Leucoencefalopatía posterior reversible en una paciente con eclampsia posparto

Postpartum Posterior Reversible Encephalopathy Syndrome (PRES): Three Case Reports and Literature Review

Posterior reversible encephalopathy syndrome is a rare complication generally associated with headache and acute changes in blood pressure. Delay in the diagnosis and treatment may result in death or in irreversible neurological sequelae. We present three cases of PRES occurring in young women during puerperium. We report a literature review ranged from January 1990 to June 2015 describing clinical features, diagnostic and medical approach, and maternal outcome.

Posterior reversible encephalopathy syndrome in malignant hypertension secondary to focal segmental glomerulosclerosis

Posterior reversible encephalopathy syndrome (PRES) is a neurological condition that occurs secondary to a variety of causes like autoimmune diseases, uncontrolled hypertension and immunosuppressive agents. We report an unusual association of PRES and malignant hypertension secondary to focal segmental glomerulosclerosis in a young woman, presenting with sudden loss of vision and seizures. She had uncontrolled hypertension and a Glasgow Coma Scale of 6/15. Brain MRI revealed high signals in cortical and subcortical white matter and some involvement of the periventricular areas. She improved dramatically with antihypertensive and antiepileptic medications and was discharged home in a stable condition. It is important to have a high clinical suspicion for this uncommon condition in an appropriate clinical setting, because a timely intervention can prevent long-term complications.

Therapy and differential diagnosis of posterior reversible encephalopathy syndrome (PRES) during pregnancy and postpartum

PURPOSE

Posterior reversible encephalopathy syndrome (PRES) is an usually reversible neuro-radiological clinical entity characterized by headache, confusion, visual disturbances or blindness and seizures. It rarely occurs without seizures.

METHODS

We conducted a literature review in MEDLINE about PRES during post partum and pregnancy, focusing on differential diagnosis and therapy. We reviewed 28 articles (case reports, original articles and reviews) describing PRES as well as a case of a severe, immediate postpartum HELLP syndrome (haemolysis, elevated liver enzyme levels, low platelet count) with PRES without generalized seizure.

RESULTS

The development of PRES after delivery is unusual. Magnetic resonance imaging represents the gold standard for the diagnosis of this condition. White matter oedema in the posterior cerebral hemispheres is typical on neuroimaging. PRES is reversible when early diagnosis is established and appropriate treatment is started without delay. The pathogenesis of PRES is discussed and the importance of a prompt diagnosis is emphasized, as the crucial role of rapid blood press reduction.

CONCLUSION

MRI is the diagnostic gold standard and it may be useful in the differential diagnosis. The goal of the therapy is to control elevated blood pressure and to prevent seizures or promptly manage it.

Posterior reversible encephalopathy syndrome (PRES) in a patient with late postpartum eclampsia

Posterior reversible encephalopathy syndrome (PRES) is a reversible neurological entity characterised by seizure, headaches, visual symptoms, impaired consciousness and other focal neurological findings. It is caused by a wide variety of causes ultimately leading to a vasogenic cerebral oedema of occipital and parietal lobes of the brain. We present here a young woman with headache, generalised tonic-clonic seizures and cortical blindness in a late postpartum stage. Reversibility of the symptoms and characteristic imaging findings led us to a diagnosis of PRES in our patient.

Clinical and radiological spectrum of posterior reversible encephalopathy syndrome

OBJECTIVE

Symptoms of posterior reversible encephalopathy syndrome (PRES) include headache, altered mental status, visual disturbances, and seizures. Typical radiological features include edema of the parieto-occipital lobes. The purpose of this study is to review the clinical and radiological findings in patients diagnosed with PRES.

METHODS

All patients diagnosed with PRES between January 2006 and December 2012 were retrospectively included in this study. We reviewed demographic and clinical characteristics, and radiological findings.

RESULTS

We identified 16 patients with PRES. The most common clinical presentation was seizure (n = 12, 75%). Clinical recovery occurred in all patients within days (mean, 5.7 ± 4.6 days). Comorbid conditions included hypertension (n = 4, 25%), cytotoxic medications (n = 3, 18.8%), sepsis (n = 4, 25%), malignancy (n = 4, 25%), subarachnoid hemorrhage (n = 1, 6.3%), autoimmune disorders (n = 1, 6.3%) and eclampsia (n = 1, 6.3%). The most commonly involved location was the parieto-occipital lobe (n = 13, 81.3%). Atypical radiological findings included significant basal ganglia involvement in 4 episodes; brainstem in 3, cerebellum in 2, and thalamus in 3. Eleven patients (68.8%) underwent diffusion-weighted imaging and apparent diffusion coefficient mapping. Of those, 9 patients (81.8%) had hypo- or isointensity on diffusion-weighted imaging. On the apparent diffusion coefficient map, 10 patients (90.9%) had hyperintensity, and the other had normal values.

CONCLUSION

We suggest that PRES may occur in patients with complex systemic conditions. The prognosis of PRES is usually benign. Physicians should be aware of certain atypical radiological findings to avoid a delayed diagnosis of PRES, as delayed diagnosis and treatment can result in permanent neurological sequlae.