Posterior reversible encephalopathy syndrome from induced hypertension during endovascular thoracoabdominal aortic aneurysm repair

Posterior Reversible Encephalopathy Syndrome After Thoraco-Abdominal Aortic Replacement

Introduction

Induced hypertension, administered peri-operatively during thoraco-abdominal aortic intervention, is one of the most effective methods to maintain spinal cord perfusion pressure. Posterior reversible encephalopathy syndrome or reversible cerebral vasoconstriction syndrome is a rare encephalopathy, possibly caused by excessive hypertension, usually encountered in the obstetric or cerebrovascular department.

Report

A 61 year old man underwent open surgery for repair of an extent II dissecting thoraco-abdominal aneurysm. Several attempts at spinal drainage tube insertion one day prior to surgery failed. The Adamkiewicz artery was anastomosed by bypass, and transcranial motor evoked potentials were generally stable. Initially, no apparent neurological abnormality was observed after surgery; however, paraplegia occurred on post-operative day 1. The patient's mean arterial pressure increased from > 85 mmHg to > 95 mmHg. His systolic blood pressure occasionally exceeded 170 mmHg. On post-operative day 3 he became blind. A serial imaging test revealed cerebral oedema of both posterior lobes and segmental constriction of the vertebral and basilar arteries. Posterior reversible encephalopathy syndrome with reversible cerebral vasoconstriction syndrome was diagnosed from the clinical context and imaging tests. Despite treatment with magnesium and calcium channel blockers, the patient's visual acuity remained poor.

Discussion

Excessive induced hypertension for spinal cord protection could rarely lead to cerebral vascular dysfunction, resulting in irreversible neurological damage. Awareness of this rare but devastating complication may help in early diagnosis, potentially mitigating permanent sequelae.

Posterior reversible encephalopathy syndrome following elevated mean arterial pressures for cervical spinal cord injury

BACKGROUND

Increasing the mean arterial pressure (MAP) is an accepted treatment modality to minimize the risk for irreversible neurologic damage secondary to spinal cord ischemia. Posterior reversible encephalopathy syndrome (PRES) is a rare complication occurring after transplantation surgery, in persons having an autoimmune disorder or after abrupt increases in blood pressure of various etiologies.

STUDY DESIGN

Case report.

METHODS

Retrospective evaluation of medical records.

RESULTS

A 68-year-old female with long-standing diabetes, and rheumatoid arthritis (treated with methotrexate) presented with bilateral upper extremity weakness and numbness developing several days after a motor vehicle accident. Physical examination confirmed decreased upper extremity motor strength and decreased sensation to light touch and pinprick in the C5-C6 dermatomal distribution. Magnetic resonance imaging (MRI) demonstrated C5-C6 subluxation with spinal cord compression. The patient had traction applied and mean arterial pressures were elevated greater than 85 mmg. The following day the patient underwent anterior and posterior cervical spine fusion and decompression. Immediately post-operatively, the patient developed status epilepticus. Head MRI revealed areas of high T2 signal intensity in the bilateral occipital lobes, consistent with a diagnosis of PRES. Two weeks later, the patient had resolution of her symptoms and resolution of PRES on imaging.

CONCLUSION

This is the first report of posterior reversible encephalopathy syndrome secondary to therapeutic blood pressure increase in the setting of cervical spine fracture with neurological deficits. The patients had resolution of symptoms following discontinuation of the MAP goals. Posterior reversible encephalopathy syndrome (PRES) is a life-threatening condition characterized by seizures, confusion, visual disturbance, and headaches alongside neuroradiological findings indicative of posterior cerebral hemispheric white matter edema.^1,2 PRES has been described in association with abrupt blood pressure elevation, autoimmune disorders, or transplantation.^1-4 In this case report PRES presented with typical status epilepticus⁵ but in an unexpected clinical setting, immediately after anterior cervical decompression and fusion (ACDF) and posterior cervical fusion (PCF) with laminectomy of C5-C6.