Posterior reversible encephalopathy syndrome

Ophthalmological symptoms in a patient with reversible cerebral vasoconstriction syndrome: a case report

Background

Reversible cerebral vasoconstriction syndrome is characterized by severe headache with reversible segmental constriction of the cerebral arteries. We present details on a patient with reversible cerebral vasoconstriction syndrome who initially visited an ophthalmologist because of visual symptoms.

Case presentation

A 34-year-old Japanese woman complained of sustained headache and insomnia starting 2 days after her first childbirth. In addition to the severe headache, a visual field defect was also observed 10 days later. Best corrected visual acuity at the initial visit was 20/20 and 20/25 for the right and left eye, respectively. Exudative retinal detachment was noted surrounding both optic heads. Visual field testing revealed left homonymous hemianopsia, while magnetic resonance imaging demonstrated the presence of edema and infarction of the bilateral basal nuclei and right occipital lobe. The homonymous hemianopsia and exudative retinal detachment recovered immediately after treatment with a free-radical scavenger and anticoagulant. There has been no recurrence of symptoms during the 4 years of follow-up.

Conclusions

We report a case of reversible cerebral vasoconstriction syndrome with ophthalmological symptoms that were reversible, including serous retinal detachment and homonymous hemianopsia.

Potential voriconazole associated posterior reversible leukoencephalopathy in children with malignancies: Report of two cases

INTRODUCTION

The fungal infection has become severe morbidity amongst patients with malignancy. Voriconazole, a new generation of triazole, has shown excellent results in treating invasive fungal infections.

CASE REPORT

Herein, we report two cases of posterior reversible encephalopathy syndrome (PRES), which induced after voriconazole exposure.Management and outcome: Magnetic resonance imaging, and the serum level of voriconazole were investigated in both patients to assess toxicity. The role of methotrexate, as one of the possible causes of PRES, is weakened significantly through precise assessing diffusion-weighted images on magnetic resonance imaging.

DISCUSSION

These unique cases emphasize that voriconazole can induce PRES even at therapeutic levels. Therefore, in the case of neurotoxicity, PRES must be considered, and voriconazole should discontinue. The prognosis seemed promising when voriconazole stopped immediately after clinical suspicion.

Posterior Reversible Encephalopathy Syndrome After Transsphenoidal Resection of Pituitary Macroadenoma

BACKGROUND

Posterior reversible encephalopathy syndrome is manifested by a reversible neurologic deficit such as vision loss, encephalopathy, and a posterior location, typically the occipital lobes. It is commonly thought to be related to acute, severe hypertension.

CASE DESCRIPTION

A 51-year-old woman presented with visual loss for several months, and a suprasellar mass was diagnosed. She underwent transsphenoidal surgery, which was complicated by cerebrospinal fluid leak, and she developed posterior reversible encephalopathy syndrome while undergoing postoperative cerebrospinal fluid drainage via lumbar catheter. Her visual acuity progressed to blindness, but blindness was reversed by discontinuation of lumbar drainage, tight blood pressure control, and high-dose steroid drip.

CONCLUSIONS

To our knowledge, this is only the second case of posterior reversible encephalopathy syndrome following transsphenoidal surgery to be reported in the neurosurgical or ophthalmic English language literature.

Posterior reversible encephalopathy syndrome (PRES) in mesenteric leiomyosarcoma: A case report

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) is a syndrome characterized by headache, confusion, visual loss and seizures. Many factors influence the appearance of this syndrome, predominantly eclampsia, certain medical treatments and malignant hypertension. Diagnosed by typical transient lesions on magnetic resonance imaging.

CASE REPORT

We present a case of mesenteric leiomyosarcoma in a 52 year old woman, who had severe headache, abdominal heaviness, and hypertension. Investigations revealed a mesenteric mass and a Posterior Reversible Encephalopathy Syndrome features on brain MRI, suggesting renin secretion by the tumor, causing the patient's symptoms.

CONCLUSION

Patient's symptoms disappeared after resection of the tumor, suggesting a renin production cessation.

Acute Progressive Visual Loss in a Case of Acute Myeloid Leukemia: Challenges in the Utility of Molecular Tests in Early Diagnose of Cytomegalovirus Retinitis

Cytomegalovirus (CMV) retinitis is one of the rare but debilitating presentations of the CMV infection in children with leukemia. Herein, we report a 12-year-old boy with acute myeloid leukemia complicated by rapid progressive visual loss during relapse of leukemia. The definite diagnosis of CMV retinitis was made after vitreous aspiration. Despite prompt treatment and ophthalmologic intervention, he died because of AML relapse. Viral infections, especially cytomegalovirus infection, may present with vague clinical pictures during any time of chemotherapy, which may not be easily distinguishable from bacterial or fungal retinitis and also chemotherapy-induced retinopathies. Clinician should consider CMV retinitis in seropositive patients especially those without detectable viremia.

Posterior Reversible Encephalopathy Syndrome and Maternal Death in an Obstetric Patient: Case Report

Cerebral events occur more often in the postpartum period and are associated with hypertensive diseases of pregnancy. Superimposed with pre-eclampsia, these cause severe complications. Posterior reversible encephalopathy syndrome occurs because of acute elevation of blood pressure above the upper limit of cerebral blood flow auto-regulation. We present a case of posterior reversible encephalopathy syndrome that developed with superimposed pre-eclampsia resulting in intraparenchymal haemorrhage and maternal death.

The clinical characteristics of posterior reversible encephalopathy syndrome in patients with chronic renal failure

Few studies have investigated posterior reversible encephalopathy syndrome (PRES) in patients with chronic renal failure (CRF). The present study analyzed the clinical manifestations, laboratory examinations and imaging features of PRES in patients with CRF. A total of 42 patients with CRF with or without PRES were recruited in the current retrospective case-control study. Patient data taken prior to the onset of PRES in patients with CRF and PRES (n=21) were collected and analyzed. At the same time, data from patients with CRF but without PRES (n=21) were also analyzed. Brain magnetic resonance imaging (MRI) scans were collected from patients in the PRES group. The mean blood pressure of patients in the PRES group was significantly higher than that of the control group (systolic blood pressure: 172±15 mmHg vs. 135±14 mmHg, P<0.01; diastolic blood pressure: 95±16 mmHg vs. 64±13 mmHg, P<0.01). Furthermore, compared with the control group, mean serum albumin (Alb) and hemoglobin (Hb) concentrations in the PRES group were significantly lower (Alb: 29.1±5.3 g/l vs. 34.6±6.1 g/l, P=0.001; Hb: 74±16 g/l vs. 89±28 g/l, P=0.037). By contrast, mean LDH concentration was significantly higher in the PRES group (LDH: 336±141 U/l vs. 235±89 U/l, P=0.004). In the PRES group, 24 h urine volume was significantly lower in the PRES group than in the control group (24 h urine volume: 651±520 ml vs. 982±518 ml, P=0.046). No significant differences in levels of serum potassium (4.5±0.6 mmol/l vs. 4.4±0.5 mmol/l, P=0.377), sodium (138.3±4.9 mmol/l vs. 139.0±6.8 mmol/l, P=0.325), calcium (2.0±0.24 mmol/l vs. 1.9±0.24 mmol/l, P=0.673), alanine aminotransferase; (24±14 U/l vs. 18±8 U/l, P=0.975); aspartate aminotransferase (29±11 U/l vs. 24±9 U/l, P=0.619) and uric acid (448±148 µmol/l vs. 378±116 µmol/l, P=0.599) were found between the two groups. PRES is a relatively common nervous system complication arising in patients with CRF. Certain biochemical markers, including Hb and Alb, may be associated with PRES. Diagnosing PRES is difficult as computed tomography (CT) brain scans may be normal and MRI scans, which are more sensitive than CT scans at diagnosing PRES, are not always performed in patients with CRF. Thus, brain MRI scans should be taken first in such patients when PRES is suspected.

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.

Late postpartum eclampsia complicated with posterior reversible encephalopathy syndrome: a case report and a literature review

Posterior reversible encephalopathy syndrome (PRES) is a rare but serious clinical-neuroradiological entity characterized by headache, vomiting, visual disturbances, altered mental status, seizures, and unconsciousness associated with the characteristic imaging findings including sub-cortical vasogenic edema at the bilateral parietal and occipital lobes. We describe a case of 28-year-old PRES patient secondary to delayed maternal postpartum eclampsia. This patient was not initially diagnosed with pre-eclampsia and PRES. The diagnosis was established after magnetic resonance imaging. After treatment this patient's PRES resolved. Early diagnosis and treatment are the keys to reverse PRES. A literature review for PRES is provided in this report.

Reversible Posterior Leukoencephalopathy Syndrome Associated with Treatment for Acute Exacerbation of Ulcerative Colitis

Reversible posterior leukoencephalopathy syndrome (RPLS) is a clinical syndrome of varying etiologies with similar neuroimaging findings. This is a case report of a 25-year-old woman who developed typical, neurological symptoms and magnetic resonance imaging abnormalities after treatment for the acute exacerbation of ulcerative colitis (UC), which included blood transfusion, the systemic administration of prednisolone, and the administration of metronidazole. It has been reported that these treatments may contribute to the development of RPLS. RPLS should therefore be considered in the differential diagnosis of UC patients who exhibit impaired consciousness, seizures or visual deficits during treatment. We report a rare case of RPLS in a patient with UC.

Rhazes and an Early Case With Possible Hypertensive or Reversible Encephalopathy

In one of Rhazes' medical treatises, Tales and Stories of Patients, descriptions, medical manifestations, and treatment approaches of 34 patients were mentioned. Among those, an epileptic patient with a florid face and congested veins was cured by performing venesection on his saphenous and basilic veins. Signs and symptoms of the case might correspond to hypertensive or reversible encephalopathy.

Sudden Bilateral Choroidal Detachment in a Patient with Posterior Reversible Encephalopathy Syndrome

BACKGROUND: Pre-eclampsia is one of the most important causes of a rare cliniconeuroradiological entity called posterior reversible encephalopathy syndrome. The syndrome is characterized by headacke, visual disturbances, seizures, altered mental status and radiological findings of edema in the white matter of the brain areas perfused by the posterior brain circulation.CASE REPORT: Here we present a patient with sudden bilateral visual loss and deafness in early postnatal period without any other neurological deficits, but with affiliated ophthalmological pathology. The correct diagnosis was made 3 days after the Cesarean section.The patient was diagnosed with posterior reversible encephalopathy syndrome and bilateral choroidal detachment.CONCLUSION: Vascular changes in posterior reversible encephalopathy syndrome can cause visual disturbances not only by brain edema, but combined brain and ocular pathology.

A study on clinical and radiological features and outcome in patients with posterior reversible encephalopathy syndrome (PRES)

Posterior reversible encephalopathy syndrome (PRES) is characterized clinically by headaches, seizures, vomiting, nausea, visual abnormalities, and altered mental function and is often (but not invariably) accompanied by parieto-occipital imaging features. The aim of this study is to describe the clinical and radiological features and outcome following PRES in a paediatric cohort. From a retrospectively identified cohort, case records were studied to confirm a diagnosis of PRES. Neuroimaging was reviewed again to assign to recently described radiological subtypes parieto-occipital pattern, holohemispheric watershed pattern, dominant superior frontal sulcus pattern, and asymmetrical or partial expression of the three primary patterns (A/P). Patient outcome was measured by the modified Rankin scale (mRS) scores. Nine boys and three girls with mean age of 12 were identified. Hypertensive episodes (n = 11), tacrolimus toxicity (n = 4), and autoimmunity (n = 1) were identified as potential risk factors/etiologies. Their median mRS at the peak of illness was 2 (range 2-5); three children required intensive care support. After mean follow-up of 35 months (median 37 months; range 3-60 months), all patients improved significantly with mean mRS of 1 (median 1; range 0-1).

CONCLUSION

PRES is easily recognizable by the clinical and radiological features. Although severe at presentation, the outcome from this condition is favorable.

Posterior Reversible Encephalopathy Syndrome and Anti-Angiogenic Therapy

Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiological entity first described in 1996 by Hinchey et al, most commonly associated with hypertensive encephalopathy, eclampsia in pregnant women, immunosuppressants and cytotoxic agents. In recent years, anti-angiogenic agents as a novel class of anti-cancer therapies have become a standard of care for certain tumours. Correspondingly, there have been an emerging number of case reports documenting PRES associated with these anti-angiogenic therapies. As the manifestations of PRES are often non-specific, but could rarely lead to permanent neurological disability or even death, it is crucial that physicians are aware of PRES in relation to anti-angiogenic therapy to promptly institute appropriate management to achieve the best outcomes for patients.

Posterior reversible encephalopathy syndrome due to malignant hypercalcemia: physiopathological considerations

CONTEXT

Posterior reversible encephalopathy syndrome (PRES) is a neurological entity characterized by seizures, headache, and reversible subcortical vasogenic edema. It is associated with many etiologies, most often hypertension, chronic renal failure, and chemotherapy. Hypercalcemia is rarely associated with PRES.

OBJECTIVE

The aim of this study is to describe and discuss a case of PRES that developed in a patient with malignant hypercalcemia, with emphasis on the possible pathophysiological mechanisms involved.

PATIENTS AND METHODS

A 38-year-old woman presented with altered mental status. She had a 2-month history of lumbar pain of moderate intensity, weight loss, and gastrointestinal complaints, in addition to a mass in her left breast. Her corrected serum calcium was 14.5 mg/dL. She was normotensive, had no focalizing signs, and her cerebrospinal fluid was normal. Despite treatment, her neurological state did not resolve, and she developed severe headaches at day 4 of her admission. Brain magnetic resonance imaging showed a bilateral and symmetric hyperintensity in the occipital and parietal lobes on T2-weighted and fluid-attenuated inversion recovery imaging, a characteristic highly suggestive of PRES. After correction of hypercalcemia, her symptoms and imaging abnormalities resolved.

CONCLUSIONS

The development of PRES in the setting of severe hypercalcemia is extremely rare. Hypercalcemia could lead to PRES in the absence of hypertension by various mechanisms, including vasospasm, endothelial dysfunction, and an inflammatory state. A high index of suspicion is needed in this setting because hypercalcemia can lead to neurological symptomatology, and prompt diagnosis is essential for adequate treatment.

Posterior reversible encephalopathy syndrome in a patient with a Chiari I malformation

Background:

The authors describe a unique case of a patient who developed posterior reversible encephalopathy syndrome (PRES) following postoperative treatment of a Chiari I malformation.

Case Decsription:

A 25-year-old female presented with complaints of left upper and lower extremity paresthesias and gait disturbances. A magnetic resonance imaging (MRI) of the brain and cervical spine showed a Chiari I malformation with tonsillar descent beyond the level of the C1 lamina. She underwent a suboccipital craniectomy and C1 laminectomy with cerebellar tonsillar cauterization and duraplasty. Postoperatively, an MRI showed bilateral acute infarcts of the cerebellar vermis. She was initially treated for cerebellar ischemia with hypertensive therapy with a subsequent decline in her neurologic status and generalized tonic–clonic seizure. Further workup showed evidence of PRES. After weaning pressors, the patient had a significant progressive improvement in her mental status.

Conclusion:

Although the mechanism of PRES remains controversial given its diverse clinical presentation, several theories implicate hypertension and steroid use as causative agents.

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.

Neuroimaging biomarkers in mild traumatic brain injury (mTBI)

Reviewed herein are contemporary neuroimaging methods that detect abnormalities associated with mild traumatic brain injury (mTBI). Despite advances in demonstrating underlying neuropathology in a subset of individuals who sustain mTBI, considerable disagreement persists in neuropsychology about mTBI outcome and metrics for evaluation. This review outlines a thesis for the select use of sensitive neuroimaging methods as potential biomarkers of brain injury recognizing that the majority of individuals who sustain an mTBI recover without neuroimaging signs or neuropsychological sequelae detected with methods currently applied. Magnetic resonance imaging (MRI) provides several measures that could serve as mTBI biomarkers including the detection of hemosiderin and white matter abnormalities, assessment of white matter integrity derived from diffusion tensor imaging (DTI), and quantitative measures that directly assess neuroanatomy. Improved prediction of neuropsychological outcomes in mTBI may be achieved with the use of targeted neuroimaging markers.

Posterior reversible encephalopathy syndrome in 46 of 47 patients with eclampsia

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.

Regional differences in dynamic cerebral autoregulation in the healthy brain assessed by magnetic resonance imaging

A novel method is described for mapping dynamic cerebral blood flow autoregulation to assess autoregulatory efficiency throughout the brain, using magnetic resonance imaging (MRI). Global abnormalities in autoregulation occur in clinical conditions, including stroke and head injury, and are of prognostic significance. However, there is limited information about regional variations. A gradient-echo echo-planar pulse sequence was used to scan the brains of healthy subjects at a rate of 1 scan/second during a transient decrease in arterial blood pressure provoked by a sudden release of pressure in bilateral inflated thigh cuffs. The signal decrease and subsequent recovery were analyzed to provide an index of autoregulatory efficiency (MRARI). MRI time-series were successfully acquired and analyzed in eleven subjects. Autoregulatory efficiency was not uniform throughout the brain: white matter exhibited faster recovery than gray (MRARI = 0.702 vs. 0.672, p = 0.009) and the cerebral cortex exhibited faster recovery than the cerebellum (MRARI = 0.669 vs. 0.645, p = 0.016). However, there was no evidence for differences between different cortical regions. Differences in autoregulatory efficiency between white matter, gray matter and the cerebellum may be a result of differences in vessel density and vasodilation. The techniques described may have practical importance in detecting regional changes in autoregulation consequent to disease.

Takayasu's arteritis and posterior reversible encephalopathy syndrome: a case-based review

Autoimmune vasculitides can have diverse neurological manifestations, including posterior reversible encephalopathy syndrome (PRES). Takayasu's arteritis (TA) is an uncommon vasculitis rarely associated with PRES. Common clinical features of TA include hypertension, audible arterial bruits, absence of peripheral pulses, claudication of the extremities, reduced blood pressure in one or both arms, and angiographic abnormalities. PRES has been mostly associated with severe hypertension, endothelial injury, and conditions such as renal disease, immunosuppressive medication use, and rheumatologic diseases. Headaches, seizures, and altered mental status are the main clinical features as well as characteristic findings in magnetic resonance imaging. TA frequently presents with hypertension and is associated with endothelial injury, making this entity an ideal setting for the development of PRES. We report the case of a 17-year-old female who presented to the emergency department with severe hypertension, headache, and seizures. Magnetic resonance imaging findings were suggestive of PRES. She had absent pulses in the right upper extremity, abdominal bruits, and angiographic findings included subclavian and renal artery stenoses. The diagnosis of TA was made, and she responded well to treatment. We found ten additional cases of TA and PRES in the literature. All patients were females under the age of 40, had renovascular hypertension, and presented with headaches and seizures. Current literature relevant to this rare association is presented and discussed.

Bilateral Visual Loss as Presenting Symptom of Posterior Reversible Encephalopathy Syndrome in a Patient with HIV/Tuberculosis Coinfection: A Case Report

Posterior reversible encephalopathy syndrome (PRES) is a neurotoxic state accompanied by a unique brain imaging pattern. This cliniconeuroradiological entity usually presents with visual disturbances (cortical blindness, homonymous hemianopia, visual neglect, and blurred vision) along with neurotoxic manifestations. Only a few cases of PRES have previously been reported in patients with advanced HIV disease. The authors describe a case of posterior reversible encephalopathy syndrome (PRES) in a patient with advanced HIV/TBC infection who developed a neurotoxic state following TB and ART therapy initiation. They present a comprehensive review of the literature and discuss the pathogenetic hypotheses.

Posterior reversible encephalopathy syndrome presenting as papilledema

Posterior reversible encephalopathy syndrome (PRES) is a central nervous system pathology characterized by headaches, altered mental status, seizures, and visual loss. The syndrome is a clincoradiologic diagnosis, which mandates neuroimaging. The aim of this study is to describe a case of asymptomatic PRES in which the only sign was incidental papilledema found on ophthalmologic examination. A thin 19-year-old female G1P1 s/p natural spontaneous vaginal delivery was referred to our emergency department (ED) by the ophthalmology clinic after finding bilateral papilledema on fundoscopic examination. She denied any fevers, chills, nausea, vomiting, as well as headache, lightheadedness, visual changes, or blurriness. Lumbar puncture was performed, and opening pressure was found to be greater than 55 cmH2O. After collecting Cerebrospinal fluid (CSF) for routine analysis, approximately 15 to 20 mL of CSF was drained. After several revisits to the ED, the neurology clinic was consulted. The magnetic resonance imaging ordered by the neurology clinic, as read by the radiologist, showed a focal lesion in splenium of the corpus callosum and diffusion restriction suggestive of acute infarction (although the anatomical location and age would be unusual). This is an atypical manifestation of PRES. The myriad of clinical symptoms and presentations of PRES has become more identifiable as more case reports of the syndrome are published. This case demonstrates that this atypical syndrome may present in an atypical way. The patient may be asymptomatic, and although imaging defines the diagnosis, a complete physical examination must not be ignored because the only sign may be papilledema.

Posterior reversible encephalopathy syndrome mimicking a cerebral tumour

Posterior reversible encephalopathy syndrome (PRES) is a syndrome characterised clinically by headache, confusion, seizures, vomiting and visual disturbances with radiographic vasogenic oedema. CT imaging is typically normal, non-specific or suggestive of PRES or stroke. MRI usually shows symmetrical parietal and occipital lobe vasogenic oedema. The authors discuss a 58-year-old man presenting with right homonymous haemianopia, hypertension and ataxia. CT imaging suggested a left occipital lobe space occupying lesion (SOL). Surprisingly, subsequent contrast enhanced MRI showed characteristic bilateral vasogenic oedema in occipital and temporal lobes indicative of PRES. Hypertension, an associated predisposing factor, was present in this case and symptoms improved with antihypertensive therapy. This case highlights PRES may present with asymmetrical CT imaging findings mimicking a SOL. PRES is a potentially reversible condition with prompt treatment. MRI is essential in diagnosing both PRES and the cause of acute visual loss.

A rare entity in ED: posterior reversible encephalopathy syndrome

Posterior reversible encephalopathy syndrome is a clinico-neuroradiologic entity with typical symptoms and symmetric high-signal intensity lesions in the bilateral parietooccipital lobes on T2-weighted or fluid-attenuated inversion recovery magnetic resonance imaging. In this presentation, we report a case of posterior reversible encephalopathy syndrome who was admitted to our emergency department because of seizure and deterioration of consciousness. The aim of this presentation is to alert the emergency physicians about one of the hypertensive emergencies with neurologic symptoms associated with hypertension.

Sex differences in primary hypertension

Men have higher blood pressure than women through much of life regardless of race and ethnicity. This is a robust and highly conserved sex difference that it is also observed across species including dogs, rats, mice and chickens and it is found in induced, genetic and transgenic animal models of hypertension. Not only do the differences between the ovarian and testicular hormonal milieu contribute to this sexual dimorphism in blood pressure, the sex chromosomes also play a role in and of themselves. This review primarily focuses on epidemiological studies of blood pressure in men and women and experimental models of hypertension in both sexes. Gaps in current knowledge regarding what underlie male-female differences in blood pressure control are discussed. Elucidating the mechanisms underlying sex differences in hypertension may lead to the development of anti-hypertensives tailored to one's sex and ultimately to improved therapeutic strategies for treating this disease and preventing its devastating consequences.

Posterior reversible encephalopathy syndrome in children with kidney diseases

Posterior reversible encephalopathy syndrome (PRES) was originally used to describe a reversible, predominantly posterior leukoencephalopathy in patients who had renal insufficiency, hypertension, or who received immunosuppressive therapy. Since PRES is prevalent in children with kidney diseases, awareness and understanding of it is important for practicing pediatric nephrologists. A comprehensive approach to the diagnosis of PRES includes thorough determination of predisposing factors, clinical symptoms, and mandatory appropriate imaging. Unfortunately, the pathophysiology of PRES is still obscure and specificity of radiological examination has not yet been established. Two major predisposing factors, namely hypertension and calcineurin inhibitors, are well recognized. In addition, nephrotic syndrome is a common underlying condition for development of PRES. Frequent symptoms include altered consciousness (coma, stupor, lethargy, confusion), seizure, headache, and visual disturbance. Most of these symptoms usually develop abruptly and resolve within a few weeks after proper management. Cranial magnetic resonance (MR) imaging is the first-line modality of imaging studies for detecting PRES. Diffusion-weighted imaging with quantification of apparent diffusion coefficient (ADC) values by ADC mapping may provide more accurate and specific images in the future.

Neurological manifestations of Takayasu arteritis

OBJECTIVE

To investigate the clinical neurological manifestations of Takayasu arteritis (TA).

METHODS

A retrospective study was conducted with 63 consecutive TA cases admitted to Peking Union Medical College Hospital from January 2009 to May 2010. All the patients fulfilled the diagnostic criteria of TA by the American College of Rheumatology. Among the 63 TA patients, 27 with neurological manifestations were included in the present study. All the patients were evaluated using standardized neurological examination, sonography, computed tomography (CT) angiography, and cerebral CT or magnetic resonance imaging.

RESULTS

Dizziness and visual disturbance were the most common symptoms, which occurred in 20 (74.1%) and 16 (59.3%) patients respectively. Another common symptom was headache, observed in 15 (55.6%) patients. Six (22.2%) patients had suffered from ischemic stroke; 7 (25.9%) patients had epileptic seizures. Two (7.4%) patients were diagnosed as reversible posterior encephalopathy syndrome (RPES) based on typical clinical and imaging manifestations.

CONCLUSIONS

Neurological manifestations are common symptoms in TA patients in the chronic phase, including dizziness, visual disturbance, headache, ischemic stroke, seizures, and some unusual ones such as RPES. We suggested RPES be included into the differential diagnosis of acute neurological changes in TA.

Posterior Reversible Encephalopathy Syndrome in Early Postpartum Woman

There have been reports about posterior reversible encephalopathy syndrome (PRES) associated with pregnancy, especially peripartum. However, the pathophysiology of PRES is not still clear. Tonic-clonic seizure occurred during early postpartum in a woman with the tendency toward pre-eclampsia developed after vaginal delivery followed by emergency cesarean hysterectomy. Postictal findings included headache, loss of vision, and short-term memory loss and magnetic resonance imaging (MRI) findings suggesting PRES were noted. Neurologic symptoms and cerebral lesions were gradually improved with immediate supportive managements.

First description of posterior reversible encephalopathy syndrome as a complication of glycerolnitrate patch following open cardiac surgery

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) affects predominantly the parietal and occipital lobes. Frequent clinical features are epileptic seizure, altered mental status and visual disturbances.

CLINICAL PRESENTATION

We present the first case of a patient with pericarditis and mitral valve insufficiency, who developed PRES after application of a glycerolnitrate patch day three post-operatively and whose neurological deficits improved within 2 days after withdrawal of patch therapy.

CONCLUSION

The precise pathomechanism of PRES is unknown. The lower sympathetic innervation of the posterior circulation may be one explanation for its particular vulnerability to vasodilatation caused by glycerolnitrate.

[Posterior reversible encephalopathy syndrome and eclampsia: a descriptive study of 13 cases in Morocco]

INTRODUCTION

The occurrence of posterior reversible encephalopathy in eclampsia is a rare but known event. We propose to describe the clinical and radiological features and the outcome.

METHODS

A retrospective study was conducted from January 2005 to April 2010 including all cases of posterior reversible encephalopathy syndrome (PRES) occurring on eclampsia in patients hospitalized in the obstetrical intensive care unit, University Hospital of Casablanca.

RESULTS

Thirteen cases of PRES on eclampsia were collected, the average age was 29 years (18-42). Systolic pressure and diastolic blood pressure at admission were higher than 150 mmHg and 100 respectively in 10 cases. The signs found were: a regressive blindness in five patients and focal signs in four. The complications were thrombocytopenia in 10 patients, abnormal liver function in eight, Hellp syndrome in nine, and acute renal failure in two. The brain regions most commonly affected were the parietal and occipital areas (13 patients), followed by temporal regions, frontal, and basal ganglia (eight patients each). Five patients required assisted ventilation (AV) over 24 hours. Death complicated the outcome in four of our patients, but no deaths were directly attributable to PRES itself, and all four patients had Hellp syndrome and required AV greater than 48 hours. In the other patients, total regression of neurological signs was noted.

CONCLUSION

This study emphasizes the severity of the Posterior 'reversible' encephalopathy syndrome on eclampsia.

A case of catatonia due to posterior reversible encephalopathy syndrome treated successfully with antihypertensives and adjunctive olanzapine

Catatonia is a distinct neuropsychiatric syndrome with prominent motor manifestations. Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiologic syndrome usually precipitated by malignant hypertension. Given the overlapping neuropathology in both syndromes, we present a case of catatonia precipitated by PRES, with full resolution of the former after successful treatment of the latter.

Acute neurological issues in pregnancy and the peripartum

Acute neurological diseases requiring hospitalization are relatively rare in women of childbearing age. However, during pregnancy and the postpartum period, several diseases increase in prevalence. Some are unique to the pregnant/postpartum state including preeclampsia and delivery-associated neuropathies. Others, although indirectly related to pregnancy, such as cerebral venous thrombosis, ischemic stroke, and intracerebral hemorrhage, increase in frequency and carry considerable risk of morbidity and mortality. In addition, treatment options are often limited. This review discusses the diseases more commonly seen during pregnancy and the postpartum period, with a focus on emergent neurological diseases and their management. Interventional therapies will also be discussed.

Disrupted balance of angiogenic and antiangiogenic signalings in preeclampsia

The placenta plays a central role in governing local circulatory system that mediates maternal condition and fetal growth. In early gestational phases, the placenta exerts properties of invasion and neovascularization for successful placentation. Extravillous invasive trophoblasts replace uterine endometrial vasculature and establish local blood pathway to obtain oxygen and nutrients from the mother. In later phases, the placenta promotes villous angiogenesis and vascular maturation that are finely controlled by angiogenic and antiangiogenic molecules. Among various molecules involved in placental neovascularization, vascular endothelial growth factor receptors (VEGFRs) and angiotensin II receptor type 1 (AT1) mediate important signaling pathways for maternal circulatory system and fetal growth. VEGFR1 and VEGFR2 are functional receptors for placental growth factor (PlGF) and VEGF, respectively, and PlGF-VEGFR1 and VEGF-VEGFR2 interactions are disturbed in many preeclamptic patients by excess amount of soluble form of VEGFR1 (also named sFlt1), a natural PlGF/VEGF antagonist. Recent studies have disclosed that excessive sFlt1 production in the placenta and aberrant AT1 signaling in the mother are closely associated with the pathology of preeclampsia and intrauterine growth restriction (IUGR). In this paper, neovascularization of the placenta and pathological events associated with disrupted balance between angiogenic and antiangiogenic signaling in preeclampsia are discussed.

Posterior Reversible Encephalopathy Syndrome and Anti-Angiogenic Agents: A Case Report

Posterior reversible encephalopathy syndrome is an increasingly recognised clinico-radiological entity, associated with several medical conditions (such as systemic arterial hypertension) and characterised by seizures, altered mental status, headaches, and visual symptoms. Magnetic resonance imaging is a key component in this diagnosis, with hyperintense foci in T₂-weighted images, corresponding to vasogenic oedema. The pathophysiology is not fully understood but probably involves loss of auto-regulation of cerebral vasculature or endothelial dysfunction or both. A 56-year-old male, suffering from a gastro-intestinal stromal tumour with hepatic metastasis resistant to imatinib, on therapy with sunitinib, came to the Emergency Department because of headaches, hallucinations, and loss of vision. There was no previous history of high blood pressure. A hypertensive crisis was diagnosed; ophthalmological examination on admission showed no light perception bilaterally. Brain imaging displayed bilateral parieto-occipital and frontal vasogenic oedema, consistent with the clinical diagnosis of posterior reversible encephalopathy syndrome. After treatment of hypertension and suspension of sunitinib, the patient recovered from his symptoms. Control imaging showed no oedema. Angiogenesis inhibitors, such as sunitinib and bevacizumab, can cause hypertension, one of the many medical conditions associated with the posterior reversible encephalopathy syndrome. This syndrome should be considered in cases of acute visual loss, particularly in view of its reversible nature when diagnosed and treated promptly.

Reversible posterior leukoencephalopathy syndrome in a patient with thrombotic thrombocytopenic purpura

Thrombotic thrombocytopenic purpura (TTP) is an autoimmune disorder characterised by fever, microangiopathic haemolytic anaemia, renal insufficiency, and thrombocytopenia. Neurological involvement, a prominent component of TTP, is characterised by a variety of brain lesions which include reversible cerebral oedema or magnetic resonance imaging (MRI) features of reversible posterior leukoencephalopathy syndrome (RPLS). TTP is frequently associated with deficiency of the von Willebrand factor-cleaving protease, ADAMTS13.Here, we report a case of TTP with severe acute encephalopathy. Posterior leukoencephalopathy and brainstem oedema with triventricular hydrocephalus were observed on MRI. The low activity of ADAMTS13 was not observed and ADAMTS-13 antibodies were absent. Neurological symptoms and patient's condition were completely resolved by plasma exchange therapy in addition to high dose of methylprednisolone.

Early central nervous system complications after allogeneic hematopoietic stem cell transplantation in children

BACKGROUND

Central nervous system (CNS) complications after allogeneic hematopoietic stem cell transplantation (HSCT) have not been well characterized in the pediatric population.

METHODS

We retrospectively analyzed data of 202 consecutive children who underwent allogeneic HSCT (60 from matched related donors, 9 from mismatched related donors, and 133 from unrelated donors) at Asan Medical Center between 1998 and 2009.

RESULTS

Twenty-seven children (13.5%) developed CNS complications within 6 months after HSCT. Calcineurin inhibitor (CNI)-associated neurotoxicity was the most common CNS complication (n=16), followed by CNS infection (n=2), cerebrovascular events (n=2), thrombotic microangiopathy-associated events (n=2), metabolic encephalopathy (n=2), irradiation/chemotherapy injury (n=1), and encephalopathy/myelopathy of unknown causes (n=2). Univariate analysis showed that a transplant from an alternative donor and the occurrence of acute graft-versus-host disease (GVHD) (>grade 2) were associated with a significantly increased risk of CNS complications. In the multivariate analysis, acute GVHD >grade 2 was identified as an independent risk factor for early CNS complications. The 5-year overall survival rate was significantly lower in patients with CNS complications (52.1% vs. 64.9%, P=0.014), whereas CNI-associated neurotoxicity did not affect the survival outcome.

CONCLUSION

CNS complications are frequent among children undergoing HSCT, contributing to early death after transplant. More attention should be paid to the development of CNS complications for recipients of alternative donor transplants and patients with severe acute GVHD who are at increased risk for CNS complications.