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El Aissaouy M, Douqchi B, El Aidouni G, Bkiyar H, Housni B. Chemotherapy-Induced Leukoencephalopathy Revealed by Seizure and Alteration of the Mental Status. Cureus 2023; 15:e39364. [PMID: 37362474 PMCID: PMC10285338 DOI: 10.7759/cureus.39364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2023] [Indexed: 06/28/2023] Open
Abstract
Leukoencephalopathy is progressive demyelination of the white matter, induced by a variety of factors. Among the causes of leukoencephalopathy, chemotherapy is an uncommon cause that generates potentially reversible lesions. The clinical presentation is classically made of alterations in mental status, hallucinations, hypertension, seizures, and acute visual changes. Imaging plays an important role in the diagnosis of this entity, especially by conventional and diffusion-weighted magnetic resonance imaging which enables an accurate diagnosis by identifying symmetric white matter lesions, especially in the parietal and occipital lobes. Herein, we report a 54-year-old female patient, newly diagnosed with non-metastatic moderately differentiated adenocarcinoma of the cecum. The patient received her first cancer chemotherapy (5-fluorouracil at 300 mg/m2). Five days later she was admitted to the intensive care unit for confusion following two generalized seizures. Conventional and diffusion-weighted magnetic resonance imaging was performed and showed diffuse white matter lesions of the parietal and occipital lobes. A diagnosis of 5-fluorouracil-induced leukoencephalopathy was established. The diagnosis of leukoencephalopathy should be considered in patients receiving cancer chemotherapy with alterations in mental status and seizures.
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Affiliation(s)
- Mohammed El Aissaouy
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, MAR
- Anesthesiology, Mohammed I University, Oujda, MAR
| | - Badie Douqchi
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, MAR
- Intensive Care Unit, Mohammed I University, Oujda, MAR
| | | | - Houssam Bkiyar
- Anesthesiology/Critical Care Unit, Mohammed VI University Hospital Center, Oujda, MAR
| | - Brahim Housni
- Anesthesiology/Critical Care Unit, Mohammed VI University Hospital Center, Oujda, MAR
- Intensive Care Unit/Anesthesiology, Mohammed I University, Oujda, MAR
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Frati A, Armocida D, Tartara F, Cofano F, Corvino S, Paolini S, Santoro A, Garbossa D. Can Post-Operative Posterior Reversible Encephalopathy Syndrome (PRES) Be Considered an Insidious Rare Surgical Complication? Brain Sci 2023; 13:brainsci13050706. [PMID: 37239179 DOI: 10.3390/brainsci13050706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/11/2023] [Accepted: 04/20/2023] [Indexed: 05/28/2023] Open
Abstract
Introduction: Posterior reversible encephalopathy syndrome (PRES) is a neurological disorder characterized by neurological symptoms and distinctive neuroimaging findings. There are a few cases reported in the literature in which PRES can occur after surgery, and there is no clear direct relationship between a procedure and its debut. Methods: We performed a review of the literature by analyzing all reported cases of PRES syndrome which debuted after a surgical procedure with the aim of identifying the clinical features, the timing of the symptoms' onset and the therapy of patients suffering from this unusual surgical complication. Results: The total number of patients collected was 47, with a mean age of 40.9 years. Postoperative PRES can occur in either pediatric or adult patients (ages 4-82 years). The most frequent form of comorbidity reported was cardiovascular disease (fourteen patients, 29.78%). Sixteen patients (36%) had no relevant risk factors or comorbidities at the time of the surgical procedure. The types of surgery most correlated were cranial neuro and maxillofacial surgery (twenty-one patients, 44.68%) followed by transplant surgery (eight patients, 17%). The time of onset of PRES after surgery occurred within the first 3 weeks (mean time of onset 4.7 days), and when rapidly treated with antihypertensive and antiepileptic drugs appeared to have a reversible and benign course. Conclusion: PRES syndrome can be considered a rare complication of procedures and can occur following a wide range of surgeries, especially cranial and transplant surgery. Being able to recognize it in time and treat it ensures a full reversibility of symptoms in most cases.
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Affiliation(s)
- Alessandro Frati
- Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S), Neuromed, Via Atinense 18, 86077 Pozzilli, Italy
| | - Daniele Armocida
- Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S), Neuromed, Via Atinense 18, 86077 Pozzilli, Italy
- Human Neurosciences Department, Neurosurgery Division "Sapienza" University, AOU Policlinico Umberto I, 00161 Rome, Italy
| | - Fulvio Tartara
- Headache Science and Neurorehabilitation Center, IRCCS Mondino Foundation, Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy
| | - Fabio Cofano
- Neurosurgery, Department of Neuroscience, A.O.U. Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy
| | - Sergio Corvino
- Department of Neuroscience, Reproductive and Odontostomatological Sciences, Division of Neurosurgery Università degli Studi di Napoli Federico II, 80131 Naples, Italy
| | - Sergio Paolini
- Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S), Neuromed, Via Atinense 18, 86077 Pozzilli, Italy
| | - Antonio Santoro
- Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S), Neuromed, Via Atinense 18, 86077 Pozzilli, Italy
| | - Diego Garbossa
- Neurosurgery, Department of Neuroscience, A.O.U. Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy
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Ramanathan S, Subramani V, Kembhavi S, Prasad M, Roy Moulik N, Dhamne C, Narula G, Banavali S. Clinical features, predictors and outcome of posterior reversible encephalopathy syndrome (PRES) in children with hematolymphoid malignancies. Childs Nerv Syst 2022; 38:1689-1698. [PMID: 35614149 DOI: 10.1007/s00381-022-05557-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 05/10/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIM Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiological syndrome characterized by a neurotoxic state with vasogenic edema. We studied the clinical profile, predisposing factors, imaging features, and outcome of PRES in children receiving treatment for hematolymphoid malignancies. METHODS Retrospective analysis of the clinical data and radiological features of patients with PRES diagnosed between June 2014 and December 2019. RESULTS Fifty-two patients (boy: girl = 3:1) were diagnosed with PRES during the study period with a median age of 11 (range:1-15) years. Primary diagnoses were acute leukemias (n = 42), non-Hodgkin lymphoma (n = 8), Hodgkin lymphoma (n = 1), and Langerhan's cell histiocytosis (n = 1). Most common presenting symptoms were seizures (n = 52), altered sensorium (n = 42), headache (n = 39), and visual disturbances (n = 8). Hypertension at time of diagnosis was noted in 50 (96%) patients. Classic hyper-intense lesions on FLAIR and diffusion weighed (DW) images were noted in parieto-occipital region in 39 patients (75%). Central PRES involving basal ganglia was seen in 3 (6%) patients. A subsequent neuro-imaging was done in 18 patients (MRI: 13; CT: 5) at a median interval of 16.2 weeks. Neurological sequelae were observed in 10 (19%) patients, whereas 1 succumbed due to PRES. CONCLUSIONS PRES is an important clinico-radiological syndrome in patients undergoing chemotherapy for hematological malignancies. High index of suspicion, early diffusion-weighted images on MRI in children with classic symptoms help in early diagnosis. A small minority of patients may develop long-term sequelae.
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Affiliation(s)
| | - Vignesh Subramani
- Department Of Pediatric Oncology, Tata Memorial Hospital, Mumbai, India
| | - Seema Kembhavi
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Maya Prasad
- Department Of Pediatric Oncology, Tata Memorial Hospital, Mumbai, India
| | | | - Chetan Dhamne
- Department Of Pediatric Oncology, Tata Memorial Hospital, Mumbai, India.
| | - Gaurav Narula
- Department Of Pediatric Oncology, Tata Memorial Hospital, Mumbai, India
| | - Shripad Banavali
- Department Of Pediatric Oncology, Tata Memorial Hospital, Mumbai, India
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Posterior Reversible Encephalopathy Syndrome in Childhood Hematological/Oncological Diseases: Multicenter Results. J Pediatr Hematol Oncol 2021; 43:e462-e465. [PMID: 33060391 DOI: 10.1097/mph.0000000000001965] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 09/10/2020] [Indexed: 11/27/2022]
Abstract
The aim of the study was to analyze the characteristics of posterior reversible encephalopathy syndrome (PRES) cases treated at 10 different institutions in our country. Fifty-eight patients diagnosed with PRES were included in this study. The data of PRES cases from 10 departments of pediatric hematology/oncology were analyzed. The mean age of the patients at the time of diagnosis of PRES was 8.95±3.66 years. Most patients (80.4%) had a primary diagnosis of acute leukemia. Patients received chemotherapy (71.4%) and/or used steroids within 14 days before the diagnosis of PRES (85.7%). Hypertension was found in 83.9% of the patients. Twenty-six patients had infections and 22 of them had febrile neutropenia. The most common electrolyte disorders were hypocalcemia, hypomagnesemia, and hypopotassemia. Six patients had tumor lysis syndrome and 4 had inappropriate antidiuretic hormone syndrome. Magnetic resonance imaging was used for diagnosis in all patients. The most commonly involved regions by magnetic resonance imaging were occipital (58%), parietal (51%), and frontal lobes (45%), respectively. Twenty-five patients required intensive care and 7 patients were intubated. In conclusion, PRES may develop during the follow-up and treatment of hematological diseases. In addition to steroid and intense combined chemotherapies, immunosuppressive agents and hypertension are also factors that may be responsible for PRES.
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Morana G, Bagnasco F, Leoni M, Pasquini L, Gueli I, Tortora D, Severino M, Giardino S, Pierri F, Micalizzi C, Verrina E, Ravelli A, Mancardi MM, Rossi A, Faraci M. Multifactorial Posterior Reversible Encephalopathy Syndrome in Children: Clinical, Laboratory, and Neuroimaging Findings. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0040-1714109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractThe aim of this study was to investigate the association of neuroimaging, clinical, and laboratory findings in children with different underlying diseases who developed posterior reversible encephalopathy syndrome (PRES). All consecutive pediatric patients referred to our institute between 2000 and 2017 were retrospectively evaluated for newly diagnosed PRES. Clinical data, medical history, and therapies administered at the time of PRES and laboratory findings were reviewed as the magnetic resonance imaging (MRI) obtained at PRES presentation and during follow-up. Statistics included Mann–Whitney U, Chi-square, and Fisher's exact tests. A total of 39 pediatric patients (25 males, median age = 8.8 years) with a confirmed diagnosis of PRES were included. The patients were divided into four groups based on the underlying disease: (1) patients with hemato-oncological diseases not transplanted (n = 15, 38.5%), (2) who underwent hematopoietic stem cell transplantation (HSCT; n = 12, 30.8%), (3) affected by renal (n = 8, 20.5%), and (4) by autoimmune diseases (n = 4, 10.2%). Hemato-oncological patients and those undergoing HSCT presented a higher incidence of involvement of deep gray matter structures and hemorrhagic lesions when compared with patients with renal and autoimmune disorders (p = 0.036 and p = 0.036, respectively). No differences emerged among different groups of patients regarding presenting PRES symptoms, arterial blood pressure, laboratory findings, and extent of MRI abnormalities and these parameters did not show association with outcome.In conclusion, in pediatric patients with different diseases who develop PRES, involvement of deep gray matter structures and hemorrhagic lesions are more common in hemato-oncological patients and those undergoing HSCT. Clinical and radiologic outcome is favorable independently of clinical data and extent of MRI abnormalities.
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Affiliation(s)
- Giovanni Morana
- Neuroradiology Unit, IRCSS Istituto Giannina Gaslini, Genova, Italy
| | - Francesca Bagnasco
- Epidemiology and Biostatistics Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | | | - Luca Pasquini
- Neuroradiology Unit, NESMOS Department, Sant'Andrea Hospital, La Sapienza University, Roma, Italy
| | - Ilaria Gueli
- Department of Pediatric, IRCSS Istituto Giannina Gaslini, Genova, Italy
| | - Domenico Tortora
- Neuroradiology Unit, IRCSS Istituto Giannina Gaslini, Genova, Italy
| | | | - Stefano Giardino
- Hematopoietic Stem Cell Transplantation Unit, IRCSS Istituto Giannina Gaslini, Genova, Italy
| | - Filomena Pierri
- Hematopoietic Stem Cell Transplantation Unit, IRCSS Istituto Giannina Gaslini, Genova, Italy
| | | | - Enrico Verrina
- Dialysis Unit, IRCSS Istituto Giannina Gaslini, Genova, Italy
| | - Angelo Ravelli
- Pediatric Rheumatology Unit, IRCSS Istituto Giannina Gaslini, Genova, Italy
| | | | - Andrea Rossi
- Neuroradiology Unit, IRCSS Istituto Giannina Gaslini, Genova, Italy
| | - Maura Faraci
- Hematopoietic Stem Cell Transplantation Unit, IRCSS Istituto Giannina Gaslini, Genova, Italy
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Fisler G, Monty MA, Kohn N, Assaad P, Trope R, Kessel A. Characteristics and Outcomes of Critically Ill Pediatric Patients with Posterior Reversible Encephalopathy Syndrome. Neurocrit Care 2021; 32:145-151. [PMID: 31069660 DOI: 10.1007/s12028-019-00720-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVE Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiologic entity, typically manifesting as reversible neurological symptoms and signs of white matter edema on magnetic resonance imaging. PRES has been widely described in adults. Studies of PRES in children are mostly limited to case series and case controls. METHODS Retrospective chart review of patients under 21 years with PRES admitted at a tertiary children's hospital from 2011 to 2016. They were compared to controls matched for age and mortality risk using the Pediatric Index of Mortality-2 score.
RESULTS: Sixteen cases of PRES were identified in 13 patients (ages 5-17 years, 46% male). PRES presented with altered mental status (75%), seizures (77%), headache (31%), and vision changes (23%). In patients who recovered (n = 11), median days to symptom resolution was three (range 1-8). PRES patients had a higher mortality rate (15% vs. 5%, p < 0.05) and higher mean length of stay (13.1 vs. 4.6 days) and were more likely to have autoimmune disease (p < 0.05), immunosuppression (p < 0.05), and anemia (p < 0.05). No PRES patients were diagnosed with epilepsy by last known follow-up, and all of whom had been started on an antiepileptic drug were discontinued within 13 months. Sepsis was suspected in 53% of PRES patients and 59% of controls (p = 1.00). All PRES patients had stage II hypertension, versus 41% of controls (p < 0.05). Average creatinine in PRES was 2.35 mg/dL compared to 0.90 mg/dL in controls (p < 0.05). PRES patients had lower serum calcium (p < 0.05). After correcting for albumin, no association between PRES and hypocalcemia remained. PRES patients had a higher length of stay (13.1 vs. 4.6 days, p < 0.05) and mortality rate (15% vs. 3%, p < 0.05). CONCLUSIONS Immunosuppression, autoimmune disease, renal insufficiency, anemia, and hypertension are associated with PRES after controlling for mortality risk in critically ill children. There was no association between corrected serum calcium and sepsis with PRES.
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Affiliation(s)
- Grace Fisler
- Department of Pediatrics, Graduate Medical Education Office, Steven and Alexandra Cohen Children's Medical Center of New York, 269-01 76th Ave New, Hyde Park, NY, 11040, USA.
| | - Mikhaela A Monty
- Department of Pediatrics, Hasbro Children's Hospital, 593 Eddy Street, Providence, RI, 02903, USA
| | - Nina Kohn
- Biostatistics Unit, Feinstein Institute for Medical Research, 125 Community Drive, Great Neck, NY, 11021, USA
| | - Peter Assaad
- Department of Pediatric Radiology, Steven and Alexandra Cohen Children's Medical Center of New York, 269-01 76th Ave, New Hyde Park, NY, 11040, USA
| | - Randi Trope
- Pediatric Critical Care Medicine, Steven and Alexandra Cohen Children's Medical Center of New York, 269-01 76th Ave, New Hyde Park, NY, 11040, USA
| | - Aaron Kessel
- Pediatric Critical Care Medicine, Steven and Alexandra Cohen Children's Medical Center of New York, 269-01 76th Ave, New Hyde Park, NY, 11040, USA
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Musioł K, Waz S, Boroń M, Kwiatek M, Machnikowska-Sokołowska M, Gruszczyńska K, Sobol-Milejska G. PRES in the course of hemato-oncological treatment in children. Childs Nerv Syst 2018; 34:691-699. [PMID: 29198072 PMCID: PMC5856901 DOI: 10.1007/s00381-017-3664-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Accepted: 11/14/2017] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Posterior reversible leukoencephalopathy syndrome (PRES) is a clinical syndrome of varying aetiologies, characterised by acute neurological symptoms of brain dysfunction with MRI abnormalities in posterior cerebral white and grey matter. In most cases, symptoms resolve without neurological consequences. AIM The aim of this paper is the analysis of predisposing factors, clinical outcomes and radiological features of PRES in eight children with hemato-oncological disease. MATERIAL AND METHODS We analysed the medical records of eight hemato-oncological patients aged from 3.0 to 16.1 years. The mean of age at primary diagnosis was 8.5 years. RESULTS All patients had both clinical and radiological PRES features. Seven out of eight underwent intensive chemotherapy regimens. Time elapsed from start of treatment to the occurrence of PRES ranged from 6 to 556 days. In one case, PRES occurred before chemotherapy and was the first symptom of cancer. Most (six of eight) patients had history of hypertension (> 95pc) and some (two of eight) occurred electrolyte imbalance-mainly hypomagnesaemia. Patients presented headache (seven of eight), disturbances of consciousness (six of eight), seizures (six of eight), visual changes (four of eight) and vomiting (three of eight). MRI demonstrated abnormalities in seven children: typical cerebral oedema in the white matter of the occipital to the parietal lobes. Most patient lesions in the MRI shrunk after 4 weeks, and clinical symptoms of PRES disappeared completely within a few hours to few days. CONCLUSION PRES may complicate oncological treatment in children. Hypertension is the most important risk factor of PRES. PRES should be included in differential diagnosis in all patients with acute neurological symptoms.
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Affiliation(s)
- Katarzyna Musioł
- Department of Pediatric Oncology, Hematology and Chemotherapy, Medical University of Silesia, Upper Silesia Children's Care Health Centre, 16 Medykow Str, 40-752, Katowice, Poland.
| | - Sylwia Waz
- Department of Pediatric Oncology, Hematology and Chemotherapy, Medical University of Silesia, Upper Silesia Children's Care Health Centre, 16 Medykow Str, 40-752, Katowice, Poland
| | - Michał Boroń
- Department of Pediatric Oncology, Hematology and Chemotherapy, Medical University of Silesia, Upper Silesia Children's Care Health Centre, 16 Medykow Str, 40-752, Katowice, Poland
| | - Magdalena Kwiatek
- Department of Pediatric Oncology, Hematology and Chemotherapy, Medical University of Silesia, Upper Silesia Children's Care Health Centre, 16 Medykow Str, 40-752, Katowice, Poland
| | | | - Katarzyna Gruszczyńska
- Department of Diagnostic Imaging, Medical University of Silesia, Upper Silesia Children's Care Health Centre, Katowice, Poland
| | - Grażyna Sobol-Milejska
- Department of Pediatric Oncology, Hematology and Chemotherapy, Medical University of Silesia, Upper Silesia Children's Care Health Centre, 16 Medykow Str, 40-752, Katowice, Poland
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Aureli V, Giammattei L, Maduri R, Daniel RT, Messerer M. Posterior reversible encephalopathy syndrome (PRES) due to neuroblastoma in a child presenting with acute hydrocephalus. Childs Nerv Syst 2018; 34:15-17. [PMID: 29079894 DOI: 10.1007/s00381-017-3640-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 10/17/2017] [Indexed: 11/30/2022]
Affiliation(s)
- V Aureli
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland.
| | - L Giammattei
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - R Maduri
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - R T Daniel
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - M Messerer
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
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Posterior Reversible Encephalopathy Syndrome: Risk Factors and Impact on the Outcome in Children With Acute Lymphoblastic Leukemia Treated With Nordic Protocols. J Pediatr Hematol Oncol 2018; 40:e13-e18. [PMID: 29200159 DOI: 10.1097/mph.0000000000001009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) in children with acute lymphoblastic leukemia has been increasingly recognized as a clinicoradiological entity. Our aim was to describe the incidence of PRES in pediatric patients with ALL, identify its risk factors, and examine its prognostic importance. For this research, we conducted a systematic, retrospective review of the patient records in a population-based series of children with acute lymphoblastic leukemia (n=643) treated in Finland from 1992 to 2008. Of the patients with ALL, 4.5% (n=29) developed radiologically confirmed PRES, of which 28 cases occurred during induction. Hypertension (P=0.006; odds ratio [OR], 4.10, confidence interval [CI], 1.50-11.25), constipation (P=0.001; OR, 5.60; CI, 2.02-15.52), and >14 days of alkalinization (P=0.017; OR, 3.27; CI, 1.23-8.68) were significant independent risk factors for PRES. One-third of the patients developed epilepsy. Relapses occurred significantly more often in those patients with PRES (P=0.001), which was associated with worse overall survival (P=0.040; 5-year survival=75.9% [60.3%-91.4%] vs. 88.4% [85.8%-90.9%]). Using NOPHO-ALL 92/2000 protocols, PRES is a significant early complication of therapy in ALL, and was associated with a poorer prognosis and significant neurological morbidity.
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Tambasco N, Mastrodicasa E, Salvatori C, Mancini G, Romoli M, Caniglia M, Calabresi P, Verrotti A. Prognostic factors in children with PRES and hematologic diseases. Acta Neurol Scand 2016; 134:474-483. [PMID: 26876986 DOI: 10.1111/ane.12570] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiological entity characterized by focal neurological signs, headache, confusion, and seizure, associated with transitory lesions in the posterior areas of the brain detectable with neuroimaging. Among children, one of the most common causes of PRES is cancer. MATERIALS AND METHODS In this review, we present the cases of 5 children developing PRES after stem cell transplantation for hematological disease and review all the cases reported in English literature to investigate outcomes and associated risk factors. RESULTS One hundred and eleven cases were reported. Hypertension was very frequent (80%). Clinical features included seizures (80.1%), headache (44.1%), visual disturbance (26.1%), and mental change (48.6%). EEG was abnormal in 27 of 32 patients. MRI revealed characteristic lesions in all patients even in early stages. Abnormal MRI findings in late stages were associated with neurological sequelae. Nineteen patients died (17.1%) of which 2 of PRES. Among alive patients, 17 had neurological sequelae. Four cases of PRES relapse were described. CONCLUSIONS Thus, all transplant recipients with symptoms consistent with PRES should be promptly recognized to avoid long-term complications or even death.
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Affiliation(s)
- N. Tambasco
- Department of Neurology; Perugia General Hospital and University of Perugia; Perugia Italy
| | - E. Mastrodicasa
- Pediatric Oncology Hematology Unit; Perugia General Hospital; Perugia Italy
| | - C. Salvatori
- Department of Pediatrics; Perugia General Hospital and University of Perugia; Perugia Italy
| | - G. Mancini
- Department of Pediatrics; Perugia General Hospital and University of Perugia; Perugia Italy
| | - M. Romoli
- Department of Neurology; Perugia General Hospital and University of Perugia; Perugia Italy
| | - M. Caniglia
- Pediatric Oncology Hematology Unit; Perugia General Hospital; Perugia Italy
| | - P. Calabresi
- Department of Neurology; Perugia General Hospital and University of Perugia; Perugia Italy
- IRCCS Fondazione Santa Lucia; Roma Italy
| | - A. Verrotti
- Department of Pediatrics; University of L'Aquila; Italy
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11
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Neil EC, Hanmantgad S, Khakoo Y. Neurological Complications of Pediatric Cancer. J Child Neurol 2016; 31:1412-20. [PMID: 26719497 PMCID: PMC4927408 DOI: 10.1177/0883073815620673] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 10/26/2015] [Indexed: 01/07/2023]
Abstract
Neurologists are often consulted for diagnosis and management of neurologic complications in patients undergoing therapy for cancer. Pediatric patients with cancer, often undergoing the same types of therapy as adults with cancer, may experience different adverse events. The set of neurologic complications in children differs from that in adults and the neurologist must take into account the continuing growth and development of the patient as well as significant differences in primary diagnosis across the population. Correctly recognizing complications and initiating prompt treatment may reduce pain and prevent further progression and permanent deficits. Herein, we review the most recent literature on the neurological complications of cancer therapy organized by frequency in the pediatric population.
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Affiliation(s)
- Elizabeth C Neil
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sharyu Hanmantgad
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yasmin Khakoo
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA Department of Pediatrics, Weill Medical College of Cornell University, New York, NY, USA
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12
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Yu J, Sun L, Lin W. Reversible posterior leukoencephalopathy associated with chronic graft-versus-host disease: A case report. Exp Ther Med 2016; 11:2509-2512. [PMID: 27284340 DOI: 10.3892/etm.2016.3240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2014] [Accepted: 01/14/2016] [Indexed: 11/06/2022] Open
Abstract
The present study describes the clinical manifestations, magnetic resonance imaging (MRI) features and treatments of a 22-year-old male patient diagnosed with reversible posterior leukoencephalopathy syndrome (RPLS) associated with graft-versus-host disease (GVHD) 7 months after a haploid hematopoietic stem cell transplantation. The patient was admitted to hospital after falling unconscious. Head MRI demonstrated abnormal signals in the bilateral, frontal, parietal, temporal and occipital lobes, consistent with reversible posterior leukoencephalopathy syndrome (RPLS). Based on a detailed diagnosis, the response to treatment and follow-up, it was concluded that RPLS was closely associated with chronic graft-versus-host disease in the patient. The present case report is described in order to increase the awareness of RPLS.
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Affiliation(s)
- Jinbei Yu
- Epilepsy Center, Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Lichao Sun
- Epilepsy Center, Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Weihong Lin
- Epilepsy Center, Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
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Tang JH, Tian JM, Sheng M, Hu SY, Li Y, Zhang LY, Gu Q, Wang Q. Study of Posterior Reversible Encephalopathy Syndrome in Children With Acute Lymphoblastic Leukemia After Induction Chemotherapy. J Child Neurol 2016; 31:279-84. [PMID: 26060305 DOI: 10.1177/0883073815589758] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 04/21/2015] [Indexed: 12/16/2022]
Abstract
Increasing occurrence of posterior reversible encephalopathy syndrome has been reported in children with acute lymphoblastic leukemia. However, the etiology of posterior reversible encephalopathy syndrome is not clear. To study the possible pathogenetic mechanisms and treatment of this complication, we reported 11 cases of pediatric acute lymphoblastic leukemia who developed posterior reversible encephalopathy syndrome after induction chemotherapy. After appropriate treatment, the clinical symptoms of posterior reversible encephalopathy syndrome in most cases disappeared even though induction chemotherapy continued. During the 1-year follow-up, no recurrence of posterior reversible encephalopathy syndrome was observed. Although the clinical and imaging features of posterior reversible encephalopathy syndrome may be diverse, posterior reversible encephalopathy syndrome should be recognized as a possible important complication of acute lymphoblastic leukemia when neurologic symptoms appear. In line with previous reports, our study also indicated that posterior reversible encephalopathy syndrome was reversible when diagnosed and treated at an early stage. Thus, the occurrence of posterior reversible encephalopathy syndrome should be considered and investigated to optimize the early induction scheme of acute lymphoblastic leukemia treatment.
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Affiliation(s)
- Ji-Hong Tang
- Department of Neurology, Children's Hospital Affiliated to Soochow University, Suzhou, China
| | - Jian-Mei Tian
- Department of Internal Medicine, Children's Hospital Affiliated to Soochow University, Suzhou, China
| | - Mao Sheng
- Radiology Department, Children's Hospital Affiliated to Soochow University, Suzhou, China
| | - Shao-Yan Hu
- Department of Hematology and Oncology, Children's Hospital of Soochow University, Suzhou, China
| | - Yan Li
- Department of Neurology, Children's Hospital Affiliated to Soochow University, Suzhou, China
| | - Li-Ya Zhang
- Department of Hematology and Oncology, Children's Hospital of Soochow University, Suzhou, China
| | - Qing Gu
- Department of Neurology, Children's Hospital Affiliated to Soochow University, Suzhou, China
| | - Qi Wang
- Radiology Department, Children's Hospital Affiliated to Soochow University, Suzhou, China
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Tavares M, Arantes M, Chacim S, Júnior AC, Pinto A, Mariz JM, Sonin T, Pereira S. Posterior Reversible Encephalopathy Syndrome in Children With Hematologic Malignancies. J Child Neurol 2015; 30:1669-75. [PMID: 25862738 DOI: 10.1177/0883073815578525] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Accepted: 02/24/2015] [Indexed: 11/17/2022]
Abstract
Since its original description 2 decades ago, posterior reversible encephalopathy syndrome has been reported in children with several predisposing conditions. Epidemiologic data of posterior reversible encephalopathy syndrome in children with hematologic malignancies is still scarce. Herein, we describe the clinical and radiologic features along with the outcome and follow-up of posterior reversible encephalopathy syndrome complicating the treatment of children with hematologic malignancies. Ten patients with a median age of 6.3 years were diagnosed with posterior reversible encephalopathy syndrome. Six of them were undergoing chemotherapy and the remaining 4 were at 37, 52, 78, and 857 days after allogenic hematopoietic stem cell transplant. The median follow-up was 27.6 months. Even though follow-up imaging showed complete resolution of abnormalities in those 10 children, 2 developed secondary epilepsy. Despite accurate diagnosis of posterior reversible encephalopathy syndrome and immediate intervention, neurologic sequelae may still develop. Thus, a close follow-up should be considered in all patients.
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Affiliation(s)
- Márcio Tavares
- Department of Onco Hematology, Portuguese Institute of Oncology, Porto, Portugal
| | - Mavilde Arantes
- Division of Neuro Radiology, Department of Radiology, Portuguese Institute of Oncology, Porto, Portugal
| | - Sérgio Chacim
- Department of Onco Hematology, Portuguese Institute of Oncology, Porto, Portugal
| | | | - Armando Pinto
- Department of Pediatrics, Portuguese Institute of Oncology, Porto, Portugal
| | - José Mário Mariz
- Department of Onco Hematology, Portuguese Institute of Oncology, Porto, Portugal
| | - Teresa Sonin
- Department of Neurology, Portuguese Institute of Oncology, Porto, Portugal
| | - Susana Pereira
- Department of Neurology, Portuguese Institute of Oncology, Porto, Portugal
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Posterior reversible encephalopathy syndrome in patients with hematologic tumor confers worse outcome. World J Pediatr 2015; 11:245-9. [PMID: 26041496 DOI: 10.1007/s12519-015-0027-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 12/02/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND This study aimed to evaluate the clinical features of posterior reversible encephalopathy syndrome (PRES) in children. METHODS The medical records of 31 patients from five medical centers who were diagnosed with PRES from 2001 to 2013 were retrospectively analyzed. In the 31 patients, 16 were males, and 15 females, with a median age of 7 years (3-12 years). Patients younger than 10 years accounted for 74.2% of the 31 patients. RESULTS Seizure, the most common clinical sign, occurred in 29 of the 31 patients. Visual disturbances were also observed in 20 patients. Cerebral imaging abnormalities were bilateral and predominant in the parietal and occipital white matter. In this series, three patients died in the acute phase of PRES. One patient had resolution of neurologic presentation within one week, but no apparent improvement in radiological abnormalities was observed at eight months. One patient showed gradual recovery of both neurologic presentation and radiological abnormalities during follow-up at eight months. One patient developed long-term cortical blindness. All of the PRES patients with hematologic tumor had a worse prognosis than those without hematologic tumor. CONCLUSIONS Seizure is a prevalent characteristic of children with PRES. Poor prognosis can be seen in PRES patients with hematologic tumor.
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Sha Z, Moran BP, McKinney AM, Henry TR. Seizure outcomes of posterior reversible encephalopathy syndrome and correlations with electroencephalographic changes. Epilepsy Behav 2015; 48:70-4. [PMID: 26071927 DOI: 10.1016/j.yebeh.2015.05.027] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 04/16/2015] [Accepted: 05/15/2015] [Indexed: 10/23/2022]
Abstract
RATIONALE Seizures are among the most common clinical presentations of posterior reversible encephalopathy syndrome (PRES). This syndrome has rarely been reported to cause chronic epilepsy or persistent cortical dysfunction. The prognostic value of EEG findings during PRES is unknown. We retrospectively evaluated EEG characteristics in patients with PRES in a single medical center. We also evaluated the long-term outcome regarding seizure occurrence beyond the acute phase in these patients. METHODS We searched a radiology database at the University of Minnesota from 1997 to 2012 to identify patients with clinically and radiologically diagnosed PRES. Among the patients with PRES, we reviewed MRI images, EEG findings, clinical manifestations including seizure occurrences, and clinical outcomes beyond the acute phase. RESULTS Seventy-five patients were included in the study. Fifty-eight out of seventy-five (77.3%) patients with PRES had seizures. A total of 48 EEG studies were performed in 38 patients. Generalized slowing was the most common EEG pattern. Among the 38 patients who had EEGs, 37 (97.3%) patients had diffuse or focal slowing of the background, and 11 (28.9%) patients had IEDs. Four out of seventy-five (5.3%) patients had seizures later than one month beyond their hospitalization for PRES. None of these 4 patients had seizures before the episode of PRES. Two patients developed chronic epilepsy, with seizures occurring later than one year after the PRES. CONCLUSION Most patients who had seizures or who had epileptiform activities in EEG during PRES did not subsequently develop chronic epilepsy. No patient developed chronic epilepsy in the absence of clinical seizures during PRES. Posterior reversible encephalopathy syndrome may infrequently be associated with subsequent development of symptomatic epilepsy.
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Affiliation(s)
- Zhiyi Sha
- Department of Neurology, University of Minnesota Medical School, Minneapolis, MN, USA.
| | - Brian P Moran
- Department of Neurology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Alexander M McKinney
- Department of Radiology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Thomas R Henry
- Department of Neurology, University of Minnesota Medical School, Minneapolis, MN, USA
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Furtado A, Hsu A, La Colla L, Zuccoli G. Arterial blood pressure but not serum albumin concentration correlates with ADC ratio values in pediatric posterior reversible encephalopathy syndrome. Neuroradiology 2015; 57:721-8. [DOI: 10.1007/s00234-015-1511-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 03/11/2015] [Indexed: 11/28/2022]
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Siebert E, Bohner G, Endres M, Liman TG. Clinical and radiological spectrum of posterior reversible encephalopathy syndrome: does age make a difference?--A retrospective comparison between adult and pediatric patients. PLoS One 2014; 9:e115073. [PMID: 25514795 PMCID: PMC4267732 DOI: 10.1371/journal.pone.0115073] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 11/18/2014] [Indexed: 11/19/2022] Open
Abstract
Background Posterior reversible encephalopathy syndrome (PRES) is a serious and increasingly recognized disorder, but data from observational studies on clinicoradiological differences between etiologies and age groups are limited. In this study, we aimed to investigate the clinical and imaging characteristics of PRES in children compared to adults in a large cohort. Methods We retrospectively reviewed the radiological report data bases between January 1999 and August 2012 for patients with PRES (total of 110 patients). Patients fulfilling the criteria for PRES after detailed investigation of clinical charts and imaging studies were separated into children (<18years) and adults (≥18years). Various imaging features at onset of symptoms and on follow-up as well as clinical and paraclinical data were analyzed. Results A total of 19 pediatric and 91 adult patients with PRES were included into the study. In pediatric PRES patients, seizures were significantly more frequent as initial PRES-related symptom (p = 0.01). In addition, in children the superior frontal sulcus topographic lesion pattern occurred as frequent as the parieto-occipital one and was significantly more prevalent than in adults (p = 0.02). In contrast, in adults visual disturbances tended to occur more frequently than in children (p = 0.05). Also, severity of edema tended to be greater in adults than in children (p = 0.07). Conclusion In our PRES cohort, we found relevant clinicoradiological differences between pediatric and adult PRES patients. However, prospective studies are warranted to establish factors that are specifically associated with pediatric PRES.
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Affiliation(s)
- Eberhard Siebert
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- * E-mail:
| | - Georg Bohner
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK) Partner Site, Charité - Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE) Partner Site, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas G. Liman
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Brain MR imaging abnormalities in pediatric patients after allogeneic bone marrow transplantation. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2014. [DOI: 10.1016/j.ejrnm.2014.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Gertsch EA, Ullrich NJ. Seizures in children treated for a primary brain tumor: risk factors, evaluation and management. FUTURE NEUROLOGY 2014. [DOI: 10.2217/fnl.14.52] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
ABSTRACT Seizures may be a presenting symptom of a brain tumor in childhood or can occur as a complication of treatment or subsequent effect occurring years after completion of therapy. Seizures create a number of therapeutic challenges and represent a significant comorbidity that results in decreased quality of life. Treatment options may be limited by interactions with chemotherapy and/or increased susceptibility to side effects. Moreover, seizures in this patient population may be less responsive to the traditional therapies typically effective for nontumor related epilepsy. While the pathophysiology of tumor-related epilepsy remains unclear, advances are being made in our understanding of the possible mechanisms involved. Newer anticonvulsants and improved diagnostic tools with refined surgical techniques show promise for future treatment approaches.
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Affiliation(s)
- Emily A Gertsch
- Department of Neurology, Boston Children‘s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Nicole J Ullrich
- Department of Neurology, Boston Children‘s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
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Donmez FY, Guleryuz P, Agildere M. MRI Findings in Childhood PRES: What is Different than the Adults? Clin Neuroradiol 2014; 26:209-13. [PMID: 25293448 DOI: 10.1007/s00062-014-0350-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 09/29/2014] [Indexed: 12/20/2022]
Abstract
PURPOSE Posterior reversible encephalopathy syndrome (PRES) is a clinical scenario with convulsion, vision abnormalities, altered mental status, and headaches in the presence of an underlying etiology, and the diagnosis can be made by support of radiological studies. In this study, we evaluated the magnetic resonance imaging (MRI) findings of PRES in children and compared our findings with that of the known features in adults, and reviewed the possible pathophysiological reasons that may cause the difference. MATERIALS AND METHODS A total of 29 children (13 male, 16 female, aged 1-17 years, mean age: 10 years) diagnosed as having PRES were retrospectively reviewed. Clinical records were analyzed for the clinical symptoms and the underlying etiology. MR images were evaluated for the distribution of lesions, contrast enhancement, diffusion restriction, and hemorrhage. RESULTS Presenting symptoms and underlying etiologies were variable. Frontal lobe (66 %) edema was almost as common as parietal and occipital involvement. Cerebellar involvement was present in almost half of the patients (48 %), which was more frequent than in the adult patients. Contrast enhancement is another finding that was found to be more common in children than in the adults (39 %). Four patients had diffusion restriction (15 %) and four patients had hemorrhage (%15), which are almost the same frequency as in the adults. CONCLUSION The increased incidence of cerebellar involvement may show that the posterior circulation in children is more vulnerable than the adults. The contrast enhancement in children, which is seen more commonly than in the adults, may show that the pathophysiology in children may be more commonly related to blood-brain barrier breakdown, which can support the theory of the toxic endothelial injury.
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Affiliation(s)
- F Y Donmez
- Department of Radiology, Baskent University Faculty of Medicine, 44. Sokak No: 11/8, Bahcelievler, Ankara, Turkey.
| | - P Guleryuz
- Department of Radiology, Baskent University Faculty of Medicine, 44. Sokak No: 11/8, Bahcelievler, Ankara, Turkey
| | - M Agildere
- Department of Radiology, Baskent University Faculty of Medicine, 44. Sokak No: 11/8, Bahcelievler, Ankara, Turkey
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Lee G, Lee SE, Ryu KH, Yoo ES. Posterior reversible encephalopathy syndrome in pediatric patients undergoing treatment for hemophagocytic lymphohistiocytosis: clinical outcomes and putative risk factors. Blood Res 2013; 48:258-65. [PMID: 24466550 PMCID: PMC3894384 DOI: 10.5045/br.2013.48.4.258] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Revised: 10/21/2013] [Accepted: 11/14/2013] [Indexed: 01/11/2023] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is a rare multiorgan disease of toxic immune activation caused by the interaction of cytotoxic T cells and innate immune cells and frequently involves the central nervous system (CNS). Posterior reversible encephalopathy syndrome (PRES) might develop during treatment with the HLH-2004 protocol from the Histiocyte Society. The aims of this study were to evaluate clinical outcomes and putative risk factors for prediction of PRES related to HLH. Methods We reviewed the medical records of 28 patients with HLH who were treated between April 2005 and April 2012. We compared various clinical and laboratory parameters in patients without or with PRES to evaluate putative risk factors related to development of PRES. Results Six (21.4%) of the patients experienced PRES during treatment with the HLH-2004 protocol. Clinical and laboratory manifestations were not different compared with other conditions causing PRES. The main mechanism of PRES may be related to the HLH-2004 protocol and a high pro-inflammatory state. Most patients recovered quickly from neurologic manifestations without significant long-term sequelae. Preceding hypertension, an increase in ferritin level >50% compared with 1 week before development of PRES and hyponatremia were statistically significant factors. Conclusion PRES is clinically reversible and has a favorable outcome in patients with HLH. Awareness of PRES and a differential diagnosis of other causes of neurologic complications, including CNS involvement of HLH, can help avoid unnecessary treatment or delayed management. Patients with preceding hypertension, hyponatremia, and rising ferritin levels during HLH treatment should be closely monitored for PRES.
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Affiliation(s)
- Goni Lee
- Department of Pediatrics, Ewha Womans University School of Medicine, Seoul, Korea
| | - Seung Eun Lee
- Department of Pediatrics, Ewha Womans University School of Medicine, Seoul, Korea
| | - Kyung-Ha Ryu
- Department of Pediatrics, Ewha Womans University School of Medicine, Seoul, Korea
| | - Eun Sun Yoo
- Department of Pediatrics, Ewha Womans University School of Medicine, Seoul, Korea
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Araz C, Camkiran A, Zeyneloglu P, Sezgin A, Moray G, Pirat A, Arslan G. Early-Onset Posterior Reversible Encephalopathy Syndrome After Solid Organ Transplantation in Pediatric Patients: A Report of 2 Cases. Transplant Proc 2013; 45:3555-7. [DOI: 10.1016/j.transproceed.2013.08.101] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Chen TH, Lin WC, Tseng YH, Tseng CM, Chang TT, Lin TJ. Posterior Reversible Encephalopathy Syndrome in Children: Case Series and Systematic Review. J Child Neurol 2013; 28:1378-1386. [PMID: 24065581 DOI: 10.1177/0883073813500714] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
To study presentations and outcome of posterior reversible encephalopathy syndrome in children, we retrospectively analyzed 14 patients admitted to our pediatric intensive care unit. We further assessed 94 additional pediatric cases from a systematic review. Our patients had a mean age of 11.6 years. Their precipitating factors were hypertension (100%), immunosuppressants (71%), antineoplastic agents (21%), and hemodialysis (14%). Initial neurologic manifestations included seizures (100%), mental change (100%), headache (79%), and visual disturbance (57%). After prompt diagnosis by magnetic resonance imaging (MRI) with intensive management, all patients had complete clinical recovery with subsequent radiologic resolution. Systemic literature review indicated that seizures (90%), hypertension (85%), and atypical neuroimaging findings (80%) are common presentations in childhood posterior reversible encephalopathy syndrome. We conclude that in children presenting with seizures and hypertension, a pediatric neurologist should consider posterior reversible encephalopathy syndrome within a comprehensive differential diagnosis of acute encephalopathy. Early recognition and intensive care are essential to ensure complete neurologic recovery in children with posterior reversible encephalopathy syndrome.
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Affiliation(s)
- Tai-Heng Chen
- 1Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
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Toxicity of upfront ¹³¹I-metaiodobenzylguanidine (¹³¹I-MIBG) therapy in newly diagnosed neuroblastoma patients: a retrospective analysis. Eur J Nucl Med Mol Imaging 2013; 40:1711-7. [PMID: 23921531 PMCID: PMC3788185 DOI: 10.1007/s00259-013-2510-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Accepted: 07/02/2013] [Indexed: 12/21/2022]
Abstract
Purpose In the treatment of patients with high-risk neuroblastoma, different doses of 131I-metaiodobenzylguanidine (131I-MIBG) are administered at different time points during treatment. Toxicity, mainly haematological (thrombocytopenia), from 131I-MIBG therapy is known to occur in extensively chemotherapy pretreated neuroblastoma patients. Up to now, acute toxicity from 131I-MIBG as initial treatment has never been studied in a large cohort. The aim of this retrospective study was to document acute toxicity related to upfront 131I-MIBG. Methods All neuroblastoma patients (stages 1–4 and 4S) treated upfront with 131I-MIBG at the Emma Children’s Hospital, Academic Medical Centre (1992 – 2008) were included in this retrospective analysis. The acute toxicity (during therapy) and short-term toxicity (1st month following therapy) of the first two 131I-MIBG therapies were studied. Results Of 66 patients (34 boys, 32 girls; median age 2.2 years, range 0.1 – 9.4 years), 49 had stage 4 disease, 5 stage 4S, 6 stage 3, 1 stage 2 and 5 stage 1. The median first dose was 441 MBq/kg (range 157 – 804 MBq/kg). The median second dose was 328 MBq/kg (range 113 – 727 MBq/kg). The most frequently observed symptoms were nausea and vomiting (21 %, maximum grade II). The main toxicity was grade IV haematological, occurring only in stage 4 patients, after the first and second 131I-MIBG therapies: anaemia (5 % and 4 %, respectively), leucocytopenia (3 % and 4 %) and thrombocytopenia (2 % and 4 %). No stem cell rescue was needed. Conclusion The main acute toxicity observed was haematological followed by nausea and vomiting. One patient developed posterior reversible encephalopathy syndrome during 131I-MIBG therapy, possibly related to 131I-MIBG. We consider 131I-MIBG therapy to be a safe treatment modality. Electronic supplementary material The online version of this article (doi:10.1007/s00259-013-2510-z) contains supplementary material, which is available to authorized users.
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Chima RS, Abulebda K, Jodele S. Advances in critical care of the pediatric hematopoietic stem cell transplant patient. Pediatr Clin North Am 2013; 60:689-707. [PMID: 23639663 DOI: 10.1016/j.pcl.2013.02.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Hematopoietic stem cell transplant (SCT) remains a curative option for a variety of malignant and non-malignant disorders in children. Following transplant a proportion of SCT recipients become critically ill and need intensive care. Critical illness may occur in the setting of transplant complications such as graft versus host disease (GVHD), idiopathic pneumonia syndrome (IPS), veno-occlusive disease (VOD) and transplant associated thrombotic microangiopathy (TA-TMA). Hence, familiarity with recent advances in the transplant process and complications is crucial for the intensivist. This article will highlight common complications encountered in the critically ill SCT recipient.
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Affiliation(s)
- Ranjit S Chima
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.
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Kushner BH, Modak S, Basu EM, Roberts SS, Kramer K, Cheung NKV. Posterior reversible encephalopathy syndrome in neuroblastoma patients receiving anti-GD2 3F8 monoclonal antibody. Cancer 2013; 119:2789-95. [PMID: 23633099 DOI: 10.1002/cncr.28137] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Revised: 03/18/2013] [Accepted: 03/21/2013] [Indexed: 11/06/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) comprises clinical and radiologic findings with rapid onset and potentially dire consequences. Patients experience hypertension, seizures, headache, visual disturbance, and/or altered mentation. Magnetic resonance imaging reveals edematous changes in the brain (especially in the parietal and occipital lobes). In this report, the authors describe PRES associated with antidisialoganglioside (anti-GD2 ) monoclonal antibody (MoAb) immunotherapy, which is now standard for high-risk neuroblastoma but has not previously been implicated in PRES. METHODS Successive clinical trials using the anti-GD2 MoAb 3F8 (a murine immunoglobulin 3 MoAb specific for GD2) for patients with neuroblastoma involved multiple cycles of standard-dose 3F8 (SD-3F8) (20 mg/m2 daily for 5 days per cycle) or 2 cycles of high-dose 3F8 (HD-3F8) (80 mg/m2 daily for 5 days per cycle) followed by cycles of SD-3F8. RESULTS PRES was diagnosed in 5 of 215 patients (2.3%), including 3 of 160 (1.9%) who received SD-3F8 and 2 of 55 (3.6%) who received HD-3F8 (P = .6). All 5 patients had a rapid return to clinical-radiologic baseline. PRES occurred in 3 of 26 patients (11.5%) whose prior treatment included external-beam radiotherapy to the brain (2 of 6 patients status-post total body irradiation and 1 of 20 patients status-post craniospinal irradiation) compared with 2 of 189 patients (1.1%) who had not received prior brain irradiation (P = .01). Hypertension, which is strongly linked to PRES, reached grade 3 toxicity in 12 of 215 patients (5.6%), including the 5 patients with PRES and 7 patients without PRES. CONCLUSIONS Patients who receive anti-GD2 MoAb immunotherapy should be closely monitored for, and undergo urgent treatment or evaluation of, symptoms that may herald PRES (eg, hypertension or headaches). Prior brain irradiation may be a predisposing factor for PRES with this immunotherapy.
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Affiliation(s)
- Brian H Kushner
- Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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Anesthesia and Intensive Care Management in a Pregnant Woman with PRES: A Case Report. Case Rep Anesthesiol 2012; 2012:745939. [PMID: 22937277 PMCID: PMC3399361 DOI: 10.1155/2012/745939] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Accepted: 06/21/2012] [Indexed: 11/17/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a temporary condition that is diagnosed clinically, neurologically, and radiologically. Its symptoms vary, and nonspecific headaches, confusion, impairment of consciousness, nausea, vomiting, and visual impairment may occur. Acute hypertension often accompanies these symptoms. Patients can also suffer from convulsions, cortical visual impairment, and coma. Diagnosis can be difficult due to focal neurologic signs. Nevertheless, knowing the clinical risk factors can lead to the right diagnosis. It has been reported that this condition may also occur during organ transplantation, immunosuppressive treatment, and autoimmune diseases and chemotherapy, and also patients with eclampsia. In this paper, a 21-year-old, 31-week pregnant woman, who had been diagnosed with PRES and thanks to early diagnosis and treatment had fully recovered and discharged from the intensive care unit, is presented, and the relevant literature is discussed.
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Cordelli DM, Masetti R, Bernardi B, Barcia G, Gentile V, Biagi C, Prete A, Pession A, Franzoni E. Status epilepticus as a main manifestation of posterior reversible encephalopathy syndrome after pediatric hematopoietic stem cell transplantation. Pediatr Blood Cancer 2012; 58:785-90. [PMID: 21990274 DOI: 10.1002/pbc.23344] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Accepted: 08/18/2011] [Indexed: 11/11/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a severe neurological complication after pediatric allogeneic hematopoietic stem cell transplantation (allo-HSCT). Seizures are a common manifestation of PRES. Status epilepticus (SE) is a potentially life-threatening event rarely described in this condition. The aim of this study was to describe the clinical and electroencephalographic features of SE as a manifestation of PRES in children after allo-HSCT. PROCEDURE We retrospectively identified episodes of SE as a consequence of PRES out of 211 children who received allo-HSCT in the period January 2000 to June 2008. RESULTS PRES was diagnosed in 11 patients. We identified 12 episodes of SE associated to PRES in 10 patients. Nonconvulsive SE (NCSE) involving posterior regions of the brain (confirmed by EEG monitoring) was observed in four cases; convulsive SE (CSE) was observed in eight cases. Gaze deviation, oculoclonic movements, nystagmus, and altered mental status were the main clinical signs during NCSE and preceded CSE in 5/8 cases. Most patients needed intensive care management. A complete normalization of neurological examination and EEG pattern was observed in all patients after SE and withdrawal of causative agent. Follow-up MRI showed complete resolution of brain edema in all patients. CONCLUSIONS Our experience shows that SE is more frequent than previously reported and is often the main manifestation of PRES after pediatric allo-HSCT. Looking for suggestive clinical signs as well as routine use of EEG monitoring may allow prompt recognition of SE and therapy of both SE and PRES.
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Affiliation(s)
- Duccio Maria Cordelli
- Child Neurology and Psychiatry Unit, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
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Vázquez E, Delgado I, Sánchez-Montañez A, Barber I, Sánchez-Toledo J, Enríquez G. Side effects of oncologic therapies in the pediatric central nervous system: update on neuroimaging findings. Radiographics 2012; 31:1123-39. [PMID: 21768243 DOI: 10.1148/rg.314105180] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The need for early, accurate diagnosis of central nervous system (CNS) complications occurring during and after pediatric cancer treatment is growing because of the improvement in overall survival rates related to innovative and aggressive oncologic therapies. An elevated degree of suspicion is needed to recognize the radiologic features of these CNS complications. Radiologists need familiarity with the early and late side effects of cancer therapy in the pediatric CNS (eg, toxic effects, infection, endocrine or sensory dysfunction, neuropsychologic impairment, second malignancies), in order to accelerate the imaging diagnosis and minimize as much as possible the associated morbidity. Acquisition of knowledge about these complications will enable the development of more appropriate therapeutic trials and more effective patient surveillance and will lead to an improved quality of life by decreasing the long-term sequelae in survivors.
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Affiliation(s)
- Elida Vázquez
- Department of Pediatric Radiology and Pediatric Oncohematology, Universidad Autónoma de Barcelona, Barcelona, Spain.
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Posterior reversible encephalopathy syndrome in children with kidney diseases. Pediatr Nephrol 2012; 27:375-84. [PMID: 21556718 DOI: 10.1007/s00467-011-1873-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Revised: 03/16/2011] [Accepted: 03/16/2011] [Indexed: 10/18/2022]
Abstract
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.
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Battipaglia G, Avilia S, Morelli E, Caranci F, Perna F, Camera A. Posterior reversible encephalopathy syndrome (PRES) during induction chemotherapy for acute myeloblastic leukemia (AML). Ann Hematol 2012; 91:1327-8. [PMID: 22237936 DOI: 10.1007/s00277-011-1398-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Accepted: 12/28/2011] [Indexed: 11/30/2022]
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Early onset of posterior reversible encephalopathy syndrome (PRES) during Cyclosporine-A infusion. Leuk Res 2011; 35:1423-4. [PMID: 21397327 DOI: 10.1016/j.leukres.2011.02.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Revised: 02/19/2011] [Accepted: 02/19/2011] [Indexed: 11/22/2022]
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Zhang HL, Qin GX, Yang Y, Wu J. Posterior reversible encephalopathy syndrome during leukaemia chemotherapy. Eur J Paediatr Neurol 2011; 15:182. [PMID: 20810297 DOI: 10.1016/j.ejpn.2010.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Accepted: 07/27/2010] [Indexed: 11/30/2022]
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Gephart MGH, Taft BP, Giese AK, Guzman R, Edwards MSB. Perioperative posterior reversible encephalopathy syndrome in 2 pediatric neurosurgery patients with brainstem ependymoma. J Neurosurg Pediatr 2011; 7:235-7. [PMID: 21361759 DOI: 10.3171/2010.12.peds10299] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) has been described in pediatric neurooncology patients, although it has not been documented perioperatively in pediatric neurosurgery patients not actively receiving chemotherapy. Recently at the authors' facility, 2 cases of PRES were diagnosed perioperatively in children with brainstem ependymoma. Both patients had presented with hypertension, altered mental status, and seizures and demonstrated MR imaging features consistent with PRES. The patients were treated with antiseizure and antihypertension medications, leading to improvement in both clinical symptoms and neuroimaging findings. These cases are the first to document PRES in perioperative pediatric neurosurgery patients not actively receiving chemotherapy. Both patients had ependymoma involving the brainstem, which may have led to intra- and perioperative hemodynamic instability (including hypertension) and predisposed them to this syndrome. An awareness of PRES in similar scenarios will aid in the prevention, diagnosis, and treatment of pediatric neurosurgery patients with this syndrome.
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Affiliation(s)
- Melanie G Hayden Gephart
- Department of Neurosurgery, Stanford University Hospital and Clinics, Stanford, California 94305-5327, USA.
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Baytan B, Ozdemir O, Demirkaya M, Evim MS, Gunes AM. Reversible posterior leukoencephalopathy induced by cancer chemotherapy. Pediatr Neurol 2010; 43:197-201. [PMID: 20691942 DOI: 10.1016/j.pediatrneurol.2010.05.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2010] [Revised: 03/17/2010] [Accepted: 05/03/2010] [Indexed: 11/17/2022]
Abstract
Reversible posterior leukoencephalopathy, defined by both clinical and neuroimaging findings, can affect children receiving chemotherapy. The syndrome is characterized by hypertension, alterations in mental status, seizures, hallucinations, and acute visual changes and is associated with abnormalities seen in magnetic resonance imaging of symmetric white matter lesions, especially in the parietal and occipital lobes. The etiology of reversible posterior leukoencephalopathy is as yet unknown. Presented here are four cases of reversible posterior leukoencephalopathy induced by chemotherapy, with a brief review of the literature and consideration of possible mechanisms. A diagnosis of reversible posterior leukoencephalopathy should be considered when patients receiving cancer chemotherapy suddenly develop hypertension followed by neurologic complications, especially if presenting with seizures.
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Affiliation(s)
- Birol Baytan
- Department of Pediatric Hematology, Uludag University Medical Faculty, Görükle Bursa, Turkey.
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de Laat P, Te Winkel ML, Devos AS, Catsman-Berrevoets CE, Pieters R, van den Heuvel-Eibrink MM. Posterior reversible encephalopathy syndrome in childhood cancer. Ann Oncol 2010; 22:472-8. [PMID: 20699277 DOI: 10.1093/annonc/mdq382] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is characterized by seizures, headaches, altered mental status, cortical blindness and typical transient lesions on magnetic resonance imaging. PATIENTS AND METHODS We describe seven childhood cancer patients with clinical and radiological symptoms of PRES, and reviewed all well-documented PRES cases reported during childhood cancer treatment. RESULTS Fifty-six children with PRES, including our 7 cases, were identified in the literature. Mean age at onset was 9 (range: 2-17) years. Primary diagnoses were acute lymphoblastic leukemia (n = 31), acute myeloid leukemia (n = 5), non-Hodgkin lymphoma (n = 7) and solid tumors (n = 13). PRES patients presented with seizures (n = 50), altered mental status (n = 20), visual disturbances (n = 24) and/or headaches (n = 17). PRES was associated with hypertension in 49 patients. About 86% of the patients had both clinical and radiological reversible symptoms. Four patients developed epilepsy, in one patient ataxia remained and one patient had a persistent mydriasis. CONCLUSION Although PRES has predominantly been described in leukemia patients, it occurs in children with solid tumors as well. Hypertension seems to be the most important trigger for the occurrence of PRES during childhood cancer treatment. Seizures are the most common accompanying sign. Symptoms and radiological findings normalize in ∼90% of the cases, but in 10% neurological symptoms remain.
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Affiliation(s)
- P de Laat
- Department of Pediatric Oncology/Hematology, Erasmus MC-Sophia Children’s Hospital, University Medical Center, Rotterdam, The Netherlands
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Progressive necrotic encephalopathy following tacrolimus therapy for liver transplantation. Neurol Sci 2009; 30:527-9. [PMID: 19779798 DOI: 10.1007/s10072-009-0149-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2009] [Accepted: 09/04/2009] [Indexed: 10/20/2022]
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