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Sagir A, Ahuja S, Soliman LM, Farag E. Co-presentation of Posterior Reversible Encephalopathy Syndrome in a patient with Post Dural Puncture Headache. PAIN MEDICINE 2021; 23:1029-1031. [PMID: 34260726 DOI: 10.1093/pm/pnab216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Post Dural Puncture Headache (PDPH) is a well-known complication of neuraxial anesthesia, however the occurrence of seizures and vision loss within few days after dural puncture could be alarming. Posterior Reversible Encephalopathy Syndrome (PRES) is associated with reversible edema and leukoencephalopathy in the posterior parieto-occipital cortex. We report the co-presentation of PRES and PDPH after labor epidural analgesia. CASE PRESENTATION 25-year-old multiparous African-American woman was admitted for evaluation of new onset seizures and headache in the postpartum period. She had a recent history of multiple needle insertion attempts and inadvertent dural puncture during epidural analgesia for delivery. Soon after delivery, she was diagnosed with PDPH and was treated with epidural blood patch, with no relief of symptoms. Six days later, she developed sudden onset transient blindness, seizures and altered sensorium and magnetic resonance imaging (MRI) of the brain revealed white matter changes suggestive of PRES. CONCLUSION PRES is an uncommon complication of cerebrospinal fluid (CSF) leak and intracranial hypotension. We report the occurrence of PRES in a patient with no known risk factors, except a traumatic dural tap. Is it important to expand the differentials for headache after dural puncture to encompass PRES as a possibility, especially in patients with a delayed presentation of seizures and cortical blindness.
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Affiliation(s)
- Afrin Sagir
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
| | - Sanchit Ahuja
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH.,Department of Anesthesiology, Pain Management & Perioperative Medicine, Henry Ford Health Systems, Detroit, MI
| | - Loran M Soliman
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
| | - Ehab Farag
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH.,Department of Outcomes Research, Cleveland Clinic, Cleveland, OH
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Cantone M, Lanza G, Puglisi V, Vinciguerra L, Mandelli J, Fisicaro F, Pennisi M, Bella R, Ciurleo R, Bramanti A. Hypertensive Crisis in Acute Cerebrovascular Diseases Presenting at the Emergency Department: A Narrative Review. Brain Sci 2021; 11:brainsci11010070. [PMID: 33430236 PMCID: PMC7825668 DOI: 10.3390/brainsci11010070] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/02/2021] [Accepted: 01/04/2021] [Indexed: 02/07/2023] Open
Abstract
Hypertensive crisis, defined as an increase in systolic blood pressure >179 mmHg or diastolic blood pressure >109 mmHg, typically causes end-organ damage; the brain is an elective and early target, among others. The strong relationship between arterial hypertension and cerebrovascular diseases is supported by extensive evidence, with hypertension being the main modifiable risk factor for both ischemic and hemorrhagic stroke, especially when it is uncontrolled or rapidly increasing. However, despite the large amount of data on the preventive strategies and therapeutic measures that can be adopted, the management of high BP in patients with acute cerebrovascular diseases presenting at the emergency department is still an area of debate. Overall, the outcome of stroke patients with high blood pressure values basically depends on the occurrence of hypertensive emergency or hypertensive urgency, the treatment regimen adopted, the drug dosages and their timing, and certain stroke features. In this narrative review, we provide a timely update on the current treatment, debated issues, and future directions related to hypertensive crisis in patients referred to the emergency department because of an acute cerebrovascular event. This will also focus greater attention on the management of certain stroke-related, time-dependent interventions, such as intravenous thrombolysis and mechanic thrombectomy.
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Affiliation(s)
- Mariagiovanna Cantone
- Department of Neurology, Sant’Elia Hospital, ASP Caltanissetta, Via Luigi Russo, 6, 93100 Caltanissetta, Italy;
| | - Giuseppe Lanza
- Department of Surgery and Medical-Surgical Specialties, University of Catania, Via Santa Sofia, 78, 95123 Catania, Italy
- Department of Neurology IC, Oasi Research Institute—IRCCS, Via Conte Ruggero, 73, 94018 Troina, Italy
- Correspondence: or ; Tel.: +39-095-3782448
| | - Valentina Puglisi
- Department of Neurology and Stroke Unit, ASST Cremona, Viale Concordia, 1, 26100 Cremona, Italy; (V.P.); (L.V.)
| | - Luisa Vinciguerra
- Department of Neurology and Stroke Unit, ASST Cremona, Viale Concordia, 1, 26100 Cremona, Italy; (V.P.); (L.V.)
| | - Jaime Mandelli
- Department of Neurosurgery, Sant’Elia Hospital, ASP Caltanissetta, Via Luigi Russo, 6, 93100 Caltanissetta, Italy;
| | - Francesco Fisicaro
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia, 89, 95123 Catania, Italy; (F.F.); (M.P.)
| | - Manuela Pennisi
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia, 89, 95123 Catania, Italy; (F.F.); (M.P.)
| | - Rita Bella
- Department of Medical and Surgical Sciences and Advanced Technologies, University of Catania, Via Santa Sofia, 78, 95123 Catania, Italy;
| | - Rosella Ciurleo
- IRCCS Centro Neurolesi Bonino-Pulejo, S.S. 113, Via Palermo C/da Casazza, 98123 Messina, Italy; (R.C.); (A.B.)
| | - Alessia Bramanti
- IRCCS Centro Neurolesi Bonino-Pulejo, S.S. 113, Via Palermo C/da Casazza, 98123 Messina, Italy; (R.C.); (A.B.)
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3
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Hypertensive Crisis in Acute Cerebrovascular Diseases Presenting at the Emergency Department: A Narrative Review. Brain Sci 2021. [PMID: 33430236 DOI: 10.3390/brainsci11010070.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Hypertensive crisis, defined as an increase in systolic blood pressure >179 mmHg or diastolic blood pressure >109 mmHg, typically causes end-organ damage; the brain is an elective and early target, among others. The strong relationship between arterial hypertension and cerebrovascular diseases is supported by extensive evidence, with hypertension being the main modifiable risk factor for both ischemic and hemorrhagic stroke, especially when it is uncontrolled or rapidly increasing. However, despite the large amount of data on the preventive strategies and therapeutic measures that can be adopted, the management of high BP in patients with acute cerebrovascular diseases presenting at the emergency department is still an area of debate. Overall, the outcome of stroke patients with high blood pressure values basically depends on the occurrence of hypertensive emergency or hypertensive urgency, the treatment regimen adopted, the drug dosages and their timing, and certain stroke features. In this narrative review, we provide a timely update on the current treatment, debated issues, and future directions related to hypertensive crisis in patients referred to the emergency department because of an acute cerebrovascular event. This will also focus greater attention on the management of certain stroke-related, time-dependent interventions, such as intravenous thrombolysis and mechanic thrombectomy.
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4
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Chao AS, Chen YL, Chang YL, Chao A, Su SY, Wang TH. Severe pre-eclamptic women with headache: is posterior reversible encephalopathy syndrome an associated concurrent finding? BMC Pregnancy Childbirth 2020; 20:336. [PMID: 32487027 PMCID: PMC7268303 DOI: 10.1186/s12884-020-03017-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 05/15/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND A high incidence of posterior reversible encephalopathy syndrome (PRES) has been observed in women with eclampsia on imaging. However this association was documented mostly after convulsions occurred. This study aimed to detect the development of PRES using magnetic resonance imaging (MRI) in women with severe preeclampsia and headache, and evaluate the clinical and radiological findings in obstetric outcomes. METHODS A prospective single-center cohort study comprising 20 pregnant women with severe pre-eclampsia related headache was conducted using Numeric Rating Scale (NRS) score of ≧4. Additionally, non-contrast brain MRI was used to detect PRES and related radiological central nervous system (CNS) abnormalities. RESULTS Patients were enrolled at a mean gestational age of 32 weeks (range 29-38 weeks). Two women were unable to complete the scanning. Of the 18 MRI scans, 15 (83%) revealed abnormal findings. One patient developed an altered mental state and diffuse PRES, with the occipital, temporal, thalamus, and basal ganglia, the brain stem, and the cerebellum being affected. Two patients had abnormal susceptibility-weighted imaging (SWI) findings, indicating micro-hemorrhages. The majority (12 cases, 66%) of the patients had abnormal cortical hyperintensities in the occipital and temporal lobes. Only three patients had normal MRI pictures. None of the women had eclampsia occurred during the peripartum period, and only one unrelated neonatal death due to congenital anomalies. CONCLUSION A high incidence of abnormal cortical hyperintensity changes at locations typical for PRES on MRI was noted in women with severe pre-eclampsia and headache. These early hypertensive neurological signs allowed prompt and efficient obstetrical management, to prevent the development of eclampsia and PRES.
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Affiliation(s)
- An-Shine Chao
- Department of Obstetrics & Gynecology, Chang Gung Memorial Hospital and Chang Gung University, 5, Fu-Shin street, Kei-Shan, Tao-Yuan, 333 The People’s Republic of China
- Department of Obstetrics & Gynecology, New Taipei Municipal Tu Cheng Hospital, 6, Sec.2, Jincheng Road, Tu Cheng, New Taipei City, 236 Taiwan
| | - Yao-Liang Chen
- Department of Diagnostic Radiology, Keelung, Chang Gung Memorial Hospital and Chang Gung University, 222, Maijin Road, Keelung, Taiwan
| | - Yao-Lung Chang
- Department of Obstetrics & Gynecology, Chang Gung Memorial Hospital and Chang Gung University, 5, Fu-Shin street, Kei-Shan, Tao-Yuan, 333 The People’s Republic of China
| | - Angel Chao
- Department of Obstetrics & Gynecology, Chang Gung Memorial Hospital and Chang Gung University, 5, Fu-Shin street, Kei-Shan, Tao-Yuan, 333 The People’s Republic of China
| | - Seng-Yuan Su
- Department of Obstetrics & Gynecology, China Medical University HsinChu Hospital, Taiwan, 199, Sec., 1, Xinglong road, HsinChu, 302 Taiwan
| | - Tzu-Hao Wang
- Department of Obstetrics & Gynecology, Chang Gung Memorial Hospital and Chang Gung University, 5, Fu-Shin street, Kei-Shan, Tao-Yuan, 333 The People’s Republic of China
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Wang Q, Huang B, Shen G, Zeng Y, Chen Z, Lu C, Lerner A, Gao B. Blood-Brain Barrier Disruption as a Potential Target for Therapy in Posterior Reversible Encephalopathy Syndrome: Evidence From Multimodal MRI in Rats. Front Neurol 2019; 10:1211. [PMID: 31849806 PMCID: PMC6901929 DOI: 10.3389/fneur.2019.01211] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 10/30/2019] [Indexed: 12/16/2022] Open
Abstract
Background: To explore blood-brain barrier disruption in hypertensive posterior reversible encephalopathy syndrome. Methods: The hypertension rat models were successfully established and scanned on 7T micro-MRI. MRI parameter maps including apparent diffusion coefficient, T1 value, and perfusion metrics such as cerebral blood volume, cerebral blood flow, mean transit time and time to peak maps, were calculated. Results: The ADC values of the experimental group were higher than those of the control group both in cortical (P < 0.01) and subcortical (P < 0.05) regions. Voxel-wise analysis of ADC maps localized vasogenic edema primarily to the posterior portion of the brain. The increase in cerebral blood volume and cerebral blood flow values were found in the cortical and subcortical regions of rats with acute hypertension. No correlation was found between perfusion metrics and mean arterial pressure. The Evans blue dye content was higher in the posterior brain region than the anterior one (P < 0.05). Conclusions: Cerebral vasogenic edema resulting from acute hypertension supports the hypothesis of posterior reversible encephalopathy syndrome as the result of blood-brain barrier disruption, which maybe the potential therapeutic target for intervention.
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Affiliation(s)
- Quanlai Wang
- Department of Imaging, Zhoukou Central Hospital, Zhoukou, China.,Department of Radiology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Bin Huang
- Department of Radiology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Guiquan Shen
- Department of Radiology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Yu Zeng
- Department of Radiology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Zheng Chen
- Department of Radiology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Chunqiang Lu
- Jiangsu Key Laboratory of Molecular and Functional Imaging, Southeast University, Nanjing, China
| | - Alexander Lerner
- Division of Neuroradiology, Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Bo Gao
- Department of Radiology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
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Wajngarten M, Silva GS. Hypertension and Stroke: Update on Treatment. Eur Cardiol 2019; 14:111-115. [PMID: 31360232 PMCID: PMC6659031 DOI: 10.15420/ecr.2019.11.1] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 05/14/2019] [Indexed: 12/16/2022] Open
Abstract
Stroke is the second most common cause of mortality worldwide and the third most common cause of disability. Hypertension is the most prevalent risk factor for stroke. Stroke causes and haemodynamic consequences are heterogeneous which makes the management of blood pressure in stroke patients complex requiring an accurate diagnosis and precise definition of therapeutic goals. In this article, the authors provide an updated review on the management of arterial hypertension to prevent the first episode and the recurrence. They also present a discussion on blood pressure management in hypertensive urgencies and emergencies, especially in the acute phase of hypertensive encephalopathy, ischaemic stroke and haemorrhagic stroke.
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Affiliation(s)
| | - Gisele Sampaio Silva
- Neurology and Neurosurgery Department, Federal University of São Paulo Brazil.,Academic Research Organization, Hospital Israelita Albert Einstein São Paulo, Brazil
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Weiss ZF, Rich J, Wing EJ. Posterior reversible encephalopathy syndrome in a patient with HIV/AIDS and immune reconstitution syndrome: a case study and literature review. Oxf Med Case Reports 2018; 2018:omy046. [PMID: 30151215 PMCID: PMC6101588 DOI: 10.1093/omcr/omy046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 05/20/2018] [Indexed: 11/13/2022] Open
Abstract
The etiology of posterior reversible encephalopathy (PRES) is typically multifactorial. Patients with HIV are at risk for the development of this syndrome. We review 17 published cases of HIV and PRES and describe the second reported case of PRES in the setting of HIV and immune reconstitution syndrome (IRIS). IRIS has not yet been described as a risk factor for PRES.
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Affiliation(s)
- Zoe F Weiss
- Department of Internal Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Josiah Rich
- Division of Infectious Disease, Warren Alpert Medical School, Brown University, The Miriam Hospital, Providence, RI, USA
| | - Edward J Wing
- Division of Infectious Disease, Warren Alpert Medical School, Brown University, The Miriam Hospital, Providence, RI, USA
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8
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Yoon JE, Lee CY, Kim HW. Posterior Reversible Encephalopathy Syndrome after Head Trauma Surgery in Pediatric Patient without Any Underlying Disease. Korean J Neurotrauma 2017; 13:167-170. [PMID: 29201855 PMCID: PMC5702756 DOI: 10.13004/kjnt.2017.13.2.167] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 09/11/2017] [Accepted: 09/14/2017] [Indexed: 01/05/2023] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a neurological disorder characterized by signs of posterior cerebral edema upon radiographic examination. A 16-year-old girl was involved in motorcycle accident and depressed frontal fracture was presented. She had generalized seizures 3 days after dural repair and fracture reduction. Signal changes was noted on both parietal lobes in the magnetic resonance images and it was completely resolved in 3 months follow-up. We would like to present the case that demonstrated PRES related hypertension after head trauma surgery for cerebrospinal fluid leakage in pediatric patient without any underlying disease.
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Affiliation(s)
- Jae Eon Yoon
- Department of Neurosurgery, Konyang University Hospital, Konyang University Collge of Medicine, Daejeon, Korea
| | - Cheol Young Lee
- Department of Neurosurgery, Konyang University Hospital, Konyang University Collge of Medicine, Daejeon, Korea
| | - Hyun Woo Kim
- Department of Neurosurgery, Konyang University Hospital, Konyang University Collge of Medicine, Daejeon, Korea
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Abstract
Preeclampsia is a hypertensive, multisystem disorder of pregnancy that affects several organ systems, including the maternal brain. Cerebrovascular dysfunction during preeclampsia can lead to cerebral edema, seizures, stroke, and potentially maternal mortality. This review will discuss the effects of preeclampsia on the cerebrovasculature that may adversely affect the maternal brain, including cerebral blood flow (CBF) autoregulation and blood-brain barrier disruption and the resultant clinical outcomes including posterior reversible encephalopathy syndrome (PRES) and maternal stroke. Potential long-term cognitive outcomes of preeclampsia and the role of the cerebrovasculature are also reviewed.
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Affiliation(s)
- Erica Shields Hammer
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Vermont, Burlington, VT, USA,
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10
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Schreurs MP, Cipolla MJ, Al-Nasiry S, Peeters LLH, Spaanderman MEA. Formerly eclamptic women have lower nonpregnant blood pressure compared with formerly pre-eclamptic women: a retrospective cohort study. BJOG 2015; 122:1403-9. [PMID: 25753846 DOI: 10.1111/1471-0528.13285] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2014] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To compare nonpregnant blood pressure and circulating metabolic factors between formerly pre-eclamptic women who did and did not deteriorate to eclampsia. DESIGN Retrospective observational cohort study. SETTING Tertiary referral centre. POPULATION Formerly pre-eclamptic women with (n = 88) and without (n = 698) superimposed eclampsia. METHODS Women who experienced pre-eclampsia with or without superimposed eclampsia during their pregnancy or puerperium were tested for possible underlying cardiovascular risk factors at least 6 months postpartum. We measured blood pressure and determined cardiovascular and metabolic risk markers in a fasting blood sample. Groups were compared using Mann-Whitney U test, Spearman's Rho test or Fisher's Exact test (odds ratios). MAIN OUTCOME MEASURES Differences in postpartum blood pressures and features of the metabolic syndrome between formerly pre-eclamptic and formerly eclamptic women. RESULTS Formerly pre-eclamptic women who developed eclampsia differed from their counterparts without eclampsia by a lower blood pressure (P < 0.01) with blood pressure correlating inversely with the likelihood of having experienced eclampsia (P < 0.001). In addition, formerly eclamptic women had higher circulating C-reactive protein levels than formerly pre-eclamptic women (P < 0.05). All other circulating metabolic factors were comparable. Finally, 40% of all eclamptic cases occurred in the puerperium. CONCLUSIONS Formerly pre-eclamptic women with superimposed eclampsia have lower nonpregnant blood pressure compared with their counterparts without neurological sequelae with blood pressure negatively correlated to the occurrence of eclampsia. As about 40% of all eclamptic cases occur postpartum, routine blood pressure monitoring postpartum should be intensified.
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Affiliation(s)
- M P Schreurs
- Department of Obstetrics and Gynaecology, University of Maastricht, Maastricht, the Netherlands
| | - M J Cipolla
- Department of Obstetrics, Gynaecology and Reproductive Sciences, University of Vermont, Burlington, VT, USA.,Department of Neurological Sciences, University of Vermont, Burlington, VT, USA
| | - S Al-Nasiry
- Department of Obstetrics and Gynaecology, University of Maastricht, Maastricht, the Netherlands
| | - L L H Peeters
- Department of Obstetrics and Gynaecology, University of Maastricht, Maastricht, the Netherlands
| | - M E A Spaanderman
- Department of Obstetrics and Gynaecology, University of Maastricht, Maastricht, the Netherlands
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Armstrong AE, Gillan E, DiMario FJ. SMART syndrome (stroke-like migraine attacks after radiation therapy) in adult and pediatric patients. J Child Neurol 2014; 29:336-41. [PMID: 23364656 DOI: 10.1177/0883073812474843] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
SMART syndrome (stroke-like migraine attacks after radiation therapy) is a rare condition that involves complex migraines with focal neurologic findings in patients following cranial irradiation for central nervous system malignancies. Little is known about the mechanisms behind the disorder, making successful treatment challenging. We report 2 new cases of SMART syndrome in pediatric patients as well as review all documented cases of the syndrome. Each of our 2 pediatric patients suffered multiple episodes. Attacks were characterized by severe headache, visual disturbance, aphasia, and weakness. Recovery occurred over several days to weeks. The data from all documented reports of SMART syndrome indicate a greater prevalence for male gender. An age-dependent pattern of onset was also observed, with a greater variability of syndrome onset in patients who received cranial irradiation at a younger age. SMART appears to be a reversible, recurrent long-term complication of radiation therapy with possible age- and gender-related influences.
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Affiliation(s)
- Amy E Armstrong
- 1University of Connecticut School of Medicine, Farmington, CT, USA
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12
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Doherty H, Hameed S, Ahmed I, Russell IF. Post-dural puncture headache and posterior reversible encephalopathy syndrome: a misdiagnosis or co-presentation? Int J Obstet Anesth 2014; 23:279-82. [PMID: 24768557 DOI: 10.1016/j.ijoa.2014.02.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Revised: 01/05/2014] [Accepted: 02/09/2014] [Indexed: 10/25/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a rare neurological condition associated with a variety of underlying conditions, including preeclampsia. The headache associated with PRES may be indistinguishable from post-dural puncture headache, which may result in diagnostic delay. We report a case of PRES that was initially diagnosed as post-dural puncture headache. The case was unique because there were no features of preeclampsia, initial presentation was typical of post-dural puncture headache, and there was a five-day interval between the onset of headache and the development of seizures and cortical blindness, pathognomonic of PRES. It remains unclear whether this was an atypical presentation of PRES, initially misdiagnosed as post-dural puncture headache, or whether delayed treatment of headache triggered PRES.
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Affiliation(s)
- H Doherty
- Department of Anaesthesia, Hull Royal Infirmary, Hull, UK.
| | - S Hameed
- Department of Anaesthesia, Hull Royal Infirmary, Hull, UK
| | - I Ahmed
- Department of Anaesthesia, Hull Royal Infirmary, Hull, UK
| | - I F Russell
- Department of Anaesthesia, Hull Royal Infirmary, Hull, UK
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13
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Edvardsson B. Hypertensive encephalopathy and cerebral infarction. SPRINGERPLUS 2014; 3:741. [PMID: 25932363 PMCID: PMC4409617 DOI: 10.1186/2193-1801-3-741] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2014] [Accepted: 12/10/2014] [Indexed: 11/10/2022]
Abstract
Introduction Hypertensive encephalopathy is one cause of posterior reversible encephalopathy syndrome. Hypertensive encephalopathy and cerebral infarction have only been reported in a few individual case reports. Case description A 51-year-old woman presented with hypertensive encephalopathy. T2-weighted images from magnetic resonance imaging showed hyperintense lesions in both occipital and parietal lobes. Diffusion-weighted imaging showed that this represented cytotoxic oedema and perfusion magnetic resonance imaging revealed reduced blood volume and flow. The magnetic resonance imaging was repeated 5 months later and subtotal regression of theT2-hyperintensity had occurred. However, small bilateral infarcts were seen on T1-weighted images. Perfusion magnetic resonance imaging presented reduced blood volume and flow on the right side. Discussion and evaluation The patient in this report had posterior reversible encephalopathy syndrome caused by hypertensive encephalopathy. Magnetic resonance imaging of the brain showed bilateral cytotoxic oedema that partially resolved and resulted in small infarcts. The imaging findings are compatible with posterior reversible encephalopathy syndrome with subtotal resolution and infarct evolution. Conclusion The case report suggests that the presence of hypertensive encephalopathy and posterior reversible encephalopathy syndrome should alert clinicians and lead to prompt treatment in order to prevent cerebral damage.
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Affiliation(s)
- Bengt Edvardsson
- Department of Clinical Sciences, Lund, Neurology, Skane University Hospital, Lund University, S-221 85 Lund, Sweden
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14
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Brewer J, Owens MY, Wallace K, Reeves AA, Morris R, Khan M, LaMarca B, Martin JN. Posterior reversible encephalopathy syndrome in 46 of 47 patients with eclampsia. Am J Obstet Gynecol 2013; 208:468.e1-6. [PMID: 23395926 DOI: 10.1016/j.ajog.2013.02.015] [Citation(s) in RCA: 115] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Revised: 01/04/2013] [Accepted: 02/05/2013] [Indexed: 01/08/2023]
Abstract
OBJECTIVE We sought to investigate the concurrence of posterior reversible encephalopathy syndrome (PRES) with eclampsia and to describe the obstetric, radiological, and critical care correlates. STUDY DESIGN This was a single-center, 2001-2010 retrospective cohort study of all patients with eclampsia who underwent neuroimaging via magnetic resonance imaging (MRI) or computerized tomography (CT) with or without contrast. RESULTS Forty-six of 47 of eclamptic patients (97.9%) revealed PRES on neuroimaging using 1 or more modalities: MRI without contrast, 41 (87.2%); MRI with contrast, 27 (57.4%); CT without contrast, 16 (34%); CT with contrast, 7 (14.8%); and/or magnetic resonance angiography/magnetic resonance venography, 2 (4.3%). PRES was identified within the parietal, occipital, frontal, temporal, and basal ganglia/brainstem/cerebellum areas of the brain. Eclampsia occurred antepartum in 23 patients and postpartum in 24 patients. Headache was the most common presenting symptom (87.2%) followed by altered mental status (51.1%), visual disturbances (34%), and nausea/vomiting (19.1%). Severe systolic hypertension was present in 22 patients (47%). CONCLUSION The common finding of PRES in patients with eclampsia suggests that PRES is a core component of the pathogenesis of eclampsia. Therapy targeted at prevention or reversal of PRES pathogenesis may prevent or facilitate recovery from eclampsia.
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15
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Schusse CM, Peterson AL, Caplan JP. Posterior Reversible Encephalopathy Syndrome. PSYCHOSOMATICS 2013; 54:205-11. [PMID: 23473451 DOI: 10.1016/j.psym.2013.01.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 01/23/2013] [Accepted: 01/24/2013] [Indexed: 10/27/2022]
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Plötzlicher beidseitiger Visusverlust bei posteriorem reversiblem Enzephalopathiesyndrom. Ophthalmologe 2013; 110:247-50. [DOI: 10.1007/s00347-012-2614-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Peter P, George A. Posterior reversible encephalopathy syndrome and the pediatric population. J Pediatr Neurosci 2012; 7:136-8. [PMID: 23248696 PMCID: PMC3519074 DOI: 10.4103/1817-1745.102579] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Posterior reversible encephalopathy syndrome presents with neurological and imaging features that are reversible, if prompt diagnosis and treatment is undertaken. However, the disease has been more commonly described in adult population, especially in eclampsia. In the background of predisposing factors like renal disease or chemotherapy, the pediatric population is also at equal risk for this condition, as we would like to present through this case and also demonstrate the potential for complete reversal of symptoms and imaging findings if diagnosed without delay.
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Affiliation(s)
- Prasant Peter
- Department of Radiodiagnosis, Christian Medical College and Hospital, Ludhiana, Punjab, India
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Teotónio R, Marmoto D, Januário C, Bento C. Posterior reversible encephalopathy syndrome: the importance of early diagnosis. BMJ Case Rep 2012; 2012:bcr-2012-006852. [PMID: 22987908 DOI: 10.1136/bcr-2012-006852] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 14-year-old boy was submitted to cardiac transplant due to a dilated cardiomyopathy. On the fourth day of immunosuppression (corticosteroids, mycophenolate mofetil and tacrolimus), he developed right focal seizures and drowsiness. Blood pressure was in the normal range and laboratory findings in cerebral spinal fluid and blood were unremarkable, with drugs in non-toxic levels. The EEG showed a slow background rhythm more pronounced on the right and a seizure onset in the right occipital region. MRI revealed a diffuse hyperintense subcortical white-matter lesion on fluid attenuated inversion recovery, with lesser involvement of left temporal-occipital region. There was no enhancement with gadolinium and MRI diffusion-weighted imaging was consistent with vasogenic oedema. Tacrolimus was stopped with regression of MRI abnormalities and clinical recovery. Posterior reversible encephalopathy associated with tacrolimus is a rare but potentially serious complication of solid organ transplants. A prompt diagnosis and correct treatment is essential to avoid irreversible brain damage.
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Affiliation(s)
- Rute Teotónio
- Department of Neurology, Hospitais da Universidade de Coimbra, Coimbra, Portugal.
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Komur M, Delibas A, Arslankoylu AE, Okuyaz C, Kara E. Recurrent and atypical posterior reversible encephalopathy syndrome in a child with hypertension. Ann Indian Acad Neurol 2012; 15:208-10. [PMID: 22919196 PMCID: PMC3424801 DOI: 10.4103/0972-2327.99721] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2011] [Revised: 12/04/2011] [Accepted: 12/30/2011] [Indexed: 11/05/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiologic entity with typical symptoms including headache, seizures, visual disturbance, altered mental status, vomiting, nausea and focal neurologic signs. In this article, we report recurrent and atypical PRES in a child with hypertension due to end-stage renal disease (ESRD) who was on a peritoneal dialysis program for 6 months. After the second hypertension attack, PRES findings did not recover and persisted as encephalomalacia. As far as we know, this case is the first child with ESRD who developed encephalomalacia after recurrent episodes of PRES. When a patient with a history of PRES presented with new clinical and neuroradiological findings, recurrent PRES should be considered.
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Affiliation(s)
- Mustafa Komur
- Department of Pediatric Neurology, Mersin University School of Medicine, Mersin, Turkey
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Cipolla MJ, Bishop N, Chan SL. Effect of pregnancy on autoregulation of cerebral blood flow in anterior versus posterior cerebrum. Hypertension 2012; 60:705-11. [PMID: 22824983 DOI: 10.1161/hypertensionaha.112.198952] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Severe preeclampsia and eclampsia are associated with brain edema that forms preferentially in the posterior cerebral cortex possibly because of decreased sympathetic innervation of posterior cerebral arteries and less effective autoregulation during acute hypertension. In the present study, we examined the effect of pregnancy on the effectiveness of cerebral blood flow autoregulation using laser Doppler flowmetry and edema formation by wet:dry weight in acute hypertension induced by phenylephrine infusion in the anterior and posterior cerebrum from nonpregnant (n=8) and late-pregnant (n=6) Sprague-Dawley rats. In addition, we compared the effect of pregnancy on sympathetic innervation by tyrosine hydroxylase staining of posterior and middle cerebral arteries (n=5-6 per group) and endothelial and neuronal NO synthase expression using quantitative PCR (n=3 per group). In nonpregnant animals, there was no difference in autoregulation between the anterior and posterior cerebrum. However, in late-pregnant animals, the threshold of cerebral blood flow autoregulation was shifted to lower pressures in the posterior cerebrum, which was associated with increased neuronal NO synthase expression in the posterior cerebral cortex versus anterior. Compared with the nonpregnant state, pregnancy increased the threshold of autoregulation in both brain regions that was related to decreased expression of endothelial NO synthase. Lastly, acute hypertension during pregnancy caused greater edema formation in both brain cortices that was not attributed to changes in sympathetic innervation. These findings suggest that, although pregnancy shifted the cerebral blood flow autoregulatory curve to higher pressures in both the anterior and posterior cortices, it did not protect from edema during acute hypertension.
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Affiliation(s)
- Marilyn J Cipolla
- Department of Neurology, University of Vermont, 149 Beaumont Ave, HSRF 416, Burlington, VT 05405, USA.
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Abstract
AbstractObjective:Despite the high prevalence of delirium in palliative care settings, this diagnosis is frequently missed, particularly in patients with hypoactive delirium. These patients are also commonly misdiagnosed with depression because of the overlap in symptoms between the two diagnoses. Failure to promptly diagnose delirium can have significant ramifications in terms of delirium reversal, subsequent patient involvement in end-of-life decision making, and the recognition and treatment of other symptoms.Method:We report a case of a 63-year-old French-speaking woman admitted to our inpatient palliative care unit with colorectal cancer and a history of depression. This case report highlights the major challenges associated with making the diagnosis of delirium in a patient with a complex medical history, including depression.Results:The patient presented with symptoms of depressed mood and fluctuation in psychomotor activity, but failed to respond to an increase in her fluoxetine treatment in addition to methylphenidate and treatment of her hypothyroidism. A psychiatric assessment in her own language detected features of inattention and confirmed a diagnosis of delirium that was multifactorial, secondary to a combination of posterior reversible encephalopathy syndrome (PRES), hypothyroidism, hepatic dysfunction, and medication.Significance of Results:Subsyndromal delirium may present with mood lability, and as delirium and depression can coexist, clinicians should perform a delirium screen for all patients presenting with symptoms of depression, preferably in the patient's first language. Cognitive testing can be particularly helpful in distinguishing delirium, especially hypoactive delirium, from depression.
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Abstract
Eclampsia is defined in the obstetrical literature as the occurrence of unexplained seizure during pregnancy in a woman with preeclampsia. In the Western world, the incidence of eclampsia is ~1 per 2000 to 1 per 3000 pregnancies, but the incidence is 10-fold higher in tertiary referral centers and undeveloped countries where there is poor prenatal care, and in multi-fetal gestations. Nearly 1 in 50 women with eclampsia die as do 1 in 14 of their offspring, and mortality rates are considerably higher in undeveloped countries. Eclampsia is also associated with significant life-threatening complications, including neurological events. Seizure acutely can cause stroke, haemorrhage, oedema and brain herniation and thus lead to epilepsy and cognitive impairment later in life.
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de Broucker T. Semeiologia e orientamento diagnostico delle encefalopatie dell’adulto. Neurologia 2011. [DOI: 10.1016/s1634-7072(11)70698-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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A case of reversible posterior leukoencephalopathy syndrome with acute hypotension. Neurol Sci 2010; 32:165-8. [PMID: 20967478 DOI: 10.1007/s10072-010-0417-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2009] [Accepted: 09/02/2010] [Indexed: 10/18/2022]
Abstract
Reversible posterior leukoencephalopathy syndrome (RPLS) is theoretically associated with hypertensive encephalopathy because the most patients demonstrate abrupt increasing of blood pressure (BP). A 59-year-old woman, who had undergone cholecystectomy 4 days before, complained of a headache and rapidly progressing visual disturbance. Her BP was postoperatively controlled at around 150/80, but her BP was 89/46 when she noticed her symptoms. Magnetic resonance imaging showed vasogenic edema in bilateral occipital and right parietal lobes, and intracranial magnetic resonance angiography revealed bilateral diffuse peripheral vasoconstriction. After discontinuing ropivacaine administration via epidural catheter, her BP rose to 114/62 and her symptoms completely disappeared within a few days. Except for hypotension, the clinical course and the radiological evidences in our case were consistent with RPLE. This case supports another hypothesis of RPLS mechanism that arterial endothelial injury by toxic drug effect results in transudation of fluid from blood vessels causing vasogenic brain edema.
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Branson JA, Dale RC. Transient bilateral blindness and posterior reversible encephalopathy syndrome: a rare complication of enuresis treatment. J Paediatr Child Health 2008; 44:380-2. [PMID: 18476934 DOI: 10.1111/j.1440-1754.2008.01337.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Enuresis is a common paediatric problem which is sometimes treated with anticholinergic drugs. We report a 4-year-old girl who presented with acute bilateral blindness, a focal seizure and hypertension 10 days after commencing oxybutynin to treat enuresis. Magnetic resonance imaging brain showed features of posterior reversible encephalopathy syndrome, a recognised but rare complication of hypertension in children. Discontinuing the oxybutynin leads to complete neurological recovery associated with normalisation of her blood pressure. We believe this case represents a rare complication of anticholinergic therapy. Posterior reversible encephalopathy syndrome is a treatable and reversible cause of acute encephalopathy with blindness, as long as an early diagnosis is made.
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Nguyen-Lam J, Kiernan MC. Acute cortical blindness due to posterior reversible encephalopathy. J Clin Neurosci 2008; 15:1182-5. [PMID: 18501611 DOI: 10.1016/j.jocn.2007.04.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2007] [Revised: 03/31/2007] [Accepted: 04/05/2007] [Indexed: 11/24/2022]
Abstract
An acutely hypertensive 55 year-old male experienced seizures and cortical blindness post-operatively. CT scans demonstrated hypointensities in the occipital lobes bilaterally. MRI revealed symmetrical bilateral hyperintense signals in the same region, involving both grey and white matter. Thromboembolic screening investigations including vertebral artery doppler studies were normal and echocardiography demonstrated borderline left ventricular hypertrophy. A diagnosis of posterior reversible encephalopathy syndrome (PRES) was reached and there was complete resolution of blindness with antihypertensive therapy. This case supports the vasogenic theory of PRES which suggests that sustained high grade fluctuations in blood pressure lead to a reduction in cerebral vascular autoregulatory function. The resultant failure of compensatory vasoconstriction to prevent hyperperfusion causes fluid to extravasate into the occipital lobes, which in the present case resulted in cortical blindness.
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Affiliation(s)
- Jenny Nguyen-Lam
- Prince of Wales Clinical School, Prince of Wales Medical Research Institute, University of New South Wales; Institute of Neurological Sciences, Prince of Wales Hospital, Randwick, New South Wales, Australia
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O'Hara McCoy H. Posterior reversible encephalopathy syndrome: an emerging clinical entity in adult, pediatric, and obstetric critical care. ACTA ACUST UNITED AC 2008; 20:100-6. [PMID: 18271765 DOI: 10.1111/j.1745-7599.2007.00292.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE To describe the signs, symptoms, causative factors, and treatment for posterior reversible encephalopathy syndrome (PRES), an emerging clinical neuroradiologic entity which may be encountered by nurse practitioners in almost any clinical setting. DATA SOURCES Extensive review of worldwide literature, including peer-reviewed medical specialty journals, supplemented by an actual case study. Currently, a paucity of information exists in the nursing literature. CONCLUSIONS PRES occurs as a result of disordered cerebral circulatory autoregulation and/or endothelial dysfunction, usually as a result of acute, intermittent hypertension. Clinical manifestations include mental status change, headache, visual disturbance, and seizures. Characteristic abnormalities in the posterior cerebral white matter, seen best on diffusion-weighted magnetic resonance imaging, confirm the presence of the syndrome. PRES has been documented worldwide among a diverse patient population, yet many clinicians are still unfamiliar with this diagnosis. IMPLICATIONS FOR PRACTICE PRES is a clinical-radiographic diagnosis that requires close collaboration between the clinician and interpreting radiologist. Rapid identification and appropriate diagnostics are essential, as prompt treatment usually results in reversal of symptoms; permanent neurologic injury or death can occur with treatment delay.
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Affiliation(s)
- Heather O'Hara McCoy
- Scottsdale Healthcare Osborn, Department of Neurosurgery, Scottsdale, Arizona 85251, USA.
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Ngoungou EB, Poudiougou B, Dulac O, Dicko A, Boncoeur MP, Traoré AM, Coulibaly D, Keita MM, Preux PM, Doumbo OK, Druet-Cabanac M. [Persistent neurological sequelae due to cerebral malaria in a cohort of children from Mali]. Rev Neurol (Paris) 2007; 163:583-8. [PMID: 17571026 DOI: 10.1016/s0035-3787(07)90464-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Several neurological complications are associated with cerebral malaria (CM). However, few long-term data from childhood survivors have been published. METHODS A cross-sectional study was carried out in Mali among children followed from 1999 to 2002 after serious and complicated malaria. Our aim was to evaluate the persistent neurological sequelae associated with CM. RESULTS This study concerned 101 subjects who had had CM. Mean age was 5.6+/-3.6 years. Twenty-eight children presented persistent neurological sequelae (27.7p.cent). Among them eight (7.9p.cent) children had developed these sequelae just after CM and 20 (19.8p.cent) a few months later: headaches, mental retardation, speech delay, bucco-facial dyspraxia, diplegia and frontal syndrome (one case each), dystonia (two cases), epilepsy (five cases) and behavior and attention disorders (15 cases). CONCLUSIONS In this study, we show that neurological signs due to CM can persist in the long run. Long-term follow-up and proper management after CM are essential.
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Affiliation(s)
- E B Ngoungou
- Institut d'Epidémiologie Neurologique et de Neurologie Tropicale (EA 3174), Faculté de Médecine de Limoges, France
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Torrillo TM, Bronster DJ, Beilin Y. Delayed diagnosis of posterior reversible encephalopathy syndrome (PRES) in a parturient with preeclampsia after inadvertent dural puncture. Int J Obstet Anesth 2007; 16:171-4. [PMID: 17270428 DOI: 10.1016/j.ijoa.2006.08.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2006] [Accepted: 08/18/2006] [Indexed: 11/24/2022]
Abstract
Posterior reversible encephalopathy syndrome is a rare complication generally associated with headache and acute changes in blood pressure. We present a case of posterior reversible encephalopathy syndrome where diagnosis was delayed because the patient also had preeclampsia and an inadvertent dural puncture, both associated with headache. The clinical challenge and the need for prompt diagnosis and treatment are emphasized.
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Affiliation(s)
- T M Torrillo
- Department of Anesthesiology, Mount Sinai School of Medicine, New York, NY 10029-6574, USA.
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