1
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Lin TC, Wang YC, Yu KJ, Hsieh PC. Is decompressive craniectomy necessary in malignant posterior reversible encephalopathy syndrome with brain edema caused uncal herniation? A case report of reversible coma without surgical decompression. Br J Neurosurg 2023; 37:1336-1338. [PMID: 33464131 DOI: 10.1080/02688697.2021.1873247] [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] [Received: 03/21/2019] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is considered a benign entity and is usually reversible with only medical management, but persistent neurologic deficits and disability or death can occur without adequate treatment. Favorable outcomes have been associated with surgical decompression in malignant-type PRES in which hemorrhagic transformation or brain stem compression has developed. CASE DESCRIPTION Here we report a case of malignant PRES in a 61-year-old female of Asian descent in which the disease rapidly progressed to coma and a near-fatal condition with uncal herniation caused by severe brain edema; however, this patient achieved a dramatic recovery without surgical decompression. CONCLUSION After reviewing previous reports regarding malignant PRES, we propose that hemorrhagic transformation is a crucial indicator for surgical decompression and an important prognostic factor in malignant PRES.
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Affiliation(s)
- Tzu-Chin Lin
- Department of Neurosurgery, Chang Gung Memorial Hospital, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Yu-Chi Wang
- Department of Neurosurgery, Chang Gung Memorial Hospital, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Kai-Jie Yu
- Department of Urology, Chang Gung Memorial Hospital, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Po-Chuan Hsieh
- Department of Neurosurgery, Chang Gung Memorial Hospital, Chang Gung Medical College and University, Taoyuan, Taiwan
- Department of Neurosurgery, New Taipei Municipal Tucheng Hospital (Built and Operated by Chang Gung Medical Foundation), Tucheng, Taiwan
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2
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Fujii N, Fujii H, Matsuki M, Doi S, Isozaki T, Watanabe Y, Nakamata A, Fujita A, Mori H. Optic pathway involvement in the posterior reversible encephalopathy syndrome: A case report and review of the literature. Radiol Case Rep 2023; 18:3769-3772. [PMID: 37649724 PMCID: PMC10462788 DOI: 10.1016/j.radcr.2023.08.003] [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: 07/18/2023] [Revised: 07/29/2023] [Accepted: 08/01/2023] [Indexed: 09/01/2023] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiological condition characterized by reversible vasogenic edema of the white matter and acute neurological symptoms. PRES typically affects the parieto-occipital regions but rarely affects the optic pathway. Herein, we describe a case of central-variant PRES in a 57-year-old man with abnormal signal intensities in the optic pathway on magnetic resonance imaging (MRI). The patient underwent hemodialysis, initiated diuretics and antihypertensive medications, and the abnormal signal intensities of the brainstem and optic pathway on MRI improved. Although rare, PRES can affect the optic pathway, thus suggesting the possibility of fragility of the optic pathway itself to hyperperfusion.
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Affiliation(s)
- Nana Fujii
- Department of Radiology, Jichi Medical University, Tochigi, Japan
| | - Hiroyuki Fujii
- Department of Radiology, Jichi Medical University, Tochigi, Japan
| | - Mitsuru Matsuki
- Department of Radiology, Jichi Medical University, Tochigi, Japan
| | - Shugo Doi
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Takenori Isozaki
- Department of Radiology, Jichi Medical University, Tochigi, Japan
| | - Yuriko Watanabe
- Department of Radiology, Jichi Medical University, Tochigi, Japan
| | - Akihiro Nakamata
- Department of Radiology, Jichi Medical University, Tochigi, Japan
| | - Akifumi Fujita
- Department of Radiology, Haga Red Cross Hospital, Tochigi, Japan
| | - Harushi Mori
- Department of Radiology, Jichi Medical University, Tochigi, Japan
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3
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Rodriguez W, Tseng S, Pastrana F, Wang F. Case Report: A Fatal Case of Malignant Posterior Reversible Encephalopathy Syndrome in the Setting of Diabetic Ketoacidosis. Cureus 2023; 15:e45218. [PMID: 37842403 PMCID: PMC10576405 DOI: 10.7759/cureus.45218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2023] [Indexed: 10/17/2023] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological syndrome that typically presents with headache, visual disturbances, seizures, and altered consciousness. Its hallmark radiological features involve subcortical white matter lesions on magnetic resonance imaging (MRI), predominantly in the parietal and occipital lobes. While generally reversible with favorable outcomes, a minority of cases may progress to malignant cerebral edema and herniation, resulting in death. We present an unusual case of a 47-year-old woman who developed malignant PRES associated with severe diabetic ketoacidosis (DKA). Despite aggressive medical and surgical treatments, the patient's condition worsened, indicating the potential for devastating outcomes in malignant PRES. This case adds to the limited body of literature that suggests the need for vigilance in monitoring patients with severe glycemic disturbances for neurological complications, such as PRES. It also highlights the importance of early recognition and aggressive management in improving neurological outcomes in malignant PRES. Further research is warranted to understand the underlying mechanisms better and identify optimal treatment strategies for this rare but potentially life-threatening condition.
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Affiliation(s)
- Wilson Rodriguez
- Neurology, Saint Louis University School of Medicine, Saint Louis, USA
| | - Shannon Tseng
- Neurology, Saint Louis University School of Medicine, Saint Louis, USA
| | | | - Fajun Wang
- Neurology, Saint Louis University School of Medicine, Saint Louis, USA
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4
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Affiliation(s)
- Romergryko G Geocadin
- From the Departments of Neurology, Anesthesiology-Critical Care Medicine, and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore
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5
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Bhutada AS, Kodankandath TV. Delayed Presentation of Posterior Reversible Encephalopathy Syndrome in the Setting of Serotonin-Norepinephrine Reuptake Inhibitors. Cureus 2022; 14:e22454. [PMID: 35371689 PMCID: PMC8942087 DOI: 10.7759/cureus.22454] [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] [Accepted: 02/21/2022] [Indexed: 11/09/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a complex process that has been implicated in the setting of many chronic diseases (i.e., hypertension, chronic kidney disease, autoimmune diseases, infections, transplant treatments, etc.). The exact pathogenesis of PRES is still unclear; however, it has been suggested to involve endothelial injury leading to immune system activation and cytokine release. This case report examines an atypical presentation of PRES caused by serotonin-norepinephrine reuptake inhibitors (SNRIs).
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6
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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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7
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Abstract
Posterior reversible encephalopathy syndrome (PRES) is a group of clinical syndromes typically characterized by bilateral reversible vasogenic edema of the subcortical white matter in the parieto-occipital region on neuroimaging that causes a wide variety of acute or subacute neurological symptoms, including headache, mental status alteration, seizures, and visual dysfunction. PRES is classically suspected in patients with severe hypertension, renal failure, autoimmune disorders, eclampsia, or immunosuppressant medications. Frequent neurological evaluations and neuroimaging examinations by computed tomography or magnetic resonance imaging are required for both the diagnosis and assessment of the condition. Early detection of the disease is key for a rapid recovery and good prognosis.
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Affiliation(s)
- Yuya Ando
- Department of General Medicine, National Defense Medical College, Japan
- Department of Family Medicine, Graduated School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Yosuke Ono
- Department of General Medicine, National Defense Medical College, Japan
| | - Azusa Sano
- Department of General Medicine, National Defense Medical College, Japan
| | - Naoya Fujita
- Department of General Medicine, National Defense Medical College, Japan
| | - Sachiko Ono
- Department of Eat-loss Medicine, Graduate School of Medicine, The University of Tokyo, Japan
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8
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Niznick N, Lun R, Lelli DA, Fantaneanu TA. Clinical Problem Solving: Decreased Level of Consciousness and Unexplained Hydrocephalus. Neurohospitalist 2022; 12:312-317. [PMID: 35419136 PMCID: PMC8995606 DOI: 10.1177/19418744211056781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We present a clinical reasoning case of 42-year-old male with a history of type 1 diabetes who presented to hospital with decreased level of consciousness. We review the approach to coma including initial approach to differential diagnosis and investigations. After refining the diagnostic options based on initial investigations, we review the clinical decision-making process with a focus on narrowing the differential diagnosis, further investigations, and treatment.
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Affiliation(s)
- Naomi Niznick
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Ronda Lun
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Daniel A. Lelli
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Tadeu A. Fantaneanu
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
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9
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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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10
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Omar NB, Chagoya G, Elsayed GA, Litovsky SH, Hackney JR, Fisher WS. Cerebellar talcosis following posterior reversible encephalopathy syndrome in an intravenous methamphetamine abuser. Surg Neurol Int 2021; 12:2. [PMID: 33500817 PMCID: PMC7827572 DOI: 10.25259/sni_616_2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 12/14/2020] [Indexed: 11/04/2022] Open
Abstract
Background Intravenous (IV) methamphetamine abuse is associated with a variety of short- and long-term effects on the nervous system, some of which have yet to be fully elucidated. One known systemic complication that has not been described in nervous system tissues is the deposition of substrate crystals contained in injectable drugs. Case Description An unusual case is presented of a 35-year-old active IV methamphetamine abuser with posterior reversible encephalopathy syndrome (PRES) who subsequently developed multifocal bilateral cerebellar enhancing lesions and leptomeningeal enhancement due to biopsy-proven crystalline deposits. Conclusion Although large crystalline substances will not normally penetrate the blood-brain barrier (BBB), during a state of BBB compromise such as with PRES, talc deposition may occur in the central nervous system.
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Affiliation(s)
- Nidal Bassam Omar
- Department of Neurosurgery, The University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Gustavo Chagoya
- Department of Neurosurgery, The University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Galal A Elsayed
- Department of Neurosurgery, The University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Silvio H Litovsky
- Department of Pathology, The University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - James R Hackney
- Department of Pathology, The University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Winfield S Fisher
- Department of Neurosurgery, The University of Alabama at Birmingham, Birmingham, Alabama, United States
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11
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Unsal Bilgin YO, Eskut N, Koskderelioglu A, Gedizlioglu M. Atypical posterior reversible encephalopathy syndrome with albuminocytological dissociation and late emerging neuroradiological findings: A case report. Postgrad Med 2020; 133:108-111. [PMID: 32880496 DOI: 10.1080/00325481.2020.1816359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a central nervous system disorder accompanied by vasogenic edema in white matter that is usually located in temporo-parieto-occipital area. Typically, PRES is presented with headaches, seizures, and change of consciousness. The most common etiologic factor is fluctuations in blood pressure. An eighty-eight-year-old female patient was evaluated because of her acute confused state. Medical history revealed hypertension. Blood pressure was 190/100 mmHg. The initial examination showed impaired consciousness. Radiological investigations of brain showed chronic ischemic lesions. Albuminocytological dissociation was detected in CSF examination. On the 6th day of admission, cranial MRI was repeated. Radiological findings were typical for PRES. The cranial MRI is a valuable diagnostic tool for the diagnosis of the PRES but, as in our case, despite the subtle clinical and radiological findings presented during admission, repeated MRI and CSF examination may contribute to a definite diagnosis. This case is remarkable for severe protein elevation in CSF, irreversible fatal course and radiographic evidence of vasogenic edema occurred subsequently.
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Affiliation(s)
- Yaprak Ozum Unsal Bilgin
- Department of Neurology, University of Health Sciences, Izmir Bozyaka Education and Research Hospital , Izmir, Turkey
| | - Neslihan Eskut
- Department of Neurology, University of Health Sciences, Izmir Bozyaka Education and Research Hospital , Izmir, Turkey
| | - Asli Koskderelioglu
- Department of Neurology, University of Health Sciences, Izmir Bozyaka Education and Research Hospital , Izmir, Turkey
| | - Muhtesem Gedizlioglu
- Department of Neurology, University of Health Sciences, Izmir Bozyaka Education and Research Hospital , Izmir, Turkey
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12
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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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13
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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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14
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Malignant PRES and RCVS after brain surgery in the early postpartum period. Clin Neurol Neurosurg 2019; 185:105489. [PMID: 31470358 DOI: 10.1016/j.clineuro.2019.105489] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 08/08/2019] [Accepted: 08/13/2019] [Indexed: 11/20/2022]
Abstract
The management of women with brain tumors in the early post-partum period may be demanding as the patho-physiological changes that occur during pregnancy may also manifest in the early post-partum period. The aim of our paper is to report a case of late-onset post-partum pre-eclampsia after brain tumor surgery, complicated by posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS). Hemicraniectomy and intensive care management were necessary to obtain a favorable neurological outcome. The inherent literature on the subject is also analyzed through a systematic research. This is the first case of supratentorial decompressive hemicraniectomy in post-partum PRES, while there has been only one other case of posterior fossa decompression described in this cohort of patients. PRES and RCVS can complicate the neurosurgical management of women in the postpartum period. A careful evaluation of the clinical presentation is necessary as in some particular cases an aggressive medical and surgical treatment is required to obtain a favorable outcome.
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15
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Katsevman GA, Turner RC, Cheyuo C, Rosen CL, Smith MS. Post-partum posterior reversible encephalopathy syndrome requiring decompressive craniectomy: case report and review of the literature. Acta Neurochir (Wien) 2019; 161:217-224. [PMID: 30659351 DOI: 10.1007/s00701-019-03798-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 01/04/2019] [Indexed: 10/27/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is an uncommon but potentially devastating syndrome if not recognized and treated appropriately. As the name implies, recognition of the condition and proper management may reverse the clinical and radiological findings. However, diagnosis is not always straightforward. We present the case of a 24-year-old female who was 4 days post-partum and presented with headache, neck pain, and new-onset seizures. She had undergone epidural anesthesia during labor, and initial imaging was suggestive of intracranial hypotension versus pachymeningitis. Despite initial conservative therapy including anti-epileptic drugs, magnesium therapy, empiric antibiotics, and Trendelenburg positioning, the patient continued to deteriorate. Follow-up imaging was suggestive of PRES with signs of intracranial hypertension. The patient underwent a decompressive suboccipital craniectomy for refractory and severe PRES and later fully recovered. This case highlights the sometimes difficult diagnosis of PRES, possible association with pregnancy, eclampsia/preeclampsia and/or cerebrospinal fluid drainage, and the rare but life-saving need for decompression in severe cases.
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16
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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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17
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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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18
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Zama D, Gasperini P, Berger M, Petris M, De Pasquale MD, Cesaro S, Guerzoni ME, Mastrodicasa E, Savina F, Ziino O, Kiren V, Muggeo P, Mura RM, Melchionda F, Zanazzo GA. A survey on hematology-oncology pediatric AIEOP centres: The challenge of posterior reversible encephalopathy syndrome. Eur J Haematol 2017; 100:75-82. [PMID: 29032616 DOI: 10.1111/ejh.12984] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2017] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Posterior reversible encephalopathy syndrome (PRES) is one of the most common neurological complications in hematology-oncology pediatric patients. Despite an increasingly recognized occurrence, no clear consensus exists regarding how best to manage the syndrome, because most cases of PRES have reported in single-case reports or small series. Aim of this paper is to identify incidence, clinical features, management, and outcome of PRES in a large series of hematology-oncology pediatric patients. METHODS The cases of PRES occurred in twelve centers of the Italian Association of Pediatric Hematology and Oncology were reported. RESULTS One hundred and twenty-four cases of PRES in 112 pediatric patients were recorded with an incidence of 2.1% and 4.7%, respectively, in acute lymphoblastic leukemia in first complete remission and hematopoietic stem cell transplantation (HSCT). The majority of cases occurred after a cycle of chemotherapy rather than after stem cell transplant. PRES after chemotherapy significantly differs from that after HSCT for diagnosis, time of presentation, risk factors, management, and outcome. CONCLUSIONS This study demonstrates that PRES is a common neurological complication and occurring preferentially in course of induction treatment of some hematologic malignancies, as ALL and after HSCT. It also highlights great clinical differences in the management and outcome in patients with PRES occurring after chemotherapy or after HSCT.
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Affiliation(s)
- Daniele Zama
- Department of Pediatrics, Pediatric Oncology and Haematology Unit "Lalla Seràgnoli", Sant' Orsola Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Pietro Gasperini
- Department of Pediatrics, Pediatric Oncology and Haematology Unit "Lalla Seràgnoli", Sant' Orsola Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Massimo Berger
- Pediatric Onco-Hematology and Stem Cell Transplant Division, City of Health and Science, Regina Margherita Children's Hospital, Turin, Italy
| | | | - Maria D De Pasquale
- Department of Pediatric Hematology/Oncology and Stem Cell Transplantation, Bambino Gesù Children's Hospital, Rome, Italy
| | - Simone Cesaro
- Department of Paediatrics, Paediatric Haematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Maria E Guerzoni
- Department of Medical and Surgical Sciences for Mothers, Children and Adults, Onco-hematology Pediatric Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Elena Mastrodicasa
- Pediatric Onco-Hematology and Stem Cell Transplant Unit, S.Maria della Misericordia Hospital, Perugia, Italy
| | | | - Ottavio Ziino
- Pediatric Hematology-Oncology, ARNAS Civico, Palermo, Italy
| | - Valentina Kiren
- Pediatric Hematology-Oncology, Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy
| | | | - Rosa M Mura
- Paediatric Haematology-Oncology, Ospedale Pediatrico Microcitemico, Cagliari, Italy
| | - Fraia Melchionda
- Department of Pediatrics, Pediatric Oncology and Haematology Unit "Lalla Seràgnoli", Sant' Orsola Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Giulio A Zanazzo
- Pediatric Hematology-Oncology, Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy
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Hernández-Durán S, Barrantes-Freer A, Rohde V, von der Brelie C. Posterior reversible encephalopathy syndrome presenting in the anterior circulation with malignant intracranial hypertension requiring surgical decompression: a case report and literature review. Acta Neurochir (Wien) 2017; 159:1321-1324. [PMID: 28516363 DOI: 10.1007/s00701-017-3197-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 04/24/2017] [Indexed: 12/01/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is thought to result from endothelial dysfunction and breakdown of the blood-brain barrier with subsequent vasogenic edema. Abrupt hypertension has been identified as one of its risk factors. We present a rare case of PRES in the anterior circulation with sudden onset of left hemiparesis and rapid neurological deterioration on the basis of hypertensive crisis. Due to refractory intracranial hypertension, the patient required emergent right decompressive craniectomy. Further investigations, including a biopsy, revealed an atypical form of PRES. This case illustrates the importance of aggressive medical and early surgical management to prevent permanent neurological deficits.
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Affiliation(s)
- S Hernández-Durán
- Department of Neurological Surgery, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany.
| | - A Barrantes-Freer
- Department of Neuropathology, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - V Rohde
- Department of Neurological Surgery, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - C von der Brelie
- Department of Neurological Surgery, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
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20
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Schweitzer AD, Parikh NS, Askin G, Nemade A, Lyo J, Karimi S, Knobel A, Navi BB, Young RJ, Gupta A. Imaging characteristics associated with clinical outcomes in posterior reversible encephalopathy syndrome. Neuroradiology 2017; 59:379-386. [PMID: 28289809 DOI: 10.1007/s00234-017-1815-1] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 02/22/2017] [Indexed: 11/24/2022]
Abstract
PURPOSE Posterior reversible encephalopathy syndrome (PRES) is a disorder of cerebrovascular autoregulation that can result in brain edema, hemorrhage, and infarction. We sought to investigate whether certain imaging characteristics in PRES are associated with clinically significant patient outcomes. METHODS We retrospectively reviewed all cases of PRES occurring between 2008 and 2014 at two major academic medical centers. Demographic, clinical, and radiographic data were collected. We analyzed imaging studies for vasogenic edema, hemorrhage, and diffusion restriction. We performed univariate analysis and stepwise logistic regression to assess the association between our radiologic findings of interest and clinical outcomes as defined by hospital discharge disposition and modified Rankin scale (mRS) at time of discharge. RESULTS We identified 99 cases of PRES in 96 patients. The median age was 55 years (IQR 30-65) and 74% were women. In 99 cases, 60% of patients had active cancer, 19% had history of bone marrow or organ transplantation, 14% had autoimmune disease, and 8% were peripartum. Imaging at clinical presentation showed extensive vasogenic edema in 39%, hemorrhage in 36%, hemorrhage with mass effect in 7%, and restricted diffusion in 16%. In our final logistic regression models, the presence of extensive vasogenic edema, hemorrhage with mass effect, or diffusion restriction was associated with worse clinical outcome as defined by both discharge disposition (OR = 4.3; 95% CI: 1.4-36.3; p = 0.047) and mRS (OR = 3.6; 95% CI: 1.2-10.7; p = 0.019). CONCLUSIONS Extensive vasogenic edema, hemorrhage, and restricted diffusion on initial imaging in PRES are associated with worse clinical outcomes.
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Affiliation(s)
- Andrew D Schweitzer
- Department of Radiology, Weill Cornell Medicine, 525 E. 68th Street, Box 141, Office: Starr 8A-29, New York, NY, 10065, USA.
| | - Neal S Parikh
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA.,Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Gulce Askin
- Department of Healthcare Policy & Research, Division of Biostatistics and Epidemiology, Weill Cornell Medicine, New York, NY, USA
| | - Ajay Nemade
- Department of Radiology, Weill Cornell Medicine, 525 E. 68th Street, Box 141, Office: Starr 8A-29, New York, NY, 10065, USA
| | - John Lyo
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sasan Karimi
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anna Knobel
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Babak B Navi
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA.,Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Robert J Young
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, 525 E. 68th Street, Box 141, Office: Starr 8A-29, New York, NY, 10065, USA.,Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
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Chemotherapy-associated Posterior Reversible Encephalopathy Syndrome: A Case Report and Review of the Literature. Neurologist 2017; 21:112-117. [PMID: 27801773 DOI: 10.1097/nrl.0000000000000105] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION There are increasing reports of posterior reversible encephalopathy syndrome (PRES) associated with the use of chemotherapeutic agents. Recognition of PRES is crucial given its reversibility with appropriate supportive management. We report a patient presenting with PRES after treatment with Rituximab, Cyclophosphamide, Hydroxydaunorubicin/Adriamycin, Oncovin/Vincristine, Prednisone (R-CHOP) and intrathecal methotrexate. We also perform a systematic review of the literature on chemotherapy-associated PRES. CASE REPORT A 72-year-old man with recently diagnosed diffuse large B-cell lymphoma became unresponsive 4 days after initiation of R-CHOP and intrathecal methotrexate. Brain magnetic resonance imaging showed interval development of occipital and temporal fluid attenuation inversion recovery hyperintensities consistent with PRES. The patient's blood pressure was aggressively controlled and he received 5 days of high-dose methylprednisone. He subsequently regained consciousness and his mental status gradually improved. Repeat magnetic resonance imaging showed interval resolution of the bilateral fluid attenuation inversion recovery hyperintensities. REVIEW SUMMARY We performed a systematic review of the literature and included a total of 70 unique cases involving chemotherapy-associated PRES. Platinum-containing drugs, Cyclophosphamide, Hydroxydaunorubicin/Adriamycin, Oncovin/Vincristine, Prednisone/R-CHOP regimens, and gemcitabine were the agents most commonly used in patients who developed suspected chemo-associated PRES. Median onset of symptoms occurred 8 days after chemotherapy. Hypertension was the most commonly reported risk factor associated with the development of chemotherapy-associated PRES. In most cases, PRES improved with supportive management alone within 2 weeks. CONCLUSIONS Chemotherapy-associated PRES is an increasingly encountered syndrome. Both neurologists and non-neurologists should be familiar with the most commonly implicated agents, symptoms, risk factors, and clinical course of chemotherapy-associated PRES, given its favorable prognosis with appropriate management.
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Magsi S, Zafar A. Malignant Posterior Reversible Encephalopathy Syndrome-An Exacting Challenge for Neurocritical Care Physicians. Neurohospitalist 2017; 7:196-199. [PMID: 28974999 DOI: 10.1177/1941874416688989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We report a case of malignant posterior reversible encephalopathy syndrome (PRES) in a 62-year-old Caucasian female with a complex medical history and comorbidities admitted for bowel resection and lysis of iatrogenic bowel adhesions and enterocutaneous fistulas. Postoperatively, the patient developed sudden bilateral visual loss with no other neurologic deficits. Computed tomography scan showed very severe PRES-like changes, confirmed on magnetic resonance imaging (MRI). Systolic blood pressure remained around 170 mm HG. The patient was obtunded and remained unresponsive after MRI, with minimal response and a deteriorating clinical condition. The patient was given hyperosmolar therapy with a mannitol bolus. She recovered well with near resolution of imaging findings.
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23
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[Reversible posterior leukoencephalopathy syndrome in a patient presenting granulomatosis with polyangiitis]. Ann Dermatol Venereol 2016; 144:113-120. [PMID: 27502754 DOI: 10.1016/j.annder.2016.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Revised: 03/19/2016] [Accepted: 06/21/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Reversible posterior leukoencephalopathy syndrome (RPLS) is characterised by clinical neurological features of sudden onset and brain MRI findings such as T2/Flair white matter hyperintensities. RPLS can occur in autoimmune diseases, and rarely in systemic vasculitis. We report a case of RPLS in a woman presenting granulomatosis with polyangiitis (Wegener's granulomatosis). PATIENTS AND METHODS A 22-year-old female patient was treated with methylprednisolone pulses for granulomatosis with polyangiitis and neurological impairment. A few hours after the second pulse, the patient had seizures, blindness and confusion associated with high blood pressure and acute renal failure. MRI revealed a high-intensity area on T2-Flair weighted images of the occipital-temporal lobes. The patient was treated with antiepileptic and antihypertensive medications, oral steroids and cyclophosphamide; the clinical and radiological findings proved reversible over the ensuing days. DISCUSSION The occurrence of RPLS in systemic vasculitis is rare. Six cases of RPLS associated with granulomatosis and polyangiitis have been reported. It appears important to screen for high blood pressure in patients recently treated with corticosteroids for vasculitis as this condition may represent a precipitating factor for RPLS.
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Babi MA, Gorman MJ, Cipolla MJ, Allen G, Al Jerdi S, Clouser R, Commichau C. Ondansetron-related hemorrhagic posterior reversible encephalopathy syndrome (PRES) following gastric bypass. SPRINGERPLUS 2016; 5:18. [PMID: 26759757 PMCID: PMC4703598 DOI: 10.1186/s40064-015-1644-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 12/20/2015] [Indexed: 02/06/2023]
Abstract
Background Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiographic syndrome formally recognized in 1996, which describes specific changes noted on neuroimaging thought to be related to impaired cerebral blood flow autoregulation and endothelial dysfunction. We report a case of PRES in the setting of increased ingestion of ondansetron; complicated by hemorrhagic transformation and refractory intracranial hypertension. We hypothesize an association of 5-HT3 antagonism and PRES. Findings This is a case study report; with review of previously published literature through PubMed search. We describe the case of a 25 year old man following bariatric surgery who increased his ingestion of ondansetron, taking up to 40 tablets/day due to excessive nausea and vomiting. The patient was hospitalized for progressively more severe headache of 1 week’s duration. Computed tomography (CT) revealed bilateral cerebral edema in the parietal and occipital lobes in the setting of elevated blood pressure (BP). Three days into his admission, following improvement in his BP with oral anti-hypertensive but continued use of the ondansetron, the patient developed near complete blindness. CT head imaging revealed progression of the posterior cerebral edema and intraparenchymal hemorrhage. He was admitted to our ICU and despite supportive treatment, his neurological examination worsened while CT head imaging findings remained stable. Invasive multimodality monitoring revealed elevated intracranial pressure. The patient was aggressively treated and after a prolonged hospitalization and rehabilitation course, made a significant recovery. Conclusion This case highlights a very rare potential neurological complication of ondansetron, a commonly used medication. We hypothesize an underlying association between PRES and 5-HT3 antagonism, via the latter’s potential role in endothelial dysfunction. Prompt recognition and treatment of PRES is essential, in order to prevent secondary cerebral injury and the associated potentially grave consequences.
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Affiliation(s)
- M Alain Babi
- Department of Neurological Sciences, The University of Vermont Medical Center and the University of Vermont College of Medicine, Burlington, VT 05405 USA ; Division of Neuro-critical care, Department of Neurology, Duke University Hospital, DUMC 2900, Durham, NC 27710 USA
| | - Mark J Gorman
- Department of Neurological Sciences, The University of Vermont Medical Center and the University of Vermont College of Medicine, Burlington, VT 05405 USA
| | - Marilyn J Cipolla
- Department of Neurological Sciences, The University of Vermont Medical Center and the University of Vermont College of Medicine, Burlington, VT 05405 USA
| | - Gilman Allen
- Department of Medicine, Division of Pulmonary Medicine and Critical Care, The University of Vermont Medical Center and the University of Vermont College of Medicine, Burlington, VT 05405 USA
| | - Salman Al Jerdi
- Department of Neurological Sciences, The University of Vermont Medical Center and the University of Vermont College of Medicine, Burlington, VT 05405 USA
| | - Ryan Clouser
- Department of Medicine, Division of Pulmonary Medicine and Critical Care, The University of Vermont Medical Center and the University of Vermont College of Medicine, Burlington, VT 05405 USA
| | - Christopher Commichau
- Department of Neurological Sciences, The University of Vermont Medical Center and the University of Vermont College of Medicine, Burlington, VT 05405 USA
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Martins WA, Marrone LCP. Malignant Posterior Reversible Encephalopathy Syndrome: A Case of Posterior Irreversible Encephalopathy Syndrome. J Clin Neurol 2015; 12:236-7. [PMID: 26541497 PMCID: PMC4828572 DOI: 10.3988/jcn.2016.12.2.236] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 07/13/2015] [Accepted: 07/16/2015] [Indexed: 11/17/2022] Open
Affiliation(s)
- William Alves Martins
- Department of Neurology, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil.
| | - Luiz Carlos Porcello Marrone
- Department of Neurology, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
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