Reversible posterior leukoencephalopathy syndrome after blood transfusion in a patient with end-stage renal disease

Pediatric Posterior Reversible Encephalopathy Syndrome: A Review With Emphasis on Neuroimaging Characteristics

Posterior reversible encephalopathy syndrome (PRES) is a neurological disorder characterized by the sudden onset of seizures, headaches, and visual disturbances. Its exact cause is unknown, but several triggers and associated conditions are identified, including high blood pressure, kidney dysfunction, and various medications. Magnetic resonance imaging (MRI) plays a crucial role in diagnosis due to its high sensitivity and specificity for detecting characteristic features. Pediatric PRES exhibit age-dependent differences in triggers, radiological findings, and clinical course. The lesions typically involve the posterior cortical and subcortical white matter, but atypical locations and features are also observed. While generally reversible with appropriate treatment, PRES carries a risk of permanent neurological damage. Despite increasing cases, the current literature on pediatric PRES remains limited. This review highlights the need for further research to understand the mechanisms, delineate distinct clinical and radiological features, and develop precise diagnostic and management strategies for pediatric patients.

Posterior Reversible Encephalopathy Syndrome Following Blood Transfusion: A Rare Case Report with Literature Review

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.

Blood-transfusion-related posterior reversible encephalopathy syndrome - A description of a new case and review of the literature

Posterior reversible encephalopathy syndrome (PRES) is a neurological syndrome associated with headache, altered mental status, seizures, and visual disturbances and characterized by white matter vasogenic edema affecting predominantly the posterior occipital and parietal lobes of the brain. Neurological complications of blood transfusion are uncommon, and blood-transfusion-related PRES is seldom reported. We report here one such case of PRES. A 61-year-old Asian woman with chronic anemia presented with a history of fall, causing fracture of the left femur neck. As her hemoglobin was 5 g per deciliter, she was transfused with four units of packed cells in three consecutive days. At the time of admission, she was alert, normotensive, and afebrile. Later, she developed mild headache and had a generalized tonic-clonic seizure. Her brain magnetic resonance (MR) imaging showed edema in bilateral frontal lobes and parieto-occipital lobes with normal MR venogram, consistent with PRES. We described her disorder as blood-transfusion-related PRES. Immunologic, as well as non-immunologic complications of blood transfusion, are known but, PRES is rare. Cumulative effects of blood transfusion on blood flow, blood viscosity, endothelial dysfunction leads to blood-brain barrier dysfunction, which culminates into vasogenic edema and vasoconstriction despite normal systemic blood pressure, leading to blood-transfusion-related PRES.

Etiologies, Cerebral Vasomotion, and Endothelial Dysfunction in the Pathophysiology of Posterior Reversible Encephalopathy Syndrome in Pediatric Patients

The posterior reversible encephalopathy syndrome was characterized by Hinchey and colleagues in the 1990s. The condition frequently afflicts patients suffering from hematologic and solid organ malignancy and individuals undergoing transplantation. Cases are more frequently described in the adult population compared with children. In the pediatric population, malignancy, transplantation, renal disease, and hypertension represent the most common etiologies. Theories on pathogenesis have centered upon cerebrovascular dysautoregulation with increases in blood–brain barrier permeability. This generates vasogenic edema of the cerebral parenchyma and consequent neurologic deficits. The parietal and occipital lobes are affected with greatest prevalence, though frontal and temporal lobe involvement is frequent, and that of the contents of the infratentorial posterior cranial fossa are occasionally described. The clinical presentation involves a characteristic constellation of neurologic signs and symptoms, most typically inclusive of headache, visual-field disturbances, abnormalities of visual acuity, and seizures. Supportive care, withdrawal of the offending agent, antihypertensive therapy, and prophylactic anticonvulsants affect convalescence in majority of cases. The principal challenge lies in identifying the responsible agent precipitating the condition in patients with malignancy and those having undergone transplantation and thus deciding which medication among a multidrug treatment regimen to withhold, the duration of drug cessation required to effect clinical resolution, and the safety of resuming treatment with the compound. We accordingly reviewed and evaluated the literature discussing the posterior reversible encephalopathy syndrome in children.

Epidemiology, Comorbidities, and Outcomes of Posterior Reversible Encephalopathy Syndrome in Children in the United States

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) is an increasingly recognized entity with certain identified predisposing factors in children. However, the actual incidence, comorbidities, outcomes, and hospitalization charges among children (aged less than 20 years) in the United States are largely unknown.

METHODS

We analyzed the Kids' Inpatient Database for incidence of PRES-related hospitalizations, associated diagnoses, in-hospital outcomes, and charges for children in the United States in 2016. We report demographics, risk factors, discharge status, mortality, length of stay, and hospitalization charges.

RESULTS

In 2016, 825 pediatric hospitalizations related to PRES were captured in the Kids' Inpatient Database. Hospital discharges including solid organ transplant, bone marrow transplant, hypertension, renal disorder, primary immunodeficiency, malignancy, sepsis, severe sepsis, systemic connective tissue disorder, blood transfusion, hypomagnesemia, and sickle cell anemia were queried for presence of PRES. The majority of patients were discharged home. We found that PRES-related hospitalizations were significantly associated with increased length of stay and hospitalization charges in 2016 (P < 0.001). A mortality rate of 3.2% was found in PRES-related hospitalizations when compared with 0.4% in non-PRES hospitalizations (P < 0.001).

CONCLUSION

PRES accounted for 0.04% of the hospitalizations in this database. Hypertension and the presence of a renal disorder are the most significant risk factors found to be associated with PRES. The presence of PRES was associated with a significant increase in hospitalization charges and increased length of stay.

Posterior reversible encephalopathy syndrome with extensive cytotoxic edema after blood transfusion: a case report and literature review

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.

Nonaneurysmal Subarachnoid Hemorrhage in Sickle Cell Disease: Description of a Case and a Review of the Literature

Descriptions of the natural history of cerebrovascular complications of sickle cell disease (SCD) characterize ischemic stroke as common during childhood and hemorrhagic stroke as more common in adulthood. Childhood ischemic stroke is attributed to vasculopathy with moyamoya syndrome. Hemorrhagic stroke is commonly attributed to aneurysms accompanying HbSS cerebral vasculopathy in SCD. However, a growing body of literature highlights multiple contributing factors to hemorrhagic stroke in children. Primary hemorrhagic stroke is one of the most devastating neurological complications of SCD. We describe the case of an 18-year-old female affected by HbSS genotype SCD presenting with reversible cerebral vasoconstriction syndrome (RCVS) as well as features of posterior reversible encephalopathy syndrome and convexity subarachnoid hemorrhage (SAH) after transfusion of red blood cells. We reviewed the existing literature dealing with SCD, blood transfusion, and hemorrhagic strokes. To our knowledge, this case presentation is unique with convexity SAH predominantly attributable to a RCVS spectrum disorder occurring in the setting of a recent blood transfusion in an adolescent female with SCD. As this case illustrates, neurological deterioration accompanied by intracranial hemorrhage in children and young adults with SCD after blood transfusion should raise suspicion for RCVS as part of a complex cerebral vasculopathy. A better understanding of the risk factors leading to hemorrhagic stroke may help prevent this severe complication in subjects with SCD. Neuroimaging including angiography in these subjects may enable prompt diagnosis and management.

Posterior reversible encephalopathy syndrome(PRES)

Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiological syndrome characterized by a headache, seizures, altered mental status and visual loss and characterized by white matter vasogenic edema affecting the posterior occipital and parietal lobes of the brain predominantly. This clinical syndrome is increasingly recognized due to improvement and availability of brain imaging specifically magnetic resonance imaging (MRI). A 35-year-old female with the history of unsafe abortion and massive blood transfusion 10 days ago was brought to the emergency room with three episodes of generalized tonic–clonic seizures, urinary incontinence and altered sensorium since 3 hours. MRI brain showed bilateral occipital, parietal, frontal cortex and subcortical white matter T2/Fluid-attenuated inversion recovery hyperintensities, suggestive of PRES. The patient improved after management with intravenous fluids, antibiotics, antiepileptics and monitoring of blood pressure. If recognized and treated early, the clinical syndrome commonly resolves within a week. PRES can be a major problem in rapid and massive blood transfusion. A high index of suspicion and prompt treatment can reduce morbidity, mortality and pave the path for early recovery.

Neurological Complications following Blood Transfusions in Sickle Cell Anemia

In Sickle Cell Anemia (SCA) patient blood transfusions are an important part of treatment for stroke and its prevention. However, blood transfusions can also lead to complications such as Reversible Posterior Leukoencephalopathy Syndrome (RPLS). This brief report highlights two cases of SCA who developed such neurological complications after a blood transfusion. RLPS should be considered as the cause of neurologic finding in patients with SCA and hypertension following a blood transfusion.

Neurological PRESentations in Sickle Cell Patients Are Not Always Stroke: A Review of Posterior Reversible Encephalopathy Syndrome in Sickle Cell Disease

Acute neurological changes in sickle cell disease (SCD) patients often raise the suspicion for stroke. Posterior reversible encephalopathy syndrome (PRES) can mimic stroke in its clinical presentation. We aimed to (i) review the PRES literature in SCD patients including clinical presentation, risk factors, pathophysiology, and management and (ii) elucidate the distinction between PRES and stroke in SCD. The exact pathophysiology of PRES in SCD remains elusive but is likely multifactorial and related to sickling, ischemia, and chronic anemia predisposing to vasogenic edema. PRES and stroke in SCD are distinguishable conditions. Our review may help elucidate a clinical approach to this distinction.

Reversible Posterior Leukoencephalopathy Syndrome Associated with Treatment for Acute Exacerbation of Ulcerative Colitis

Reversible posterior leukoencephalopathy syndrome (RPLS) is a clinical syndrome of varying etiologies with similar neuroimaging findings. This is a case report of a 25-year-old woman who developed typical, neurological symptoms and magnetic resonance imaging abnormalities after treatment for the acute exacerbation of ulcerative colitis (UC), which included blood transfusion, the systemic administration of prednisolone, and the administration of metronidazole. It has been reported that these treatments may contribute to the development of RPLS. RPLS should therefore be considered in the differential diagnosis of UC patients who exhibit impaired consciousness, seizures or visual deficits during treatment. We report a rare case of RPLS in a patient with UC.

Posterior Reversible Encephalopathy Syndrome in a Patient with Severe Uremia without Hypertension

A 28-year-old man was admitted to our hospital with nausea, headache and weakness of the left hand. He had severe uremia without hypertension due to recurrent/chronic pyelonephritis. Brain magnetic resonance imaging showed reversible vasogenic edema in the brainstem and bilateral frontal centrum semiovale. All of his neurological symptoms immediately improved after the introduction of hemodialysis. When a patient with uremia presents with neurological symptoms, posterior reversible encephalopathy syndrome should be considered in the differential diagnosis even if high blood pressure is not observed. Brain magnetic resonance imaging may be helpful in such a case, and an appropriate therapy could be subsequently initiated.

[Case of post-transfusion posterior reversible encephalopathy syndrome with cerebral hemorrhage that may be associated with fat-soluble vitamin deficiency]

A 36-year-old woman with a 4 year history of lower legs edema, hypermenorrhea and melena without medical treatment was admitted to our hospital. At 18 days before admission, anasarca and general fatigue appeared and she was admitted to another hospital. Her hemoglobin concentration was 1.4 g/dl and chest X-ray showed cardiomegaly. Heart failure with severe chronic anemia was diagnosed, and blood transfusion was performed. Her hemoglobin concentration increased to 10 g/dl and the anasarca disappeared. The day after discharge, she was referred to our hospital with generalized convulsion. We diagnosed posterior reversible encephalopathy syndrome (PRES) from the typical MRI imaging. We started treatment and her consciousness recovered steadily. At a week after admission, left hemiparesis appeared. Her brain imaging revealed multiple intracranial hemorrhages. In addition, her visual disturbance revealed vitamin A and vitamin K deficiency. PRES sometimes occur secondary to blood transfusion, but secondary brain hemorrhage is rare. Her fat-soluble vitamin deficiency, which resulted from a peculiar eating habit, may have contributed to the brain hemorrhage.

Diffuse Leukoencephalopathy Associated with Dialysis Disequilibrium Syndrome

A 52-year-old woman, previously treated for gastric cancer, began hemodialysis (HD) to treat the onset of severe acidemia. After her initial HD sessions, she suffered from a prolonged coma for approximately ten days. Magnetic resonance imaging revealed diffuse leukoencephalopathy, with increased apparent diffusion coefficient. Magnetic resonance spectroscopy showed a reduction of the N-acetylaspartate/creatine ratio. Her neuroimaging findings gradually resolved. Her transient cerebral white matter lesions were thought to be interstitial edema derived from dialysis disequilibrium syndrome (DDS), which might have been amplified by subclinical brain injury due to past chemotherapy. Her history of cancer chemotherapy may be a risk factor for an exacerbation of DDS.

Reversible cerebral vasoconstriction syndrome after blood transfusion

OBJECTIVES

To report 2 cases of reversible cerebral vasoconstriction syndrome (RCVS) with posterior reversible encephalopathy syndrome (PRES) after blood transfusion for severe anemia.

BACKGROUND

RCVS is presented with recurrent thunderclap headache and reversible constriction of cerebral arteries. PRES is a known complication of RCVS. Blood transfusion for severe anemia could be a cause for PRES in few cases; however, it is seldom mentioned as an etiology for RCVS.

METHODS

We report a case series.

RESULTS

We report 2 women presented with RCVS with PRES after blood transfusion for anemia, and reviewed another 4 similar cases reported in the literature. Our 2 patients were middle-aged women, with severe chronic anemia (average hemoglobin: 1.45 g/dL), and received multiple blood transfusions (average: 3250 mL) over a period of 5-7 days. They developed thunderclap headache and other symptoms about 1 week after the last blood transfusion. Cerebral vasoconstrictions were demonstrated by magnetic resonance angiography and transcranial color-coded sonography. PRES was found in both of them using magnetic resonance imaging, and one of them also had cytotoxic edema on diffusion weighted image.

CONCLUSIONS

RCVS with PRES is one complication of blood transfusion in patients under chronic severe anemia (especially when hemoglobin level increased for more than 5 g/dL), particularly in Asian women with menorrhagia. Blood pressure surge and the occurrence of severe headaches or other neurological symptoms should be aggressively monitored within 10 days after the last blood transfusion.

Posterior reversible encephalopathy syndrome-an under recognized manifestation of Chronic Kidney Disease

First Report of the Indian Chronic Kidney Disease (CKD) Registry showed that patient with CKD in India more frequently presented in Stage V. Many patients have uncontrolled hypertension and uremia due to noncompliance or non affordability of renal replacement therapy which can lead to complications such as posterior reversible encephalopathy syndrome (PRES). A 17-year-old female had end stage renal disease (ESRD) due to malignant hypertension. She developed headaches, altered consciousness, visual disturbances and seizures. A non contrast brain computed tomography revealed bilateral symmetrical white matter hypodensity in parietal, temporal, and occipital region suggesting PRES. Intravenous lorazepam was given for acute control of seizure and she required phenytoin, valproic acid, levetiracetam to control seizures. She was started on more frequent hemodialysis. She required five types of antihypertensive drugs to control blood pressure. We report successful renal transplantation (RTx) in a CKD patient with PRES. Constraints in operating an effective maintenance dialysis program leave RTx as the only viable option for ESRD patients in our country to prevent complications like PRES associated with uremia and uncontrolled hypertension

Reversible posterior leukoencephalopathy syndrome after blood transfusion in a pediatric patient with sickle cell disease

BACKGROUND

Children with sickle cell disease are at increased risk for neurological complications. Reversible posterior leukoencephalopathy syndrome is a clinico-radiological syndrome characterized by headache, vomiting, seizures, and visual disturbances along with the radiological findings of posterior leukoencephalopathy.

CASE REPORT

We report a 13-year-old female with sickle cell disease presenting with a headache and two isolated episodes of partial seizures with secondary generalization after blood transfusion. The brain MRI revealed bilateral high signal areas on T2 images in parietal, occipital, and frontal lobes; in the cerebellum; midbrain; and within the right caudate nucleus. Follow-up MRI 2 weeks later showed almost complete resolution of the previously detected findings. The clinical presentation along with the reversible aforementioned neuroimaging findings indicated reversible posterior leukoencephalopathy syndrome as the most appropriate diagnosis. Although the syndrome has been described previously in various clinical conditions, this is the first time that it is recognized after blood transfusion in an adolescent with sickle cell disease.

CONCLUSION

Neurological deterioration in children with sickle cell disease after blood transfusion should raise high suspicion for reversible posterior leukoencephalopathy syndrome, especially in the setting of elevated blood pressure.