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Nada MG, Libda YI, Gohary MM, Dessouky R. Pediatric posterior reversible encephalopathy syndrome: Can MR imaging features predict outcomes in non-oncologic patients? Eur J Radiol 2024; 170:111214. [PMID: 38007856 DOI: 10.1016/j.ejrad.2023.111214] [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: 05/20/2023] [Revised: 08/09/2023] [Accepted: 11/20/2023] [Indexed: 11/28/2023]
Abstract
PURPOSE Identify MR features predictive of poor outcomes in non-oncologic pediatric PRES. METHOD A six-year search of all non-oncologic pediatric patients with clinical and MR features of PRES was performed. Modified Rankin scores were used to classify clinical outcomes into good versus poor, then clinical and MR features were compared among groups. Univariate and multivariate analysis was performed to identify MR predictors of poor outcomes for various imaging features, and p-values < 0.05 were considered statistically significant. RESULTS One hundred and forty-one patients (mean age 10.1 ± 3.0 years, male to female ratio 1:1.1) were included. Clinically, nephrotic syndrome (p = 0.03), focal deficits (p = 0.04), longer hospitalization (p < 0.001), and mechanical ventilation (p < 0.001) were significantly associated with poor outcomes. Univariate analysis revealed that deep grey matter nuclei (OR = 5.29, 95 % CI: 1.6-18.0) and cerebellar edema patterns (OR = 3.49, 95 % CI: 1.3-9.5), cytotoxic edema (OR = 63.6, 95 % CI:16.5-244.2), hemorrhage (OR = 16.58, 95 % CI: 4.3-64.2), and severe PRES patterns (OR = 11.0, 95 % CI: 3.5-34.7) on MR were all significantly associated with poor outcomes (p-values = 0.008 and 0.014, <0.001, <0.001, and < 0.001, respectively). This remained true for cytotoxic edema (OR = 84.26, 95 % CI: 17.3-410.9, p-value < 0.001) and hemorrhage (OR = 44.56, 95 % CI: 6.9-289.7, p-value < 0.001) on multivariate analysis. CONCLUSION Diffusion restriction and hemorrhage on initial MR scans were the two independent predictors of poor outcomes in non-oncologic pediatric patients.
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Affiliation(s)
- Mohamad Gamal Nada
- Radiology Department, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | - Yasmin Ibrahim Libda
- Radiology Department, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | - Mahmoud M Gohary
- Pediatric Department, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | - Riham Dessouky
- Radiology Department, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt.
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Lin W, Xie J, Zhang J, Cheng H, Cui H, Zhang Y, Wu Y, Yu J, Qi P, Fan J, Gao H, Wang F, Zhang R, Zheng H. Posterior reversible encephalopathy syndrome in children with acute lymphoblastic leukemia during remission induction chemotherapy: a single-center retrospective study. Minerva Pediatr (Torino) 2023; 75:808-816. [PMID: 31729207 DOI: 10.23736/s2724-5276.19.05675-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
BACKGROUND This study investigated the clinical characteristics, cranial magnetic resonance imaging (MRI) features, MRI follow-up, and prognosis of children with acute lymphoblastic leukemia (ALL) who developed posterior reversible encephalopathy syndrome (PRES) during remission induction chemotherapy. METHODS We analyzed the age, gender, PRES symptoms and signs, cranial MRI findings, therapeutic effect, and prognosis of children with ALL who developed PRES during chemotherapy from January 2010 to December 2013 at the Hematology Oncology Center of Beijing Children's Hospital. Changes in cranial MRI findings were analyzed, and intelligence (IQ) and cognitive function were evaluated using the Wechsler Scale and the Wisconsin Card Score Test after the children completed chemotherapy. RESULTS There were 850 children with newly diagnosed ALL in this period; 13 (1.5%), 6 boys and 7 girls, developed PRES. All were diagnosed as B-cell ALL. The median age at PRES onset was 7 years (2-11 years). The median day of PRES onset was day 28 (day 17-34) of remission induction chemotherapy. Of the 13 children with PRES onset and seizures, 4 had visual disturbances and 2 had consciousness disturbances. Cranial MRI showed hyperintensity in the subcortical white matter on T2-weighted axial and fluid-attenuated inversion recovery (FLAIR) images. The lesion locations were as follows: occipital lobe, 12 (92.3%) patients; frontal lobe, 7 (53.8%) patients; temporal lobe, 5 (38.4%) patients; parietal lobe, 3 (23.1%) patients; and cerebellum, 1 (7.7%) patient. There were 8 (61.5%) patients with vasogenic edema and 5 (38.5%) with cytotoxic edema. After treatment, all children recovered within one month, when their PRES symptoms were relieved, they continued to receive chemotherapy. However, 1 child (1.07%) died of severe central nervous system infection one year after PRES treatment, and 3 (25%) had recurrent seizures and were diagnosed with epilepsy after three months of PRES treatment. Their cranial MRIs showed cytotoxic edema, which was acute stage on day 15, with aggravated lesions on cranial MRI. The cranial MRI lesions returned to normal at one month in 3 (23.1%) patients, at three months in 6 (46.1%) patients, at one year in 8 (61.5%) patients, and at two years in 12 (92.3%) patients. The 12 surviving children all returned to school, and their full-scale, verbal, and performance IQs were normal, with no significant differences in intelligence or cognitive function compared with children with ALL without PRES during the same period. CONCLUSIONS PRES can occur during remission induction chemotherapy treatment of children with ALL, but the incidence is low. Cranial MRI can be used for diagnosis and to characterize lesions. The children recover about a month after treatment, and cranial MRI lesions return to normal within two years. The time for complete resolution of MRI lesions differs, and children with cytotoxic edema have worse prognosis with sequelae, such as epilepsy, which requires close monitoring. PRES does not affect intelligence or cognitive development.
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Affiliation(s)
- Wei Lin
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jing Xie
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jishui Zhang
- Department of Psychiatry, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Hua Cheng
- Imaging Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Haijing Cui
- Intelligence Laboratory, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Yuanyuan Zhang
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Ying Wu
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jiaole Yu
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Peijing Qi
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jia Fan
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Huifang Gao
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Fang Wang
- Department of Psychiatry, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Ruidong Zhang
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Huyong Zheng
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China -
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Frati A, Armocida D, Tartara F, Cofano F, Corvino S, Paolini S, Santoro A, Garbossa D. Can Post-Operative Posterior Reversible Encephalopathy Syndrome (PRES) Be Considered an Insidious Rare Surgical Complication? Brain Sci 2023; 13:brainsci13050706. [PMID: 37239179 DOI: 10.3390/brainsci13050706] [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: 03/21/2023] [Revised: 04/11/2023] [Accepted: 04/20/2023] [Indexed: 05/28/2023] Open
Abstract
Introduction: Posterior reversible encephalopathy syndrome (PRES) is a neurological disorder characterized by neurological symptoms and distinctive neuroimaging findings. There are a few cases reported in the literature in which PRES can occur after surgery, and there is no clear direct relationship between a procedure and its debut. Methods: We performed a review of the literature by analyzing all reported cases of PRES syndrome which debuted after a surgical procedure with the aim of identifying the clinical features, the timing of the symptoms' onset and the therapy of patients suffering from this unusual surgical complication. Results: The total number of patients collected was 47, with a mean age of 40.9 years. Postoperative PRES can occur in either pediatric or adult patients (ages 4-82 years). The most frequent form of comorbidity reported was cardiovascular disease (fourteen patients, 29.78%). Sixteen patients (36%) had no relevant risk factors or comorbidities at the time of the surgical procedure. The types of surgery most correlated were cranial neuro and maxillofacial surgery (twenty-one patients, 44.68%) followed by transplant surgery (eight patients, 17%). The time of onset of PRES after surgery occurred within the first 3 weeks (mean time of onset 4.7 days), and when rapidly treated with antihypertensive and antiepileptic drugs appeared to have a reversible and benign course. Conclusion: PRES syndrome can be considered a rare complication of procedures and can occur following a wide range of surgeries, especially cranial and transplant surgery. Being able to recognize it in time and treat it ensures a full reversibility of symptoms in most cases.
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Affiliation(s)
- Alessandro Frati
- Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S), Neuromed, Via Atinense 18, 86077 Pozzilli, Italy
| | - Daniele Armocida
- Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S), Neuromed, Via Atinense 18, 86077 Pozzilli, Italy
- Human Neurosciences Department, Neurosurgery Division "Sapienza" University, AOU Policlinico Umberto I, 00161 Rome, Italy
| | - Fulvio Tartara
- Headache Science and Neurorehabilitation Center, IRCCS Mondino Foundation, Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy
| | - Fabio Cofano
- Neurosurgery, Department of Neuroscience, A.O.U. Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy
| | - Sergio Corvino
- Department of Neuroscience, Reproductive and Odontostomatological Sciences, Division of Neurosurgery Università degli Studi di Napoli Federico II, 80131 Naples, Italy
| | - Sergio Paolini
- Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S), Neuromed, Via Atinense 18, 86077 Pozzilli, Italy
| | - Antonio Santoro
- Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S), Neuromed, Via Atinense 18, 86077 Pozzilli, Italy
| | - Diego Garbossa
- Neurosurgery, Department of Neuroscience, A.O.U. Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy
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Ajmi H, Brahim J, Mabrouk S, Ben Abdallah A, Zouari N, Majdoub F, Nouir S, Hasni I, Ben Cheikh Y, Chemli J, Jemni H, Abroug S. Clinical and radiological findings of posterior reversible encephalopathy syndrome in children: About 16 children hospitalized in the pediatric department of a Tunisian tertiary care hospital. Eur J Paediatr Neurol 2023; 43:18-26. [PMID: 36871341 DOI: 10.1016/j.ejpn.2023.02.003] [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: 10/20/2021] [Revised: 11/24/2022] [Accepted: 02/12/2023] [Indexed: 02/21/2023]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiological entity most frequently described in young- or middle-aged adults with a rare occurrence among children. AIM To determine the clinical, radiological features and outcome of PRES in children admitted to a Tunisian tertiary care pediatric department. METHODS we retrospectively reviewed records of all children under 18 years old diagnosed with PRES and admitted to the PICU of the Pediatric department of Sahloul University Hospital from January 2000 to August 2021. RESULTS Sixteen patients were enrolled in this study. The mean age of the study population at PRES onset was 10 years (range: 4-14 years) and the male female ratio was 3. The most frequent neurological signs were seizures (n = 16 cases), headache (n = 8 cases), and impaired level of consciousness (7 cases). Visual disturbances were found in one patient. Arterial hypertension was the most underlying cause (16 cases). Brain MRI showed vasogenic edema, mostly localized in the parietal (13 cases) and occipital (11 cases) lobes. Moreover, cytotoxic edema (2 cases), pathologic contrast enhancement (1 case), and hemorrhage (3 cases) were isolated on MRI. The outcome after specific management was favorable after the first onset in 13 cases and death occurred in 3 patients. Relapses were observed in 4 patients. CONCLUSION Clinical features presented by children with PRES are variable and non-specific. MRI typically shows reversible posterior cerebral edema. However, in some cases, atypical neuro-imaging findings, such as cytotoxic edema infarction, hemorrhage and contrast enhancement can be observed.
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Affiliation(s)
- Houda Ajmi
- Department of Pediatrics, Sahloul Teaching Hospital, 4054, Sousse, Tunisia.
| | - Jawher Brahim
- Department of Pediatrics, Sahloul Teaching Hospital, 4054, Sousse, Tunisia
| | - Sameh Mabrouk
- Department of Pediatrics, Sahloul Teaching Hospital, 4054, Sousse, Tunisia
| | - Amel Ben Abdallah
- Department of Radiology, Sahloul Teaching Hospital, 4054, Sousse, Tunisia
| | - Noura Zouari
- Department of Pediatrics, Sahloul Teaching Hospital, 4054, Sousse, Tunisia
| | - Fadoua Majdoub
- Department of Pediatrics, Sahloul Teaching Hospital, 4054, Sousse, Tunisia
| | - Salsabil Nouir
- Department of Pediatrics, Sahloul Teaching Hospital, 4054, Sousse, Tunisia
| | - Ibtissem Hasni
- Department of Radiology, Sahloul Teaching Hospital, 4054, Sousse, Tunisia
| | - Yasser Ben Cheikh
- Department of Radiology, Sahloul Teaching Hospital, 4054, Sousse, Tunisia
| | - Jalel Chemli
- Department of Pediatrics, Sahloul Teaching Hospital, 4054, Sousse, Tunisia
| | - Hela Jemni
- Department of Radiology, Sahloul Teaching Hospital, 4054, Sousse, Tunisia
| | - Saoussan Abroug
- Department of Pediatrics, Sahloul Teaching Hospital, 4054, Sousse, Tunisia
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Gün E, Akova BŞ, Botan E, Çelik DB, Balaban B, Özen H, Gencay AG, Bektaş Ö, Fitoz S, Kendirli T. Clinical features and outcomes of children admitted to the pediatric intensive care unit due to posterior reversible encephalopathy syndrome. Clin Neurol Neurosurg 2022; 222:107476. [DOI: 10.1016/j.clineuro.2022.107476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 01/03/2022] [Accepted: 09/27/2022] [Indexed: 11/03/2022]
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Pringle C, Portwood K, Viamonte MA, Rajderkar D. Imaging Findings in Neonatal and Pediatric Posterior Reversible Encephalopathy Syndrome (PRES) Differ From Adults. Pediatr Neurol 2022; 135:6-11. [PMID: 35963074 PMCID: PMC9903994 DOI: 10.1016/j.pediatrneurol.2022.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 06/22/2022] [Accepted: 06/27/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is classically a reversible clinical radiographic syndrome associated with predominantly posterior leukoencephalopathy on neuroimaging. Magnetic resonance imaging (MRI) in adults demonstrates almost universally reversible parietal-occipital disease. We aimed to demonstrate in a cohort of children that "atypical" distribution is expected, acutely and on follow-up. METHODS A retrospective review of children diagnosed with PRES from 2010 to 2018 at our children's hospital was performed. All had MRI at diagnoses, with over half having follow-up MRIs. Images were reviewed by a neuroradiology-trained pediatric radiologist for confirmation of findings consistent with PRES/identification of involved regions. RESULTS Nineteen patients (aged zero to 18 years, 53% female) were included. Notably, two were infants. Nearly all had seizures; all had altered mental status and hypertension. Fifteen (84%) had MRI described as "atypical." Distribution of MRI findings was anatomically widespread, including nine with frontal findings. Twelve (63%) had follow-up imaging, of which approximately half remained abnormal. CONCLUSIONS Pediatric PRES MRI findings were more often atypical at time of diagnosis. Vasogenic edema related to the acute phases of PRES typically resolved; however, follow-up imaging identified new volume loss in the areas affected. Two of our subjects were younger than 13 months, younger than typically described. Our series demonstrates that imaging distribution in children with PRES does not mirror the classical posterior, reversible distribution described in adults and continues the recent trend of identifying PRES in infants.
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Affiliation(s)
- Charlene Pringle
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida.
| | - Katherin Portwood
- Division of Pediatric Neurology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida
| | - Manuel A Viamonte
- Division of Pediatric Critical Care, Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Dhanashree Rajderkar
- Division of Pediatric Radiology, Department of Radiology, University of Florida College of Medicine, Gainesville, Florida
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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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Egoryan G, Murguia-Fuentes R, Agab M, Abou-Ghanem N, Yanez-Bello MA, Pyakuryal B, Trelles-Garcia DP, Ibrahim R, Filipiuk D, Gidron A, Rodriguez-Nava G. Posterior reversible encephalopathy syndrome in a patient with Richter's syndrome on combination DA-R-EPOCH chemotherapy regimen: a case report. J Med Case Rep 2021; 15:161. [PMID: 33840384 PMCID: PMC8040238 DOI: 10.1186/s13256-021-02780-y] [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: 01/25/2021] [Accepted: 03/10/2021] [Indexed: 12/03/2022] Open
Abstract
Background Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiologic entity characterized by headaches, altered mental status, seizures, visual loss, and a characteristic imaging pattern in brain magnetic resonance images. The exact etiology and pathogenesis of this condition are not yet fully elucidated. Case presentation A 72-year-old White man presented with 2 weeks of low-grade fever and chills, night sweats, fatigue, dysphagia, and new-onset rapidly increasing cervical lymphadenopathy. He had a history of chronic lymphocytic leukemia with transformation to diffuse large B-cell lymphoma for which he was started on dose-adjusted rituximab, etoposide, prednisone vincristine, cyclophosphamide, and doxorubicin (DA-R-EPOCH). Shortly after treatment initiation, the patient developed severe airway obstruction due to cervical lymphadenopathy that required emergency intubation. A few days later, the cervical lymphadenopathy and the status of the airway improved, and sedation was consequently weaned off to plan for extubation. However, the patient did not recover consciousness and developed generalized refractory seizures. Brain magnetic resonance imaging revealed edema in the cortical gray and subcortical white matter of the bilateral occipital and inferior temporal lobes, consistent with PRES. Conclusions Posterior reversible encephalopathy syndrome refers to a neurological disorder and imaging entity characterized by subcortical vasogenic edema in patients who develop acute neurological signs and symptoms of a usually reversible nature in different settings, including chemotherapy. Despite its name, PRES is not always fully reversible, and permanent sequelae can persist in some patients. Clinicians should be aware of the possible association between chemotherapy and PRES to ensure early recognition and timely treatment.
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Affiliation(s)
- Goar Egoryan
- Department of Internal Medicine, AMITA Health Saint Francis Hospital, 355 Ridge Ave, Evanston, IL, 60202, USA.
| | - Ricardo Murguia-Fuentes
- Department of Neurology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Mohamed Agab
- Department of Internal Medicine, AMITA Health Saint Francis Hospital, 355 Ridge Ave, Evanston, IL, 60202, USA
| | - Nagwa Abou-Ghanem
- Department of Internal Medicine, AMITA Health Saint Francis Hospital, 355 Ridge Ave, Evanston, IL, 60202, USA
| | - Maria Adriana Yanez-Bello
- Department of Internal Medicine, AMITA Health Saint Francis Hospital, 355 Ridge Ave, Evanston, IL, 60202, USA
| | - Bimatshu Pyakuryal
- Department of Internal Medicine, AMITA Health Saint Francis Hospital, 355 Ridge Ave, Evanston, IL, 60202, USA
| | | | - Rami Ibrahim
- Department of Radiology, AMITA Health Saint Francis Hospital, Evanston, IL, USA
| | - Dorota Filipiuk
- Department of Pathology, AMITA Health Saint Francis Hospital, Evanston, IL, USA
| | - Adi Gidron
- Department of Hematology-Oncology, AMITA Health Saint Francis Hospital, Evanston, IL, USA
| | - Guillermo Rodriguez-Nava
- Department of Internal Medicine, AMITA Health Saint Francis Hospital, 355 Ridge Ave, Evanston, IL, 60202, USA
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Fisler G, Monty MA, Kohn N, Assaad P, Trope R, Kessel A. Characteristics and Outcomes of Critically Ill Pediatric Patients with Posterior Reversible Encephalopathy Syndrome. Neurocrit Care 2021; 32:145-151. [PMID: 31069660 DOI: 10.1007/s12028-019-00720-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVE Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiologic entity, typically manifesting as reversible neurological symptoms and signs of white matter edema on magnetic resonance imaging. PRES has been widely described in adults. Studies of PRES in children are mostly limited to case series and case controls. METHODS Retrospective chart review of patients under 21 years with PRES admitted at a tertiary children's hospital from 2011 to 2016. They were compared to controls matched for age and mortality risk using the Pediatric Index of Mortality-2 score.
RESULTS: Sixteen cases of PRES were identified in 13 patients (ages 5-17 years, 46% male). PRES presented with altered mental status (75%), seizures (77%), headache (31%), and vision changes (23%). In patients who recovered (n = 11), median days to symptom resolution was three (range 1-8). PRES patients had a higher mortality rate (15% vs. 5%, p < 0.05) and higher mean length of stay (13.1 vs. 4.6 days) and were more likely to have autoimmune disease (p < 0.05), immunosuppression (p < 0.05), and anemia (p < 0.05). No PRES patients were diagnosed with epilepsy by last known follow-up, and all of whom had been started on an antiepileptic drug were discontinued within 13 months. Sepsis was suspected in 53% of PRES patients and 59% of controls (p = 1.00). All PRES patients had stage II hypertension, versus 41% of controls (p < 0.05). Average creatinine in PRES was 2.35 mg/dL compared to 0.90 mg/dL in controls (p < 0.05). PRES patients had lower serum calcium (p < 0.05). After correcting for albumin, no association between PRES and hypocalcemia remained. PRES patients had a higher length of stay (13.1 vs. 4.6 days, p < 0.05) and mortality rate (15% vs. 3%, p < 0.05). CONCLUSIONS Immunosuppression, autoimmune disease, renal insufficiency, anemia, and hypertension are associated with PRES after controlling for mortality risk in critically ill children. There was no association between corrected serum calcium and sepsis with PRES.
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Affiliation(s)
- Grace Fisler
- Department of Pediatrics, Graduate Medical Education Office, Steven and Alexandra Cohen Children's Medical Center of New York, 269-01 76th Ave New, Hyde Park, NY, 11040, USA.
| | - Mikhaela A Monty
- Department of Pediatrics, Hasbro Children's Hospital, 593 Eddy Street, Providence, RI, 02903, USA
| | - Nina Kohn
- Biostatistics Unit, Feinstein Institute for Medical Research, 125 Community Drive, Great Neck, NY, 11021, USA
| | - Peter Assaad
- Department of Pediatric Radiology, Steven and Alexandra Cohen Children's Medical Center of New York, 269-01 76th Ave, New Hyde Park, NY, 11040, USA
| | - Randi Trope
- Pediatric Critical Care Medicine, Steven and Alexandra Cohen Children's Medical Center of New York, 269-01 76th Ave, New Hyde Park, NY, 11040, USA
| | - Aaron Kessel
- Pediatric Critical Care Medicine, Steven and Alexandra Cohen Children's Medical Center of New York, 269-01 76th Ave, New Hyde Park, NY, 11040, USA
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Mandal D, Khanal D, Phuyal R, Bhatta A. Posterior Reversible Encephalopathy Syndrome in a Patient with Post Streptococcal Glomerulonephritis: A Case Report. JNMA J Nepal Med Assoc 2020; 58:1072-1074. [PMID: 34506399 PMCID: PMC8028524 DOI: 10.31729/jnma.5065] [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: 05/30/2020] [Accepted: 12/29/2020] [Indexed: 11/02/2022] Open
Abstract
Posterior reversible encephalopathy syndrome is a clinical-radiological syndrome neurological disorder with varied symptoms which include headache, visual field defects, seizures, altered consciousness. It is a rare complication of post-streptococcal glomerulonephritis and results in life-threatening manifestations if not managed on time. Although reversible by definition, complications like status epilepticus, intracranial hemorrhage, and ischemic infarction may lead to mortality and morbidity. We report a case of a 9-year-old female patient with posterior reversible encephalopathy syndrome who presented with multiple episodes of seizures and bilateral painless loss of vision for 1 day. Due to her severity, a computed tomography scan was sent which revealed a hypodense lesion in the brain. She was admitted to the pediatric intensive care unit and managed with supportive care for 6 days where she died on the 6th day. Vital signs are simple but important and if overlooked can lead to a series of complicated events.
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Affiliation(s)
- Deependra Mandal
- Kathmandu Medical College and Teaching Hospital, Sinamangal, Kathmandu, Nepal
| | - Deepa Khanal
- Department of Pediatrics, Kathmandu Medical College and Teaching Hospital, Sinamangal, Kathmandu, Nepal
| | - Rajan Phuyal
- Department of Pediatrics, Kathmandu Medical College and Teaching Hospital, Sinamangal, Kathmandu, Nepal
| | - Anwesh Bhatta
- Department of Pediatrics, Kathmandu Medical College and Teaching Hospital, Sinamangal, Kathmandu, Nepal
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Posterior Reversible Encephalopathy Syndrome Following Failure of Conservative Management in Renal Trauma: Case Report. Urology 2020; 145:247-249. [DOI: 10.1016/j.urology.2020.05.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 05/25/2020] [Indexed: 11/19/2022]
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Posterior Reversible Encephalopathy Syndrome after Allogeneic Stem Cell Transplantation in Pediatric Patients with Fanconi Anemia, a Prospective Study. Biol Blood Marrow Transplant 2020; 26:e316-e321. [PMID: 32860910 DOI: 10.1016/j.bbmt.2020.08.021] [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] [Received: 06/07/2020] [Revised: 07/20/2020] [Accepted: 08/16/2020] [Indexed: 12/15/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is one of the most common neurologic complications following hematopoietic stem cell transplantation (HSCT). We aimed to evaluate the incidence, clinical, and imaging features of PRES in pediatric patients with Fanconi anemia (FA) following HSCT. This prospective study included all post-HSCT patients with underlying FA disease between 2014 and 2017. Brain computed tomography scan and magnetic resonance imaging (MRI) were performed in all individuals who developed neurologic symptoms. PRES was diagnosed based on clinic-radiological evidence. Follow-up MRI was performed in all patients with PRES within two months. Forty-one patients with FA (28 males; mean age, 8.19 ± 3.25 years) were enrolled. Out of 15 patients with acute neurologic symptoms, PRES was diagnosed in 9 individuals (21.95% of the total cohort). The occurrence of PRES was significantly higher in patients who had a donor with a 1-locus mismatch (P= .02). Donor relation, stem cell source, and graft-versus-host disease grade did not have any significant association with the development of PRES. MRI showed asymmetric vasogenic edema in 5 patients, an overt infarct in 1 patient, and foci of microhemorrhages in 3 patients, 1 of whom developed a hemorrhagic infarct. This patient died shortly, and persistent microhemorrhages were noted in the other 2 patients. Our findings demonstrate a greater risk of developing PRES after HSCT in patients with FA compared with those with other diseases (21.95% versus 1% to 10%), and in contrast to its term, it might be irreversible and has adverse effects on HSCT outcomes. The increased vascular and endothelial fragility in FA may contribute to the higher frequency of PRES in these individuals.
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Prognostic factors and seizure outcome in posterior reversible encephalopathy syndrome (PRES) in children with hematological malignancies and bone marrow failure: A retrospective monocentric study. Seizure 2019; 72:1-10. [PMID: 31521834 DOI: 10.1016/j.seizure.2019.08.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 07/10/2019] [Accepted: 08/14/2019] [Indexed: 01/15/2023] Open
Abstract
PURPOSE The aim of this study was to evaluate seizure outcome in children with hematological malignancies and PRES and to identify prognostic factors that could help manage the syndrome. METHOD We retrospectively reviewed the report data of 21 patients diagnosed with hematological malignancy or aplastic anemia and PRES between 2008 and 2018. Basic demographic data, oncology treatment, presymptomatic hypertension before PRES manifestation, neurological status, seizure type, and EEG and MRI findings at PRES onset and at the one-year follow-up visit were studied. Patients who developed remote symptomatic seizures or epilepsy were identified. RESULTS We included 21 children (11 females and 10 males) in the study. Sixteen patients (76.2%) were diagnosed with ALL and the rest individually with AML, CML, T-lymphoma, Burkitt lymphoma, and severe aplastic anemia. Presymptomatic hypertension (PSH) was evaluated in 19 patients and was present in 18 (94.7%). The duration was 9 h and more in 16 patients (88.8%); the severity was grade II in 12 patients (66.7%). Seizures as the initial symptom of PRES were present in 17 patients (80.9%). Four patients (19.0%) were assessed with remote symptomatic seizures. Two of them (9.5%) had ongoing seizures at the one-year follow-up visit and were diagnosed with epilepsy. The presence of gliosis on follow-up MRI indicated worse outcome with development of epilepsy (without statistical significance). CONCLUSIONS PRES syndrome has an overall good prognosis and the evolution to epilepsy is rare. The severity and duration of PSH or seizure severity and EEG findings at PRES onsetwere not associated with worse neurological outcomes in this study.
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Posterior reversible encephalopathy syndrome: a case report. NEUROLOGÍA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.nrleng.2018.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Fonseca J, Oliveira K, Cordeiro M, Real M. Síndrome de encefalopatía posterior reversible: a propósito de un caso clínico. Neurologia 2019; 34:135-137. [DOI: 10.1016/j.nrl.2016.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 07/21/2016] [Accepted: 07/25/2016] [Indexed: 10/20/2022] Open
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Komori A, Mizu D, Ariyoshi K. Posterior Reversible Encephalopathy Syndrome: A Rare Childhood Case with Unconsciousness. J Emerg Med 2018; 54:540-543. [PMID: 29338905 DOI: 10.1016/j.jemermed.2017.12.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 11/10/2017] [Accepted: 12/01/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a condition characterized by seizures, altered consciousness, visual disturbances, and headache. Characteristic findings on neuroimaging include cerebral edema, typically involving the parieto-occipital white matter. PRES has been associated with hypertension, autoimmune disease, and Henoch-Schölein purpura (HSP), but few cases have been reported, and fewer cases of PRES have been reported in children. CASE REPORT We report the case of a 4-year-old girl who presented with blindness and semi-consciousness. The patient had no significant medical history and no abnormalities on physical examination or laboratory testing, although she had slightly elevated blood pressure. After hospitalization, the patient showed some characteristic signs of HSP and cranial magnetic resonance imaging revealed PRES as the cause of semi-consciousness. In our discussion, we examine the clinical features of PRES and remarkable points for the clinical diagnosis and management of this rare but important disease. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although reports of PRES in children are rare, PRES should be considered in the differential diagnosis of children presenting with disturbance of consciousness. Emergency physicians should consult with pediatric physicians to confirm diagnoses of PRES and determine an appropriate treatment plan, given its variable etiology. Measurements of blood pressure, which are often missing in pediatric cases, can help physicians to arrive at a correct diagnosis.
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Affiliation(s)
- Akira Komori
- Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Daisuke Mizu
- Kobe City Medical Center General Hospital, Hyogo, Japan
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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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Shkalim-Zemer V, Konen O, Levinsky Y, Michaeli O, Yahel A, Krauss A, Yaniv I, Stein J. Calcineurin inhibitor-free strategies for prophylaxis and treatment of GVHD in children with posterior reversible encephalopathy syndrome after stem cell transplantation. Pediatr Blood Cancer 2017; 64. [PMID: 28417553 DOI: 10.1002/pbc.26531] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 02/20/2017] [Accepted: 02/23/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a distinct clinico-radiologic entity that can occur following allogeneic hematopoietic stem cell transplantation, often in the context of treatment with calcineurin inhibitors (CNIs). PROCEDURE We describe the results of CNI-free management of 14 children with PRES and review the clinical and radiologic manifestations of their presentation. RESULTS Discontinuation of CNIs usually resulted in remission of PRES, but patients with established graft versus host disease (GVHD) at the time when treatment was changed often experienced progressive GVHD despite administration of immune suppressive and modulating treatments. All but three patients experienced full neurologic recovery. Nine children died as a result of either GVHD, disease relapse, or severe infection. CONCLUSIONS Discontinuation of CNIs results in neurologic improvement in most cases, but superior alternative immune modulatory treatment is needed to prevent progression of established GVHD.
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Affiliation(s)
- Vered Shkalim-Zemer
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Osnat Konen
- Department of Imaging, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoel Levinsky
- Department of Pediatrics B, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Orli Michaeli
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Anat Yahel
- Bone Marrow Transplant Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Aviva Krauss
- Bone Marrow Transplant Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Isaac Yaniv
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jerry Stein
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Bone Marrow Transplant Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Ninomiya I, Kanazawa M, Akaiwa Y, Shimohata T, Okamoto K, Onodera O, Nishizawa M. Apparent diffusion coefficient reduction might be a predictor of poor outcome in patients with posterior reversible encephalopathy syndrome. J Neurol Sci 2017; 381:1-3. [PMID: 28991655 DOI: 10.1016/j.jns.2017.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 08/01/2017] [Accepted: 08/02/2017] [Indexed: 10/19/2022]
Abstract
It is thought that posterior reversible encephalopathy syndrome (PRES) is both clinically and radiologically reversible. However, its reversible nature has been challenged based on reports of permanent neurological impairments. The factors that predict the development of irreversible neurological impairment are still unclear. In the present study, we investigated clinical manifestations, laboratory findings, and neuroradiological images to identify predictors of functional outcomes in PRES. We investigated 23 PRES patients. Apparent diffusion coefficient (ADC) reduction was observed in 4 patients in the poor outcome group, whereas no patients presented ADC reduction in the favourable outcome group (p<0.01). Further studies are warranted to evaluate the association between ADC reduction and functional outcome after PRES.
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Affiliation(s)
- Itaru Ninomiya
- Department of Neurology, Brain Research Institute, Niigata University, 1-757 Asahimachi-dori, Niigata 951-8585, Japan
| | - Masato Kanazawa
- Department of Neurology, Brain Research Institute, Niigata University, 1-757 Asahimachi-dori, Niigata 951-8585, Japan.
| | - Yasuhisa Akaiwa
- Department of Neurology, Brain Research Institute, Niigata University, 1-757 Asahimachi-dori, Niigata 951-8585, Japan
| | - Takayoshi Shimohata
- Department of Neurology, Brain Research Institute, Niigata University, 1-757 Asahimachi-dori, Niigata 951-8585, Japan
| | - Kouichirou Okamoto
- Department of Neurosurgery, Brain Research Institute, Niigata University, 1-757 Asahimachi-dori, Niigata 951-8585, Japan
| | - Osamu Onodera
- Department of Neurology, Brain Research Institute, Niigata University, 1-757 Asahimachi-dori, Niigata 951-8585, Japan
| | - Masatoyo Nishizawa
- Department of Neurology, Brain Research Institute, Niigata University, 1-757 Asahimachi-dori, Niigata 951-8585, Japan
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dos Santos D, Langer FW, dos Santos T, Rafael Tronco Alves G, Feiten M, Teixeira de Paula Neto W. Posterior reversible encephalopathy syndrome as a complication of Henoch–Schönlein purpura in a seven-year-old girl. Scott Med J 2017; 62:34-37. [DOI: 10.1177/0036933017690467] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Henoch–Schönlein purpura is a multisystem small vessel vasculitis. Neurologic manifestations are uncommon. Posterior reversible encephalopathy syndrome is a rare complication of Henoch–Schönlein purpura with typical clinical and neuroimaging findings that occurs most commonly in the setting of severe hypertension and renal injury. Case presentation A seven-year-old girl was admitted to our institution presenting with clinical and laboratory findings suggestive of Henoch–Schönlein purpura. Glucocorticoid therapy was initiated, but five days following her admission, she developed altered consciousness, seizures, arterial hypertension, and cortical blindness. Brain MRI scan revealed areas of vasogenic oedema in parieto-occipital lobes, consistent with posterior reversible encephalopathy syndrome. She was immediately initiated on antihypertensives and antiepileptics, which successfully improved her neurologic symptoms. Further laboratory work-up disclosed a rapidly progressive glomerulonephritis secondary to Henoch–Schönlein purpura that was the likely cause of her sudden blood pressure elevation. Immunosuppressive therapy was undertaken, and at one-year follow-up, the patient exhibited complete renal and neurologic recovery. Conclusion Posterior reversible encephalopathy syndrome is a severe complication of Henoch–Schönlein purpura. If promptly diagnosed and treated, children with Henoch–Schönlein purpura presenting with posterior reversible encephalopathy syndrome usually have a good prognosis. Clinicians should be familiar with the characteristic presentation of posterior reversible encephalopathy syndrome and be aware that hypertension and renal injury may predispose Henoch–Schönlein purpura patients to developing this complication.
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Affiliation(s)
- Daiane dos Santos
- Department of Radiology and Imaging Diagnosis, University Hospital of Santa Maria, Federal University of Santa Maria, Brazil
| | - Felipe Welter Langer
- Department of Radiology and Imaging Diagnosis, University Hospital of Santa Maria, Federal University of Santa Maria, Brazil
| | | | - Giordano Rafael Tronco Alves
- Department of Radiology and Imaging Diagnosis, University Hospital of Santa Maria, Federal University of Santa Maria, Brazil
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Fischer M, Schmutzhard E. Posterior reversible encephalopathy syndrome. J Neurol 2017; 264:1608-1616. [PMID: 28054130 PMCID: PMC5533845 DOI: 10.1007/s00415-016-8377-8] [Citation(s) in RCA: 268] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 12/16/2016] [Accepted: 12/19/2016] [Indexed: 12/02/2022]
Abstract
The posterior reversible encephalopathy syndrome (PRES) is a neurological disorder of (sub)acute onset characterized by varied neurological symptoms, which may include headache, impaired visual acuity or visual field deficits, disorders of consciousness, confusion, seizures, and focal neurological deficits. In a majority of patients the clinical presentation includes elevated arterial blood pressure up to hypertensive emergencies. Neuroimaging, in particular magnetic resonance imaging, frequently shows a distinctive parieto-occipital pattern with a symmetric distribution of changes reflecting vasogenic edema. PRES frequently develops in the context of cytotoxic medication, (pre)eclampsia, sepsis, renal disease or autoimmune disorders. The treatment is symptomatic and is determined by the underlying condition. The overall prognosis is favorable, since clinical symptoms as well as imaging lesions are reversible in most patients. However, neurological sequelae including long-term epilepsy may persist in individual cases.
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Affiliation(s)
- Marlene Fischer
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Erich Schmutzhard
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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Habetz K, Ramakrishnaiah R, Raina SK, Fitzgerald RT, Hinduja A. Posterior Reversible Encephalopathy Syndrome: A Comparative Study of Pediatric Versus Adult Patients. Pediatr Neurol 2016; 65:45-51. [PMID: 27720711 DOI: 10.1016/j.pediatrneurol.2016.09.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/31/2016] [Accepted: 09/04/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is an acute neurotoxic syndrome that, although characteristically reversible, can result in long-term disability. Our aim was to identify the clinical and radiological factors that are unique to children with PRES compared with adults with the syndrome in a single center. METHODS We retrospectively reviewed the clinical and radiological records of all patients with PRES admitted at a tertiary care medical center from 2007 to 2014. All patients who met the clinical and radiological criteria for PRES were dichotomized into children (less than 18 years) and adults (18 years or older) based on their age groups, and comparison of their baseline variables, clinical, laboratory, and imaging features was performed. RESULTS During this study period, 19 pediatric patients and 100 adult patients with PRES were identified. On univariate analysis, factors significantly associated with pediatric patients with the syndrome were multiorgan failure (84.2% vs 50%, P = 0.006), temporal lobe involvement (63.3% vs 39%, P = 0.04), restricted diffusion (42.1% vs 18%, P = 0.02), and less likelihood of cerebellar involvement (21.1% vs 57%, P = 0.004). On bivariate logistic regression analysis, all these factors remained significantly associated with pediatric PRES; multiorgan failure (odds ratio: 5.80, 95% confidence interval: 1.45 to 29.41, P = 0.03), temporal lobe involvement (odds ratio: 5.08, 95% confidence interval: 1.17 to 22.17, P = 0.03), restricted diffusion (odds ratio: 2.48, 95% confidence interval: 1.61 to 10.10, P = 0.02), and less likely to have cerebellar involvement (odds ratio: 0.08, 95% confidence interval: 0.002 to 0.39, P = 0.002). CONCLUSIONS Factors unique to PRES in children compared with adults include a greater propensity with multi-organ failure, involvement of the temporal lobe, and restricted diffusion on imaging.
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Affiliation(s)
- Kenneth Habetz
- Department of Pediatric Neurology, Arkansas Children Hospital, Little Rock, Arkansas
| | - Raghu Ramakrishnaiah
- Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Sunil Kumar Raina
- Department of Community Medicine, Dr. Rajendra Prasad Government Medical College, Tanda, India
| | - Ryan T Fitzgerald
- Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Archana Hinduja
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, Arkansas; Department of Neurology, Ohio State University Wexner Medical Center, Columbus, Ohio.
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A rare case of acute posterior reversible encephalopathy syndrome involving brainstem in a child. JOURNAL OF ACUTE DISEASE 2016. [DOI: 10.1016/j.joad.2016.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Shields LBE, Johnson JR, Shields CB. Posterior reversible encephalopathy syndrome following a thoracic discectomy–induced dural leak: case report. J Neurosurg Spine 2016; 25:586-590. [DOI: 10.3171/2016.4.spine1623] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological syndrome characterized by headaches, altered mental status, seizures, and visual disturbances. Classic MRI findings include white matter changes of the parieto-occipital regions. This syndrome has been encountered in myriad medical illnesses, including hypertension, preeclampsia/eclampsia, and immunosuppressive conditions. While the pathogenesis of the disorder is unclear, vasoconstriction and hypoperfusion leading to brain ischemia and vasogenic edema have been implicated as potential mechanisms. The authors present, to the best of their knowledge, the first case of PRES following a thoracic spinal surgery–induced dural leak noted on resection of the fifth rib during a thoracotomy for a T4–5 discectomy. Brain MRI revealed large areas of increased FLAIR and T2 hyperintensity in the superior posterior frontal lobes, superior and medial parietal lobes, and bilateral occipital lobes. Following repair of the CSF leak, the patient's symptoms resolved. Spinal surgeons should be alert to the potentially life-threatening condition of PRES, especially in a hypertensive patient who experiences surgery-induced dural leakage. The development of a severe positional headache with neurological signs is a red flag that suggests the presence of PRES. Prompt attention to the diagnosis and treatment of this condition by repairing the dural leak via surgery or expeditious blood patch increases the likelihood of a favorable outcome.
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Affiliation(s)
| | | | - Christopher B. Shields
- 1Norton Neuroscience Institute,
- 2Norton Healthcare; and
- 3Department of Anatomical Science and Neurobiology, University of Louisville, School of Medicine, Louisville, Kentucky
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Fischer M, Schmutzhard E. [Posterior reversible encephalopathy syndrome]. Med Klin Intensivmed Notfmed 2016; 111:417-24. [PMID: 27272329 DOI: 10.1007/s00063-016-0175-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 04/08/2016] [Indexed: 01/30/2023]
Abstract
Posterior reversible encephalopathy syndrome refers to a neurological disorder characterized by headache, disorders of consciousness, visual disturbances, epileptic seizures, and subcortical vasogenic edema. About two thirds of patients develop neurological symptoms, which are associated with blood pressure fluctuations. One hypothesis is that hypertensive episodes cause autoregulatory failure, and values above the upper limit of cerebral autoregulation result in a breakthrough followed by hyperperfusion and blood-brain barrier dysfunction. In another hypothesis, endothelial dysfunction triggered by numerous factors including preeclampsia, immunosuppressive agents, chemotherapeutics, sepsis, or autoimmune disorders is thought to be the key pathomechanism. Endo- or exogenic toxic agents including pharmacological substances, cytokines, or bacterial toxins are supposed to trigger endothelial activation and dysfunction resulting in the release of vasoconstrictors, pro-inflammatory mediators, and vascular leakage. Diagnosis is usually based on clinical and neuroimaging findings that frequently show a bilateral, symmetric, and parietooccipital pattern. However, the diagnosis can often only be confirmed during the course of disease after excluding important differential diagnoses. Currently, there is no specific treatment available. Lowering of arterial blood pressure and eliminating the underlying cause usually leads to an improvement of clinical and neuroradiological findings. Admission to a critical care unit is required in about 40 % of patients due to complicating conditions including status epilepticus, cerebral vasoconstriction, ischemia, or intracerebral hemorrhage. Prognosis is favorable; in the majority of patients neurological deficits and imaging findings resolve completely.
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Affiliation(s)
- M Fischer
- Klinik und Poliklinik für Anästhesiologie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
| | - E Schmutzhard
- Universitätsklinik für Neurologie, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich.
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Sigurtà A, Terzi V, Regna-Gladin C, Fumagalli R. Posterior Reversible Encephalopathy Syndrome Complicating Traumatic Pancreatitis: A Pediatric Case Report. Medicine (Baltimore) 2016; 95:e3758. [PMID: 27258506 PMCID: PMC4900714 DOI: 10.1097/md.0000000000003758] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
We are reporting a case of posterior reversible encephalopathy syndrome (PRES) developed in an unusual clinical scenario without the presence of the most described symptoms. PRES is a neurological and radiological syndrome described in many different clinical conditions. In children it has been mostly reported in association with hematological and renal disorders.Our patient was a 15 years old boy, admitted to our intensive care unit for pancreatitis after blunt abdominal trauma.During the stay in the intensive care unit, he underwent multiple abdominal surgical interventions for pancreatitis complications. He had a difficult management of analgesia and sedation, being often agitated with high arterial pressure, and he developed a bacterial peritonitis. After 29 days his neurological conditions abruptly worsened with neuroimaging findings consistent with PRES. His clinical conditions progressively improved after sedation and arterial pressure control.He was discharged at home with complete resolution of the neurological and imaging signs 2 months later.The pathophysiology of PRES is controversial and involves disordered autoregulation ascribable to hypertension and endothelial dysfunction. In this case both hypertension and endothelial activation, triggered by sepsis and pancreatitis, could represent the culprits of PRES onset. Even if there is no specific treatment for this condition, a diagnosis is mandatory to start antihypertensive and supportive treatment. We are therefore suggesting to consider PRES in the differential diagnosis of a neurological deterioration preceded by hypertension and/or septic state, even without other "typical" clinical features.
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Affiliation(s)
- Anna Sigurtà
- From the School of Medicine and Surgery, University of Milano-Bicocca, Monza (AS, RF), Anesthesia and Critical Care Service 1, Department of Anesthesia and Critical Care, Niguarda Cà Granda Hospital (VT, RF), and Neuroradiology Unit, Department of Advanced Diagnostic-Therapeutic Technology, Niguarda Cà Granda Hospital (CR-G), Milan, Italy
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