsy and recurrences; SE and irreversible brain damage (p = 0.02, p = 0.012, p = 0.025 respectively). Although PRES is usually known to have a good prognosis, the mortality and morbidity rates may increase in the long-term follow-up as in our study. In this study, the etiology, the presence of status epilepticus, PICU history, atypical MRI lesions and increased inflammatory markers were found to be important for the prognosis in PRES.
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24
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Dietz N, Mufti Z, Yousaf M, Brown R, Counts C, Bjurström MF, Williams BJ, Robertson D. Acute posterior reversible encephalopathy syndrome (PRES) in setting of interferon-beta use: case presentation with reduction of edema in 72 h after cessation of interferon-beta therapy with sub-clinical inflammation. BMC Neurol 2021; 21:445. [PMID: 34758765 PMCID: PMC8582210 DOI: 10.1186/s12883-021-02471-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 10/25/2021] [Indexed: 12/05/2022] Open
Abstract
Background Posterior reversible encephalopathy syndrome (PRES) represents a transient change in mental status with associated vasogenic edema of cortical and subcortical brain structures. It is often attributed to multifactorial etiology including hypertension and altered hemodynamics and disruption of vessel integrity. Patients with autoimmune disease and certain immune modulator therapies are at greater risk. Case presentation A 54-year-old female with past medical history of well-controlled multiple sclerosis on interferon-beta since 2013, presented with witnessed tonic colonic seizure. She also was noted to demonstrate left gaze deviation and left-sided hemiparesis. MRI fluid-attenuated inversion recovery sequence showed hyperintensity of the subcortical U fibers, concentrated in the occipital, parietal lobes and frontal lobes. Systolic blood pressure was 160 mmHg on arrival. The patient was started on seizure prophylxis and Interferon beta was discontinued. The patient’s mentation, seizures and hemiapresis significantly improved in next 72 h with tight blood pressure control, and had notble improvement on MRI imaging and inflammatory markers. Lumbar puncture CSF results were devoid of infectious and autoimmune pathology. Conclusions A middle-aged female with multiple sclerosis who was on chronic IFN-beta presented to the emergency room with a witnessed tonic-clonic seizure, with MRI T2 FLAIR imaging consistent with PRES. She had notable clinical improvement with decreased edema on imaging and improved inflammatory markers 72 h after cessation of IFN-beta therapy.
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Affiliation(s)
- Nicholas Dietz
- Department of Neurosurgery, University of Louisville, 400 Abraham Flexner Way, Louisville, KY, 40202, USA.
| | - Zarmina Mufti
- Department of Neurology, 530 S Jackson St, Louisville, KY, 40202, USA
| | - Muhammed Yousaf
- Department of Neurology, 530 S Jackson St, Louisville, KY, 40202, USA
| | - Randal Brown
- Department of Neurology, 530 S Jackson St, Louisville, KY, 40202, USA
| | - Christopher Counts
- Department of Neurosurgery, University of Louisville, 400 Abraham Flexner Way, Louisville, KY, 40202, USA
| | - Martin F Bjurström
- Department of Anesthesiology and Intensive Care, Skane University Hospital, Lund, Sweden
| | - Brian J Williams
- Department of Neurosurgery, University of Louisville, 400 Abraham Flexner Way, Louisville, KY, 40202, USA
| | - David Robertson
- Department of Neurology, 530 S Jackson St, Louisville, KY, 40202, USA
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Clinical Presentation and Risk Factors for Poor Outcomes Among Adult Patients With Posterior Reversible Encephalopathy Syndrome: A Retrospective Cohort Study. Neurologist 2021; 25:162-167. [PMID: 33181724 DOI: 10.1097/nrl.0000000000000294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is an acute neurological condition with unknown global incidence, variable clinical presentation, and prognosis. OBJECTIVES To describe a cohort of patients with PRES with a focus on brain magnetic resonance imaging (MRI) patterns and their relationship with short-term clinical outcomes. METHODS Retrospective cohort study. The authors included patients if they were older than 15 years and had a PRES diagnosis on the basis of a positive brain MRI at any time during the in-hospital stay. RESULTS Forty-four patients were included in the present analysis. The median age was 57 years (interquartile range, 32.0-68.5) and 70.5% were women. Hypertension (59.1%), history of transplantation (27.3%), previous chemotherapy (27.3%), chronic renal failure (38.6%), and autoimmune disease (15%) were the main comorbid conditions present. The classic triad of seizures, headache, and visual impairment was present in 18.0% of the cases. Eighty-six percent of patients were admitted to the intensive care unit, with 36.0% needing invasive life support. Brain MRI showed a dominant parieto-occipital pattern in 26 patients, whereas cytotoxic edema and bleeding were present in 27.3% and 29.6%, respectively. In-hospital mortality was 11.4%. The median modified Rankin Scale at hospital discharge was 1 (0-2.5). Risk factors associated with low modified Rankin Scale scores were: headache, visual impairment, and parieto-occipital pattern. Decreased level of consciousness and mechanical ventilation requirement were associated with greater discharge disability. CONCLUSIONS Characteristic symptoms and signs of PRES and classic MRI patterns are associated with better clinical outcomes.
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Gurumukhani JK, Patel HD, Patel DM, Patel MV, Patel MM, Mahuwala ZK, Desai J. Posterior Reversible Encephalopathy Syndrome Following Blood Transfusion: A Rare Case Report with Literature Review. Open Neurol J 2021. [DOI: 10.2174/1874205x02115010031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background:
Posterior reversible encephalopathy syndrome (PRES) is clinicoradiological disease entity characterized by headache, seizures, altered sensorium and corticalvisual loss with characteristic MRI features of subcortical white matter hyperintensities on T2W imaging. Though hypertension is a traditional hallmark of PRES, uncommon causes without hypertension have been described. We report an unusual such case without hypertension, precipitated by red cell transfusion.
Case Presentation:
A 40 years female received six units of packed cell transfusion for severe anemia (Hemoglobin 3.0 Gm %) transfused over 8 hours. She was having menorrhagia and was operated on for a hysterectomy. She developed a headache on the second postoperative day for five days and no cause was revealed in spite of extensive workup, including MRI brain and CSF study. On the sixth day, she had recurrent seizures followed by altered sensorium in the absence of hypertension. Her repeat MRI brain findings were consistent with PRES.
Conclusion:
We reviewed 25 cases, including the present one as PRES after the blood transfusion. 24 were females, and 16 of 19 developed PRES in the course of chronic anemia lasting over 1 month. Anemia was severe in 18 of 25 cases, with haemoglobin (Hb) levels < 4.0 Gm%. In 16 of 20 cases, Hb levels increased to 5 g/dl by red cell blood transfusion until the onset of PRES. On MRI brain, 23 of 25 cases showed vasogenic edema and 3 of 25 cases showed an irreversible neurological deficit. When treating severe chronic anemia rapid correction of Hb with blood transfusion, one should consider a possibility of PRES in post-transfusion neurological symptoms in spite of normal diagnostic workup.
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Ali K, Karan A, Biswah S, Teelucksingh S, Mohammed NB. Posterior Reversible Encephalopathy Syndrome: Tips for Diagnosis and Treatment. Cureus 2021; 13:e14087. [PMID: 33903844 PMCID: PMC8064425 DOI: 10.7759/cureus.14087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Often described as a clinico-radiological entity, posterior reversible encephalopathy syndrome (PRES) is being increasingly diagnosed nowadays. However, mystery still surrounds its exact etiology. Though there are no standardized diagnostic criteria for this syndrome, there is a consistent feature associated with it: brain vasogenic edema in combination with neurotoxicity. The nonspecific nature of this condition leaves room for the diagnosis to be overlooked, leading to delays in providing appropriate treatment and unfavorable patient outcomes. PRES is associated with a variety of medical conditions including hypertension, eclampsia, autoimmune conditions, renal failure, sepsis, and an immunocompromised state, such as that secondary to the use of immunosuppressive therapy, human immunodeficiency virus (HIV), and organ transplants. Treatment by a multidisciplinary team and prompt identification and reversal of the underlying cause can lead to beneficial outcomes, as in the case we present in this report.
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Affiliation(s)
- Kabeer Ali
- Internal Medicine, Eric Williams Medical Sciences Complex, Champs Fleurs, TTO
| | - Abhinav Karan
- Internal Medicine, Medical Associates Hospital, St. Joseph, TTO
| | - Shivonne Biswah
- Internal Medicine, Eric Williams Medical Sciences Complex, Champs Fleurs, TTO
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28
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Cognitive Sequelae of Central-Variant Posterior Reversible Encephalopathy Syndrome (PRES). Case Rep Neurol Med 2021; 2021:8850316. [PMID: 33628545 PMCID: PMC7884114 DOI: 10.1155/2021/8850316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/15/2020] [Accepted: 01/27/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction Although the posterior reversible encephalopathy syndrome (PRES) is often associated with headache and visual changes, central-variant PRES can be difficult to clinically diagnose in a patient with alteration of consciousness. Central-variant PRES has been previously described in the literature affecting subcortical white matter and the brainstem. Case Presentation. We describe a case presenting with hypertension (192/98) and altered level of consciousness requiring intubation. She was ultimately found to have extensive symmetric cortical and subcortical edema, with extensive involvement of bilateral thalami, consistent with central-variant PRES. Her mentation rapidly improved with blood pressure management. Confirmation of the diagnosis of central-variant PRES was made on repeat brain imaging. Our case is unique in demonstrating dramatic central white matter changes and their reversibility on repeat imaging six days later. Finally, persistent cognitive deficits at follow-up four months later are described. Conclusion Atypical presentations of PRES, involving alterations in levels of consciousness, can be difficult to clinically diagnose. A thorough differential diagnosis is even more important in cases of PRES with atypical imaging. Recognition of the diagnostic patterns of PRES on brain imaging, with prompt reversal of the causative factors, is crucial for the appropriate care of these patients. The long-term sequelae, which could include cognitive deficits, are poorly studied and understood.
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Dawood H, Nasir S, Ahmed M, O'Brien C, Dawood M. Posterior Reversible Encephalopathy Syndrome Secondary to Varicella Encephalitis. Cureus 2021; 13:e12484. [PMID: 33564499 PMCID: PMC7861057 DOI: 10.7759/cureus.12484] [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: 11/16/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a rapidly progressive neurologic condition presenting with typical symptoms including headache, nausea, vomiting, altered mental status, and visual defects. Neuroimaging profile, particularly magnetic resonance imaging (MRI), is the most important tool for diagnosis. The most commonly reported etiological factors include hypertensive emergency and renal disease. We describe a 67-year-old lady who developed clinical and radiological characteristics of PRES secondary to Varicella encephalitis.
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Affiliation(s)
| | - Saad Nasir
- Internal Medicine, United Medical and Dental College, Creek General Hospital, Karachi, PAK
| | - Mushtaq Ahmed
- Pediatrics, Our Lady of Lourdes Hospital, Drogheda, IRL
| | | | - Mustafa Dawood
- Nephrology, Emory University School of Medicine, Atlanta, USA
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Khan IR, Pai V, Mundada P, Sitoh YY, Purohit B. Detecting the Uncommon Imaging Manifestations of Posterior Reversible Encephalopathy Syndrome (PRES) in Adults: a Comprehensive Illustrated Guide for the Trainee Radiologist. Curr Probl Diagn Radiol 2020; 51:98-111. [PMID: 33257096 DOI: 10.1067/j.cpradiol.2020.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/28/2020] [Accepted: 11/09/2020] [Indexed: 12/11/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) has traditionally been described as a reversible leukoencephalopathy with a distinct pattern of posteriorly distributed vasogenic oedema involving the subcortical regions of parietal and occipital lobes. PRES commonly occurs in the setting of hypertensive emergencies, pre-eclampsia/eclampsia, impaired renal function, and immunosuppressive therapy. The various clinical presentations of PRES include encephalopathy, seizures, headache, visual, and focal neurological deficits. As knowledge of this entity grows, the range of clinical, and radiological features is seen to be much broader than originally described. The brain oedema may not always be posteriorly distributed and the syndrome may not be uniformly reversible. Of special note are some uncommon imaging features (unilateral cerebral involvement, and isolated posterior fossa involvement) and also some uncommon complications (haemorrhage, cytotoxic oedema, and vasoconstriction). These red herrings may lead to potential diagnostic challenges and pitfalls especially for trainee radiologists, who often read these scans in an emergency setting. Early and accurate diagnosis is crucial for prompt optimum management, thereby avoiding residual morbidity. This review article focusses on the atypical radiological features of PRES in adults with extensive case-based imaging examples. A brief description of the pathophysiology, clinical, and classic radiological features of PRES has also been included. A tabulated summary of potential mimics with diagnostic pearls is provided to highlight pertinent take home points and to serve as an easy guide for day-to-day clinical practice.
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Affiliation(s)
- Iram R Khan
- Department of Neuroradiology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore
| | - Vivek Pai
- Department of Neuroradiology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore
| | - Pravin Mundada
- Department of Diagnostic and Interventional Radiology, Raffles Hospital, 585 North Bridge Rd, Singapore
| | - Yih Yian Sitoh
- Department of Neuroradiology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore
| | - Bela Purohit
- Department of Neuroradiology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore.
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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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Hafez HA, Ragab I, Sedky M, Shams M, Youssef A, Refaat A, Habib E, Sidhom I. Patterns, risk factors and outcome predictors of posterior reversible encephalopathy syndrome in pediatric cancer patients. Leuk Lymphoma 2020; 62:462-468. [PMID: 33063564 DOI: 10.1080/10428194.2020.1832658] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The purpose of this study was to assess the clinical and radiological patterns and outcome predictors of posterior reversible encephalopathy syndrome (PRES) in pediatric cancer patients. A retrospective study included patients who developed PRES during their treatment at the Children's Cancer Hospital Egypt. A total of 50 patients developed PRES. Leukemia and lymphoma were the commonest diagnoses (64%). Regarding the MRI findings, occipital affection was the most common (92%), followed by frontal and temporal lobes involvement in 32% and 22% respectively and advanced PRES was described in 8 patients. Of the whole patients, 80% had complete clinical resolution and 60% showed complete radiological resolution at 2 weeks' evaluation and 2 patients died out of PRES. Unfavorable outcome was associated with those who had motor dysfunction, status epilepticus at presentation, frontal lobe and thalamic affection and atypical PRES. PRES might present in atypical sites with poor outcome including death.
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Affiliation(s)
- Hanafy A Hafez
- Department of Pediatric Oncology, National Cancer institute, Cairo University, Cairo, Egypt.,Department of Pediatric Oncology, Children's Cancer Hospital Egypt, Cairo, Egypt
| | - Iman Ragab
- Pediatric Department, Hematology-Oncology Unit, Ain Shams University, Cairo, Egypt
| | - Mohamed Sedky
- Department of Pediatric Oncology, Children's Cancer Hospital Egypt, Cairo, Egypt
| | - Marwa Shams
- Pediatric Department, Hematology-Oncology Unit, Ain Shams University, Cairo, Egypt
| | - Ayda Youssef
- Radiology Department, Children's Cancer Hospital Egypt, Cairo, Egypt
| | - Amal Refaat
- Radiology Department, Children's Cancer Hospital Egypt, Cairo, Egypt
| | - Elsaeed Habib
- Department of Pediatric Oncology, Children's Cancer Hospital Egypt, Cairo, Egypt.,Pediatric Department, Hematology-Oncology Unit, Ain Shams University, Cairo, Egypt
| | - Iman Sidhom
- Department of Pediatric Oncology, National Cancer institute, Cairo University, Cairo, Egypt.,Department of Pediatric Oncology, Children's Cancer Hospital Egypt, Cairo, Egypt
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Hun M, Tian J, Xie M, She Z, Abdirahman AS, Han P, Wan W, Wen C. Analysis of Risk Factors Associated With Poor Outcome in Posterior Reversible Encephalopathy Syndrome After Treatment in Children: Systematic Review and Meta-Analysis. Front Neurol 2020; 11:938. [PMID: 32982945 PMCID: PMC7479335 DOI: 10.3389/fneur.2020.00938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/20/2020] [Indexed: 12/15/2022] Open
Abstract
Objective: Chemotherapy and hematopoietic stem cell transplantation (HSCT) play important roles in clinical etiology, symptoms, signs, imaging findings, and biochemical parameters for inducing posterior reversible encephalopathy syndrome (PRES) in pediatric oncologic diseases. We aimed to evaluate various risk factors of pediatric oncologic diseases after conducting chemotherapy and HSCT to induce PRES for predicting the clinical prognosis frequency. Methods: The literature was performed on PubMed, Web of Science, and Embase databases to recognize the qualified studies. The odds ratios (ORs) of related risk factors and their corresponding 95% confidence intervals (CIs) were used to compute the pooled assessments of the outcomes. Results: Six studies were included in the meta-analysis, involving 828 records. The risk of female children has a significantly higher incidence than male children in oncologic age groups of PRES. Children over the age of 10 years old in oncologic age groups develop a significantly increased risk of PRES. Acute graft-versus-host disease (GVHD) has a significant promotion effect on the occurrence of PRES. Hypertension can promote the occurrence of PRES in children. The risk of PRES in immunodeficient children increases significantly. Children with sickle cell disease (SCD) have a significantly increased risk of PRES. The risk of PRES in children with T-cell leukemia rises considerably. The central nervous system (CNS) leukemia/involvement has a significant role in promoting the occurrence of PRES in children. The pooled OR for the factors male, ≥ 10 years old of age, acute GVHD, hypertension, immunodeficiency, SCD, T-cell leukemia, CNS leukemia/involvement was 0.66 (95% CI: 0.58, 0.76; P < 0.00001), 2.06 (95% CI: 1.23, 3.43; P < 0.006), 1.32 (95% CI: 1.14, 1.53; P < 0.0003), 8.84 (95% CI: 7.57, 10.32; P < 0.00001), 2.72 (95% CI: 1.81, 4.08; P < 0.00001), 2.87 (95% CI: 2.15, 3.83; P < 0.00001), 2.84 (95% CI: 1.65, 4.88; P < 0.0002), and 3.13 (95% CI: 1.43, 6.84; P < 0.004), respectively. Conclusions: The result of this meta-analysis suggests that female children, age over 10 years old, acute GVHD, hypertension, immunodeficiency, SCD, T-cell leukemia, and CNS leukemia/involvement are likely to have the poor outcome in pediatric oncologic/hematologic diseases in PRES.
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Affiliation(s)
- Marady Hun
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Jidong Tian
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Min Xie
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Zhou She
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Amin Sheikh Abdirahman
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Phanna Han
- Department of Ophthalmology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Wuqing Wan
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Chuan Wen
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
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Parasher A, Jhamb R. Posterior reversible encephalopathy syndrome (PRES): presentation, diagnosis and treatment. Postgrad Med J 2020; 96:623-628. [PMID: 32467104 DOI: 10.1136/postgradmedj-2020-137706] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/09/2020] [Accepted: 05/10/2020] [Indexed: 11/03/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a neurological disorder which is characterised by variable symptoms, which include visual disturbances, headache, vomiting, seizures and altered consciousness. The exact pathophysiology of PRES has not been completely explained, but hypertension and endothelial injury seem to be almost always present. Vasoconstriction resulting in vasogenic and cytotoxic edema is suspected to be responsible for the clinical symptoms as well as the neuro-radiological presentation. On imaging studies, Symmetrical white matter abnormalities suggestive of edema are seen in the computer tomography (CT) and magnetic resonance imaging (MRI) scans, commonly but not exclusively in the posterior parieto-occipital regions of the cerebral hemispheres. The management is chiefly concerned with stabilization of the patient, adequate and prompt control of blood pressure, prevention of seizures and timely caesarean section in obstetric cases with pre-eclampsia/eclampsia. In conclusion, persistently elevated blood pressures remain the chief culprit for the clinical symptoms as well as the neurological deficits. Early diagnosis by diffusion weighted MRI scans, and differentiation from other causes of altered sensorium i.e. seizures, meningitis and psychosis, is extremely important to initiate treatment and prevent further complications. Although most cases resolve successfully and carry a favorable prognosis, patients with inadequate therapeutic support or delay in treatment may not project a positive outcome.
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Affiliation(s)
- Anant Parasher
- Medicine, Guru Teg Bahadur Hospital, New Delhi, India .,Medicine, Guru Teg Bahadur Hospital, New Delhi, India
| | - Rajat Jhamb
- Medicine, Guru Teg Bahadur Hospital, New Delhi, India
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Zappia F, Verzicco I, Simoni R, Ferrari M, Coghi P, Bozzetti F, Cannone V, Volpi R, Cabassi A. Posterior reversible encephalopathy syndrome in an oncological normotensive patient: evidence for a pathogenic role of concomitant low magnesium serum levels and chemotherapy treatment. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:365-372. [PMID: 32420975 PMCID: PMC7569613 DOI: 10.23750/abm.v91i2.8685] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 07/21/2019] [Indexed: 12/12/2022]
Abstract
Background: Posterior reversible encephalopathy (PRES) is a rare syndrome characterized by headache, confusion, seizures, visual changes and white matter edema at radiological imaging. Its pathophysiology is not clarified and different causes, including uncontrolled hypertension, eclampsia, chemotherapy and hypomagnesemia have been suggested. Case report: A woman affected by stage IV breast cancer with lower extremity deep vein thrombosis treated with low-molecular-weight-heparin, currently in therapy with Palbociclib/Fulvestrant (antiCDK4 and 6/estrogen receptor antagonist) but previously treated with several other chemotherapy lines (including VEGF inhibitor bevacizumab), was admitted to our Internal Medicine department because of ascites and abdominal pain. She was treated with diuretics (and paracentesis). Recently (six-month earlier) a pan-encephalic radiotherapy was done because of brain and skull metastasis. Among blood tests, low serum levels of hypomagnesemia were observed. She developed PRES that rapidly progressed to lethargy, unresponsiveness till coma without changes in blood pressure. Magnetic Resonance Imaging study showed bilateral parieto-occipital edema and a thrombosis of left transverse and sigmoid sinuses. Anti-edema therapy, intravenous supplementation of magnesium and decoagulation were started, with complete and rapid recovery (within 18 hours) of clinical and radiologic changes. Conclusions: PRES diagnosis was based on the rapid clinical recovery after antiedema treatment and magnesium supplementation. Low magnesium level related to both diuretic and Fulvestrant/Palbociclib therapies and recent radiotherapy can represent potential mechanisms favouring PRES development. The previous bevacizumab treatment may also be involved as a PRES predisposing factor. The concomitant occurrence of cerebral thrombosis can have precipitated the clinical situation. (www.actabiomedica.it)
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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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Takaoka Y, Akaho R, Inada K, Muraoka H, Hokama C, Inoue A, Nishimura K. <p>Posterior Reversible Encephalopathy Syndrome Due to Acute Water Intoxication in a Patient with Schizophrenia</p>. Int Med Case Rep J 2020; 13:117-121. [PMID: 32308504 PMCID: PMC7150669 DOI: 10.2147/imcrj.s237430] [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: 11/05/2019] [Accepted: 02/26/2020] [Indexed: 11/23/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinical syndrome that presents as transient cerebral edema (vasogenic edema), usually on a background of hypertensive encephalopathy, puerperal eclampsia, or immunosuppressant drug use. We describe a case of PRES that arose in the context of a psychiatric disorder. The patient was a 26-year-old woman with schizophrenia who was hospitalized upon falling into a catatonic stupor and then suffered acute anxiety leading to impulsive polydipsia and subsequent water intoxication. She lost consciousness, and brain magnetic resonance imaging revealed a high density area, primarily affecting the cortex and subcortical white matter in areas in the occipital and parietal lobes, leading to the diagnosis. We did not treat the hyponatremia by means of aggressive sodium supplementation but rather balanced the extracellular fluid by continuous infusion of isotonic electrolyte replacement fluid. The patient’s level of consciousness improved gradually, but a total 141 days passed before hospital discharge was appropriate. The prognosis for PRES is generally favorable, but irreversible neurological damage can occur. We believe, therefore, that brain magnetic resonance imaging should be performed promptly whenever PRES is suspected and that timely, appropriate treatment is of utmost importance. If PRES is observed in a psychiatric patient, it is important to investigate whether the condition might have been caused by water intoxication and to treat the condition accordingly.
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Affiliation(s)
- Yohei Takaoka
- Department of Psychiatry, Tokyo Women’s Medical University, Tokyo, Japan
- Department of Psychiatry, Kuki Suzunoki Hospital, Kuki, Saitama, Japan
| | - Rie Akaho
- Department of Psychiatry, Tokyo Women’s Medical University, Tokyo, Japan
- Correspondence: Rie Akaho Department of Psychiatry, Tokyo Women’s Medical University, Tokyo, Japan Email
| | - Ken Inada
- Department of Psychiatry, Tokyo Women’s Medical University, Tokyo, Japan
| | - Hiroyuki Muraoka
- Department of Psychiatry, Tokyo Women’s Medical University, Tokyo, Japan
| | - Choryo Hokama
- Department of Psychiatry, Tokyo Women’s Medical University, Tokyo, Japan
| | - Atsuko Inoue
- Department of Psychiatry, Tokyo Women’s Medical University, Tokyo, Japan
| | - Katsuji Nishimura
- Department of Psychiatry, Tokyo Women’s Medical University, Tokyo, Japan
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Hinduja A. Posterior Reversible Encephalopathy Syndrome: Clinical Features and Outcome. Front Neurol 2020; 11:71. [PMID: 32117030 PMCID: PMC7034490 DOI: 10.3389/fneur.2020.00071] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/21/2020] [Indexed: 01/24/2023] Open
Abstract
Background: Posterior reversible encephalopathy syndrome (PRES) is an acute neurotoxic syndrome that is characterized by a spectrum neurological and radiological feature from various risk factors. Common neurological symptoms includes headache, impairment in level of consciousness, seizures, visual disturbances, and focal neurological deficits. Common triggering factors include blood pressure fluctuations, renal failure, eclampsia, exposure to immunosuppressive or cytotoxic agents and autoimmune disorders. The classic radiographic findings include bilateral subcortical vasogenic edema predominantly affecting the parieto-occipital regions but atypical features include involvement of other regions, cortical involvement, restricted diffusion, hemorrhage, contrast enhancement. This review is aimed to summarize the updated knowledge on the typical and atypical clinical and imaging features, prognostic markers and identify gaps in literature for future research. Methods: Systematic literature review using PUBMED search from 1990 to 2019 was performed using terms PRES was performed. Results: While clinical and radiographic reversibility is common, long-standing morbidity and mortality can occur in severe forms. In patients with malignant forms of PRES, aggressive care has markedly reduced mortality and improved functional outcomes. Although seizures were common, epilepsy is rare. Various factors that have been associated with poor outcome include altered sensorium, hypertensive etiology, hyperglycemia, longer time to control the causative factor, elevated C reactive protein, coagulopathy, extensive cerebral edema, and hemorrhage on imaging. Conclusion: Large prospective studies that accurately predict factors that are associated with poor outcomes, determine the pathophysiology, and targeted therapy are required.
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Affiliation(s)
- Archana Hinduja
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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Pilato F, Distefano M, Calandrelli R. Posterior Reversible Encephalopathy Syndrome and Reversible Cerebral Vasoconstriction Syndrome: Clinical and Radiological Considerations. Front Neurol 2020; 11:34. [PMID: 32117007 PMCID: PMC7033494 DOI: 10.3389/fneur.2020.00034] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/10/2020] [Indexed: 01/14/2023] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS) are relatively uncommon neurological disorders, but their detection has been increasing mainly due to clinical awareness and spreading of magnetic resonance imaging (MRI). Because these syndromes share some common clinical and radiologic features and occasionally occur in the same patient, misdiagnosis may occur. PRES is characterized by varied neurological symptoms including headache, impaired visual acuity or visual field deficit, confusion, disorders of consciousness, seizures, and motor deficits often associated to peculiar neuroradiological pattern even if uncommon localization and ischemic or hemorrhagic lesions were described. RCVS is a group of diseases typically associated with severe headaches and reversible segmental vasoconstriction of cerebral arteries, often complicated by ischemic or hemorrhagic stroke. Pathophysiological basis of PRES and RCVS are still debated but, because they share some risk factors and clinical features, a possible common origin has been supposed. Clinical course is usually self-limiting, but prognosis may fluctuate from complete recovery to death due to complications of ischemic stroke or intracranial hemorrhage. Neuroradiological techniques such as digital angiography and MRI are helpful in the diagnostic pathway and a possible prognostic role of MRI has been suggested. This review will serve to summarize clinical, neuroradiological features and controversies underlying both syndromes that may mislead the diagnostic pathway and their possible relationship with pathophysiology, clinical course, and prognosis.
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Affiliation(s)
- Fabio Pilato
- Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy.,UOC Neurologia, Dipartimento di Scienze dell'invecchiamento, Neurologiche, Ortopediche e Della Testa-Collo, Rome, Italy
| | | | - Rosalinda Calandrelli
- Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy.,UOC Radiologia e Neuroradiologia, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Rome, Italy
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Gandini J, Manto M, Charette N. Delayed Posterior Reversible Leukoencephalopathy Syndrome Triggered by FLOT Chemotherapy. Front Neurol 2020; 10:1405. [PMID: 32082236 PMCID: PMC7002563 DOI: 10.3389/fneur.2019.01405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 12/23/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jordi Gandini
- Department of Neurology, CHU-Charleroi, Charleroi, Belgium
| | - Mario Manto
- Department of Neurology, CHU-Charleroi, Charleroi, Belgium
- Service des Neurosciences, University of Mons, Mons, Belgium
- *Correspondence: Mario Manto
| | - Nicolas Charette
- Department of Gastroenterology, CHU-Charleroi, Charleroi, Belgium
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Chen TH. Childhood Posterior Reversible Encephalopathy Syndrome: Clinicoradiological Characteristics, Managements, and Outcome. Front Pediatr 2020; 8:585. [PMID: 33042923 PMCID: PMC7518237 DOI: 10.3389/fped.2020.00585] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 08/07/2020] [Indexed: 12/15/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a novel clinicoradiological syndrome characterized by convulsions, headache, altered mentality, and impaired vision, which are usually accompanied by hypertension. As its nomination, PRES is usually diagnosed according to the presence of typical neuroimage showing vasogenic edema predominately involving the posterior brain area. With the widespread utilization of magnetic resonance imaging (MRI), PRES is becoming more perceptible in different medical fields. Compared to adult cases, childhood PRES seems to have a broader clinical and neuroradiological spectrum. PRES can be associated with various underlying comorbidities, medication use, and therapeutic modalities in children with diverse neurological manifestations. Moreover, pediatric patients with PRES have a more significant propensity for atypical MRI findings beyond the typically posterior cerebral areas. The knowledge of typical and atypical presentations in children is essential to avoid misdiagnosing or missing PRES, which is a potentially treatable entity. Early supportive care is the mainstay of treatment, with particular attention to the treatment of hypertension with rigorous attention to all body systems. Prompt identification and symptom-directed management are imperative to achieve a reversible prognosis in childhood PRES. Future studies specially designed for the child population are required to determine potential outcome predictors, and further, to develop novel strategies of neuroprotection in childhood PRES.
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Affiliation(s)
- Tai-Heng Chen
- Division of Pediatric Emergency, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,School of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Section of Neurobiology, Department of Biological Sciences, University of Southern California, Los Angeles, CA, United States.,Ph.D. Program in Translational Medicine, Graduate Institute of Clinical Medicine, Kaohsiung Medical University and Academia Sinica, Taipei, Taiwan
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42
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Chen TH. Childhood Posterior Reversible Encephalopathy Syndrome: Clinicoradiological Characteristics, Managements, and Outcome. Front Pediatr 2020. [PMID: 33042923 DOI: 10.3389/fped.2020.0058534(8):494-500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a novel clinicoradiological syndrome characterized by convulsions, headache, altered mentality, and impaired vision, which are usually accompanied by hypertension. As its nomination, PRES is usually diagnosed according to the presence of typical neuroimage showing vasogenic edema predominately involving the posterior brain area. With the widespread utilization of magnetic resonance imaging (MRI), PRES is becoming more perceptible in different medical fields. Compared to adult cases, childhood PRES seems to have a broader clinical and neuroradiological spectrum. PRES can be associated with various underlying comorbidities, medication use, and therapeutic modalities in children with diverse neurological manifestations. Moreover, pediatric patients with PRES have a more significant propensity for atypical MRI findings beyond the typically posterior cerebral areas. The knowledge of typical and atypical presentations in children is essential to avoid misdiagnosing or missing PRES, which is a potentially treatable entity. Early supportive care is the mainstay of treatment, with particular attention to the treatment of hypertension with rigorous attention to all body systems. Prompt identification and symptom-directed management are imperative to achieve a reversible prognosis in childhood PRES. Future studies specially designed for the child population are required to determine potential outcome predictors, and further, to develop novel strategies of neuroprotection in childhood PRES.
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Affiliation(s)
- Tai-Heng Chen
- Division of Pediatric Emergency, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,School of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Section of Neurobiology, Department of Biological Sciences, University of Southern California, Los Angeles, CA, United States.,Ph.D. Program in Translational Medicine, Graduate Institute of Clinical Medicine, Kaohsiung Medical University and Academia Sinica, Taipei, Taiwan
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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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Acute radiological pattern and outcome in posterior reversible encephalopathy syndrome patients. Clin Neurol Neurosurg 2019; 185:105459. [PMID: 31445327 DOI: 10.1016/j.clineuro.2019.105459] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 06/30/2019] [Accepted: 08/04/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Posterior reversible encephalopathy syndrome (PRES) is a neurological disorder of acute or subacute onset characterized by varied neurological symptoms including headache, impaired visual acuity or visual field deficits, confusion, disorders of consciousness, seizures, and motor neurological deficits. Even if recognition of severe forms of PRES has improved, mainly due to magnetic resonance imaging, pathogenesis is still unclear and management of these patients remains challenging. Moreover, prognosis is unpredictable varying from complete recovery to death and factors related to prognosis are still lacking. We studied early magnetic resonance imaging characteristics and their relationships with prognosis. PATIENTS AND METHODS We performed a retrospective analysis in patients with clinical and neuroradiological charateristics of PRES performing magnetic resonance of the brain within 2 days of symptoms onset. RESULTS After reviewing site database of magnetic resonance imaging and clinical records compatible with PRES, 157 patients were selected. After imaging reviewing, 25 patients with clinical and neuroradiological diagnosis of PRES were enrolled, 22 (88%) females. Mean age of enrolled patients at presentation was 44.4+18.4 years (range, 21-84 years). Patients were classified according to neuroradiological characteristics such as ischemic lesions, distribution and severity of edema, hemorrhage and contrast enhancement. In our group 23 patients (92%) showed an almost complete recovery but 2 patients (8%) died during hospitalization. Outcome was significantly related with hypointensity on ADC (p = 0.002) and CE (p < 0.001). CONCLUSION Early MR features may be helpful in suggesting prognosis. Moreover, neuroimaging at the early stage of PRES may give new insights in pathophysiological mechanisms underlying brain damage and neurological impairment.
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Recurrent posterior reversible encephalopathy syndrome in an HIV-HCV coinfected liver transplant recipient. AIDS 2019; 33:1679-1681. [PMID: 31305337 DOI: 10.1097/qad.0000000000002258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Nakamura Y, Sugino M, Tsukahara A, Nakazawa H, Yamamoto N, Arawaka S. Posterior reversible encephalopathy syndrome with extensive cytotoxic edema after blood transfusion: a case report and literature review. BMC Neurol 2018; 18:190. [PMID: 30419835 PMCID: PMC6231260 DOI: 10.1186/s12883-018-1194-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Accepted: 10/31/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is described as a clinical-radiological disease entity with good prognosis. In brain MRI, PRES generally presents with vasogenic edema. Although PRES is induced by various causes, a small number of PRES cases have occurred after red cell blood transfusion. It is unclear whether there are characteristic features in PRES after blood transfusion. CASE PRESENTATION Here, we report a case of 75-year-old Japanese woman who had acute exacerbation of subacute anemia by bleeding from gastric ulcer. After receiving a red cell blood transfusion, she showed disturbance of consciousness with extensive cytotoxic and small vasogenic edema in the occipitoparietal area on brain MRI. She was diagnosed as PRES and suffered irreversible impairments of visual acuity and fields in both eyes. We summarized and discussed clinical features of cases with PRES after blood transfusion. CONCLUSIONS A total of 21 cases including the present one have been reported as PRES after blood transfusion. Of the cases, 20 of 21 were female, and 15 of 17 developed PRES in the course of chronic anemia lasting over 1 month. Anemia was severe in 15 of 20 cases, with hemoglobin levels < 3.5 g/dl. In 14 of 17 cases, hemoglobin levels increased to 5 g/dl by red cell blood transfusion until the onset of PRES. On brain MRI, 2 of 21 cases showed cytotoxic edema and 3 of 21 cases showed irreversible neurological disturbance. In this patient, the occurrence of PRES in subacute anemia and the presence of extensive cytotoxic brain edema with irreversible neurological deficits were characteristic points. When treating severe anemia, even with a subacute progression, we should consider a possibility that PRES occurs after blood transfusion with extensive cytotoxic brain edema and irreversible neurological changes.
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Affiliation(s)
- Yoshitsugu Nakamura
- Division of Neurology, Aino Hospital, 11-18 Takadacho, Osaka, Ibaraki, 567-0011, Japan. .,Division of Neurology, Department of Internal Medicine IV, Osaka Medical College, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan.
| | - Masakazu Sugino
- Division of Neurology, Aino Hospital, 11-18 Takadacho, Osaka, Ibaraki, 567-0011, Japan.,Division of Neurology, Department of Internal Medicine IV, Osaka Medical College, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan
| | - Akihiro Tsukahara
- Division of Neurology, Aino Hospital, 11-18 Takadacho, Osaka, Ibaraki, 567-0011, Japan.,Division of Neurology, Department of Internal Medicine IV, Osaka Medical College, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan
| | - Hiroko Nakazawa
- Division of Internal Medicine, Aino Hospital, 11-18 Takadacho, Osaka, Ibaraki, 567-0011, Japan
| | - Naomune Yamamoto
- Division of Internal Medicine, Aino Hospital, 11-18 Takadacho, Osaka, Ibaraki, 567-0011, Japan
| | - Shigeki Arawaka
- Division of Neurology, Department of Internal Medicine IV, Osaka Medical College, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan
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Mustafa KN, Qasem U, Al-Ryalat NT, Bsisu IK. Rituximab-associated posterior reversible encephalopathy syndrome. Int J Rheum Dis 2018; 22:160-165. [PMID: 30398015 DOI: 10.1111/1756-185x.13427] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 04/26/2018] [Accepted: 09/28/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Khader N Mustafa
- Division of Rheumatology, Department of Internal Medicine, Jordan University Hospital, University of Jordan, Amman, Jordan
| | - Ula Qasem
- Division of Rheumatology, Department of Internal Medicine, Jordan University Hospital, University of Jordan, Amman, Jordan
| | - Nosaiba T Al-Ryalat
- Department of Radiology, Jordan University Hospital, University of Jordan, Amman, Jordan
| | - Isam K Bsisu
- School of Medicine, Jordan University Hospital, University of Jordan, Amman, Jordan
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Chen Z, Zhang G, Lerner A, Wang AH, Gao B, Liu J. Risk factors for poor outcome in posterior reversible encephalopathy syndrome: systematic review and meta-analysis. Quant Imaging Med Surg 2018; 8:421-432. [PMID: 29928607 DOI: 10.21037/qims.2018.05.07] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The roles of clinical etiology and symptoms, imaging findings and biochemical parameters in predicting the prognosis of posterior reversible encephalopathy syndrome (PRES) have not been well-characterized. We perform a meta-analysis of all published studies to assess the value of various risk factors in predicting the prognosis of PRES. Methods Searches of the PubMed, EMBASE, Cochrane Library, and Web of Science databases were performed to identify the eligible studies. The odds ratios (ORs) with their corresponding 95% confidence interval (CI) for related risk factors were used to calculate the pooled estimates of the outcomes. Results Six studies with 448 cases were included in the meta-analysis. Hemorrhage was associated with high risk for poor outcome in patients with PRES. Toxemia of pregnancy (pre-eclampsia/eclampsia) was associated with improved outcome in PRES patients. Cytotoxic edema was noted to be related to poor outcome, but did not show statistical significance. The pooled OR for hemorrhage, pre-eclampsia/eclampsia, cytotoxic edema was 4.93 (95% CI: 3.94-6.17; P<0.00001), 0.24 (95% CI: 0.15-0.40; P<0.00001) and 2.59 (95% CI: 0.84-7.99; P=0.10), respectively. Conclusions PRES patients with hemorrhage or cytotoxic edema are likely to have poor outcomes. Pre-eclampsia/eclampsia is associated with reduced risk of poor outcome in patients with PRES.
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Affiliation(s)
- Zheng Chen
- Department of Radiology, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, China.,Department of Radiology, Yantai Yuhuangding Hospital, Yantai 264000, China
| | - Gang Zhang
- Department of Radiology, Yantai Yuhuangding Hospital, Yantai 264000, China
| | - Alexander Lerner
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - An-Hui Wang
- Department of Epidemiology, School of Public Health, The Fourth Military Medical University, Xi'an 710032, China
| | - Bo Gao
- Department of Radiology, Yantai Yuhuangding Hospital, Yantai 264000, China
| | - Jie Liu
- Department of Neurosurgery, Yantai Yuhuangding Hospital, Yantai 264000, China
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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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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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