Discharge status and in-hospital mortality in posterior reversible encephalopathy syndrome

Posterior reversible encephalopathy syndrome in a child following hypovolemic shock: a case report

Introduction and importance

Posterior reversible encephalopathy syndrome (PRES) is a condition that causes a wide range of clinical neurological manifestations like headache, seizures, visual changes, and altered mental sensations. It is diagnosed with the help of sequential neuroimaging findings. Manifestations may occur a few hours to months after the initial precipitating cause. In the pediatric population, the most common cause is hypertension caused by renal disease or different drugs.

Case presentation

Here, the authors present the case of a 4-year-old boy with a significant medical history of acute gastroenteritis following hypovolemic shock that later developed white matter edema of the brain on T2-weighted MRI scans along with symptoms such as headache and vomiting. Here, the patient was managed symptomatically with antiepileptic medication as prophylaxis.

Clinical discussion

PRES is a rare neurological diagnosis made in the child that presents with headache, vomiting, blurring of vision, and abnormal body movements, which have several etiology like hypertension, glomerulonephritis, organ transplant, drugs, and very rarely with hypovolemic shock. It is an acute reversible condition in which a person presents with visual disturbances, headaches, and seizures. Seizures present as a life-threatening situation, so antiepileptic drugs are used as early prophylaxis.

Conclusion

PRES is a reversible neurological condition, and prognosis is typically favorable if recognized and treated early, with symptom improvement or resolution in a few days to several weeks. Complications of PRES develop if the disease is not treated promptly. Complications include focal neurologic deficits from ischemic injury and epilepsy.

Advances in imaging findings of preeclampsia-related reversible posterior leukoencephalopathy syndrome

Preeclampsia (PE)-related reversible posterior leukoencephalopathy syndrome (RPLS) is a common complication of hypertensive disorders of pregnancy. The syndrome usually occurs after 20 weeks of gestation and can lead to brain injury. Severe headache, seizures, disturbance of consciousness, and other neurological symptoms may occur in severe cases. PE-RPLS has high morbidity and mortality rates and seriously damages maternal and fetal health. In recent years, the continuous advancement of medical imaging technology has provided an important imaging basis for the early diagnosis and prognostic evaluation of RPLS. This article mainly details the research status of the etiology and pathogenesis of PE-RPLS and describes its characteristic imaging findings, especially MRI findings, to provide new insights into its early diagnosis, early treatment, and improvement of prognosis.

Central Variant Posterior Reversible Encephalopathy Syndrome in a Pregnant Woman With Eclampsia: A Case Report

Posterior Reversible Encephalopathy Syndrome (PRES) is a clinico-radiological diagnosis characterized by acute or subacute neurological symptoms. A 27-year-old woman at 35 weeks of pregnancy, who presented with generalized tonic-clonic seizures had persistently low Glasgow Coma Scale (GCS) score after delivery of the baby. Magnetic Resonance Imaging (MRI) of the brain showed T-2 Fluid Attenuated Inversion Recovery (FLAIR) hyperintensities in the brainstem, bilateral medial cerebellar hemispheres, bilateral medial temporal lobes, bilateral thalami, lentiform and caudate nuclei, and bilateral fronto-parieto-occipital lobes. There was diffusion restriction in bilateral caudate nuclei, left thalamus and right frontal lobe, and microhemorrhages in the left thalamus. These findings were suggestive of central variant PRES. She improved with strict blood pressure control and anti-edema measures. A repeat MRI brain on day 10 showed significant improvement, and she had no residual neurological deficits. The central variant of PRES is a rare entity that has to be considered in a patient presenting with neurological deficits in the setting of uncontrolled blood pressure, eclampsia, immunomodulatory medication use, or renal failure. While most patients with PRES fully recover with timely therapy targeted at reversing the primary cause, some may have residual neurological deficits or rarely, die.

Clinical features and prognostic analysis of posterior reversible encephalopathy syndrome in children

BACKGROUND

We aimed to investigate the clinical features and prognosis of posterior reversible encephalopathy syndrome (PRES) in children.

METHODS

Clinical data of children with PRES diagnosed at the Children's Hospital of Chongqing Medical University from June 2015 to May 2019 were retrospectively analyzed.

RESULTS

The study enrolled 47 patients with a mean age at diagnosis of 8.79 ± 3.72 years (range, 2-15 years). PRES causes included renal disorder (29/47), hematological disease (13/47), and hypertension (5/47). PRES manifested as seizure (43/47), headache (28/47), visual impairment (18/47), dizziness (18/47), vomiting (18/47), and mental and behavioral abnormalities (17/47). Forty-six children had hypertension (46/47) at PRES onset. Magnetic resonance imaging (MRI) mainly involved the parietal and occipital lobes (42/47), 38 cases were mild (38/47), 7 were moderate (7/47), and 2 were severe (2/47). The clinical symptoms of 41 patients (41/47) were relieved within 1-2 weeks. Thirty-seven children were followed up for 7-54 months (modified Rankin Scale). Twenty-five children had favorable outcomes (25/37). Twelve children had adverse outcomes (12/37), including epilepsy, disorders of consciousness, visual impairment, and mental decline. Analysis of single factors revealed that severity on MRI, length of in-hospital stay, and mental and behavioral abnormalities were related to adverse outcomes after PRES. Analysis of multiple factors revealed that severity on MRI and length of in-hospital stay were independent risk factors for PRES.

CONCLUSION

Pediatric PRES is a clinical radiographic syndrome with multiple etiologies. Most patients have a good prognosis. Severity on MRI and length of in-hospital stay are independent risk factors.

Posterior Reversible Encephalopathy in Sepsis-Associated Encephalopathy: Experience from a Single Center

BACKGROUND

Sepsis-associated encephalopathy (SAE) is frequently encountered in sepsis and is often accompanied by neuroimaging findings indicating ischemia, hemorrhage, and edema. Posterior reversible encephalopathy syndrome (PRES) has been vastly underrecognized in previously reported cohorts of patients with sepsis and SAE. Our aim was to determine the prevalence and distinguishing clinical, neuroimaging, and electroencephalography features of PRES in SAE.

METHODS

In this prospective observational study, patients with radiologically identified PRES were selected from a consecutively enrolled cohort of 156 patients with SAE and assessed for neurological outcome using the extended Glasgow Outcome Scale for 12 months. Patients with SAE and PRES and other types of brain lesions were compared in terms of clinical and diagnostic workup features.

RESULTS

Fourteen of 156 patients (8.9%) were determined to be radiologically compatible with PRES, whereas 48 patients displayed other types of acute brain lesions. Patients with PRES often showed lesions in atypical regions, including frontal lobes, the corpus callosum, and the basal ganglia. Source of infection was mostly gram-negative bacteria originating from pneumonia or intraabdominal infections. Patients with PRES were not different from other patients with SAE with brain lesions in terms of features of sepsis and neurological outcome. However, patients with PRES showed increased prevalence of seizures and intraabdominal source of infection.

CONCLUSIONS

PRES is highly prevalent in SAE, often encompasses unusual brain regions, and usually presents with generalized seizures. Patients with SAE and PRES do not appear to have distinguishing clinical and diagnostic workup features. However, generalized seizures may serve as warning signs for presence of PRES in patients with SAE.

Posterior reversible encephalopathy syndrome (PRES): diagnosis and management

Posterior reversible encephalopathy syndrome (PRES) may present with diverse clinical symptoms including visual disturbance, headache, seizures and impaired consciousness. MRI shows oedema, usually involving the posterior subcortical regions. Triggering factors include hypertension, pre-eclampsia/eclampsia, renal failure, cytotoxic agents and autoimmune conditions. The mechanism underlying PRES is not certain, but endothelial dysfunction is implicated. Treatment is supportive and involves correcting the underlying cause and managing associated complications, such as seizures. Although most patients recover, PRES is not always reversible and may be associated with considerable morbidity and even mortality.

Seizures in posterior reversible encephalopathy syndrome: blood pressure management in normotensive patients

Posterior reversible encephalopathy syndrome (PRES) is a rare clinical disease that refers to the subcortical vasogenic edema involving bilateral parieto-occipital regions, with a usually reversible syndrome when causes are eliminated or controlled. Hypertension or blood pressure fluctuations are most common causes of PRES, but other contributors like chemotherapy and autoimmune disorders have also been reported. PRES has rapid onset of symptoms. Therefore, it is of major importance to determine whether blood pressure management plays an important role in prognosis. We presented two PRES patients who developed non-convulsive seizure but had normal baseline blood pressure at the time of presence of cause. The diagnosis of PRES was made by neurologists. The patients had no history of seizure or hypertension, but during the disease course they presented with temporal elevation of blood pressure with different durations. The second patients without instant blood pressure control developed residual symptoms of seizure at 90- and 120-day follow-up. Although the exact pathophysiology of PRES remains to be fully understood, primary and secondary prolonged blood pressure fluctuations may be associated with the prognosis of this syndrome. Early blood pressure management would be critical to favorable outcome.

Posterior reversible encephalopathy syndrome (PRES) due to acute hypertension in children: 12 years single-center experience

The objective of the study is to evaluate the clinical and neuroradiological findings, the risk factors for recurrence and the prognosis in patients with posterior reversible encephalopathy syndrome developed secondary to acute hypertension in children. The study was conducted between 2008 and 2019 at Mersin University Faculty of Medicine. A total of 49 episodes were evaluated retrospectively in 38 patients with PRES secondary to acute hypertension. The demographic data, etiology, and clinical and neuroradiological findings were recorded. Twenty-one (55.3%) patients were female; the mean age was 11.8 years. The etiology of acute hypertension in 29 (76.3%) patients was end-stage renal disease (ESRD). The most common clinical findings were seizure (81.6%) and altered consciousness (79.6%). Status epilepticus developed in eight (16.3%) episodes. MRI lesions were atypical in 33 episodes (67.3%). In eight (21%) patients, PRES recurred. Irreversible brain damage was detected after PRES in three (7.8%) patients. C-reactive protein and erythrocyte sedimentation rate were elevated in 82.2% and 71.4% of the episodes, respectively. A statistically significant relationship was found between the recurrence, the duration of hospitalization at the PICU, SE and the occurrence of irreversible lesion (p = 0.013, p = 0.015, p = 0.001 respectively). Also, there were statistically significant relationships between recurrence and ESRD; epilepsy and recurrences; SE and irreversible brain damage (p = 0.02, p = 0.012, p = 0.025 respectively). Although PRES is usually known to have a good prognosis, the mortality and morbidity rates may increase in the long-term follow-up as in our study. In this study, the etiology, the presence of status epilepticus, PICU history, atypical MRI lesions and increased inflammatory markers were found to be important for the prognosis in PRES.

Posterior Reversible Encephalopathy Syndrome: Tips for Diagnosis and Treatment

Often described as a clinico-radiological entity, posterior reversible encephalopathy syndrome (PRES) is being increasingly diagnosed nowadays. However, mystery still surrounds its exact etiology. Though there are no standardized diagnostic criteria for this syndrome, there is a consistent feature associated with it: brain vasogenic edema in combination with neurotoxicity. The nonspecific nature of this condition leaves room for the diagnosis to be overlooked, leading to delays in providing appropriate treatment and unfavorable patient outcomes. PRES is associated with a variety of medical conditions including hypertension, eclampsia, autoimmune conditions, renal failure, sepsis, and an immunocompromised state, such as that secondary to the use of immunosuppressive therapy, human immunodeficiency virus (HIV), and organ transplants. Treatment by a multidisciplinary team and prompt identification and reversal of the underlying cause can lead to beneficial outcomes, as in the case we present in this report.

Posterior Reversible Encephalopathy Syndrome

Purpose of Review

This review provides an updated discussion on the clinical presentation, diagnosis and radiographic features, mechanisms, associations and epidemiology, treatment, and prognosis of posterior reversible encephalopathy syndrome (PRES). Headache is common in PRES, though headache associated with PRES was not identified as a separate entity in the 2018 International Classification of Headache Disorders. Here, we review the relevant literature and suggest criteria for consideration of its inclusion.

Recent Findings

COVID-19 has been identified as a potential risk factor for PRES, with a prevalence of 1–4% in patients with SARS-CoV-2 infection undergoing neuroimaging, thus making a discussion of its identification and treatment particularly timely given the ongoing global pandemic at the time of this writing.

Summary

PRES is a neuro-clinical syndrome with specific imaging findings. The clinical manifestations of PRES include headache, seizures, encephalopathy, visual disturbances, and focal neurologic deficits. Associations with PRES include renal failure, preeclampsia and eclampsia, autoimmune conditions, and immunosuppression. PRES is theorized to be a syndrome of disordered autoregulation and endothelial dysfunction resulting in preferential hyperperfusion of the posterior circulation. Treatment typically focuses on treating the underlying cause and removal of the offending agents.

Posterior reversible encephalopathy syndrome: A neuropsychiatric manifestation of systemic lupus erythematosus

Posterior Reversible Encephalopathy Syndrome (PRES) is an acute neurological syndrome clinically characterized by seizures, altered mental status, headache, and visual disturbances. It is caused by a variety of abnormalities in the endothelial function that ultimately result in vasogenic edema in the circulation of the central nervous system. This is reflected by the neuroimaging findings, that most often show reversible parieto-occipital edema. An important proportion of patients with PRES present with Systemic Lupus Erythematosus (SLE), and its complications, as their sole risk factors. This review describes the relationship between these two clinical entities and explains the pathophysiological models that have been proposed to describe the development of PRES. We explain how SLE can cause alterations in every pathway implicated in the development of PRES. Given the relatively high frequency and the distinct clinical course, PRES in the setting of SLE might be best described as a distinct neuropsychiatric syndrome associated with SLE.

Posterior reversible encephalopathy syndrome coexists with acute cerebral infarction: challenges of blood pressure management

Hypertension is the most common cause of posterior reversible encephalopathy syndrome (PRES) and acute cerebral infarction. Due to the lack of randomized controlled clinical trials (RCTs), early antihypertensive methods are diverse, even contradictory. So far, there is no consensus on the method of blood pressure (BP) management when the 2 diseases coexist. Generally, antihypertensive therapy should be initiated quickly in the acute phase of PRES, as most patients have elevated BP. However, various factors must be considered before the administration of early antihypertensive therapy in acute cerebral infarction. The coexistence of PRES and acute cerebral infarction is uncommon clinically, and more complicated subsequent BP management. This article reports a case of PRES coexisting with acute lacunar cerebral infarction, which was caused by hypertension. We have analyzed and summarized the antihypertensive principles in PRES and different phases of acute cerebral ischemic injury. We assert that when PRES and acute cerebral infarction coexist, the antihypertensive treatment should be individualized, and careful consideration should be given to the various influencing factors.

Chemotherapy and Immunosuppressant Therapy-Induced Posterior Reversible Encephalopathy Syndrome

Posterior reversible encephalopathy syndrome (PRES) is an entity which is characterized by acute to subacute onset of neurological symptoms like altered mental status, seizures, headaches and other focal neurological deficits. It is diagnosed with the help of MRI findings which typically involve the subcortical white matter of parieto-occipital lobes. In this review, we will discuss the various etiologies and risk factors including some of the most common chemotherapeutic agents and immunosuppressant agents associated with this disorder. We will discuss the mechanism of actions and side effect profiles of a few drugs and their role in causation of PRES. This review article discusses if there is any difference in presentation and imaging findings of PRES caused by cytotoxic agents versus caused by other etiologies. It also highlights the difficulty in management of PRES caused by cytotoxic agents as the discontinuation of these drugs could be life-threatening due to graft rejections or graft versus host disease.

Atypical posterior reversible encephalopathy syndrome with albuminocytological dissociation and late emerging neuroradiological findings: A case report

Posterior reversible encephalopathy syndrome (PRES) is a central nervous system disorder accompanied by vasogenic edema in white matter that is usually located in temporo-parieto-occipital area. Typically, PRES is presented with headaches, seizures, and change of consciousness. The most common etiologic factor is fluctuations in blood pressure. An eighty-eight-year-old female patient was evaluated because of her acute confused state. Medical history revealed hypertension. Blood pressure was 190/100 mmHg. The initial examination showed impaired consciousness. Radiological investigations of brain showed chronic ischemic lesions. Albuminocytological dissociation was detected in CSF examination. On the 6^th day of admission, cranial MRI was repeated. Radiological findings were typical for PRES. The cranial MRI is a valuable diagnostic tool for the diagnosis of the PRES but, as in our case, despite the subtle clinical and radiological findings presented during admission, repeated MRI and CSF examination may contribute to a definite diagnosis. This case is remarkable for severe protein elevation in CSF, irreversible fatal course and radiographic evidence of vasogenic edema occurred subsequently.

Etiologies, Cerebral Vasomotion, and Endothelial Dysfunction in the Pathophysiology of Posterior Reversible Encephalopathy Syndrome in Pediatric Patients

The posterior reversible encephalopathy syndrome was characterized by Hinchey and colleagues in the 1990s. The condition frequently afflicts patients suffering from hematologic and solid organ malignancy and individuals undergoing transplantation. Cases are more frequently described in the adult population compared with children. In the pediatric population, malignancy, transplantation, renal disease, and hypertension represent the most common etiologies. Theories on pathogenesis have centered upon cerebrovascular dysautoregulation with increases in blood–brain barrier permeability. This generates vasogenic edema of the cerebral parenchyma and consequent neurologic deficits. The parietal and occipital lobes are affected with greatest prevalence, though frontal and temporal lobe involvement is frequent, and that of the contents of the infratentorial posterior cranial fossa are occasionally described. The clinical presentation involves a characteristic constellation of neurologic signs and symptoms, most typically inclusive of headache, visual-field disturbances, abnormalities of visual acuity, and seizures. Supportive care, withdrawal of the offending agent, antihypertensive therapy, and prophylactic anticonvulsants affect convalescence in majority of cases. The principal challenge lies in identifying the responsible agent precipitating the condition in patients with malignancy and those having undergone transplantation and thus deciding which medication among a multidrug treatment regimen to withhold, the duration of drug cessation required to effect clinical resolution, and the safety of resuming treatment with the compound. We accordingly reviewed and evaluated the literature discussing the posterior reversible encephalopathy syndrome in children.

Posterior reversible leukoencephalopathy syndrome: Case series and review of the literature

OBJECTIVE

To describe clinical manifestations, antecedents, comorbidities and associated treatments, imaging findings, and follow-up in patients with posterior reversible encephalopathy syndrome.

METHODS

A retrospective, descriptive analysis of admitted patients was performed between June 2009 and May 2014 in a third-level care hospital. We evaluated age, sex, comorbidities, symptoms, values of blood pressure at admission, renal function, medication and time elapsed until the disappearance of symptoms.

RESULTS

Thirteen patients were included. In all, 77% of them had a history of hypertension at baseline and 85% had impaired renal function. The most prevalent comorbidity was renal transplantation, and 85% had deterioration of renal function. Five of the patients had undergone renal transplantation. The most common clinical manifestation was seizures. All had subcortical lesions and bilateral parietooccipital involvement was the finding most frequently observed.

CONCLUSION

This syndrome should be taken into account in the differential diagnoses of patients presenting with acute neurological syndromes and the abovementioned risk factors.

Posterior Reversible Encephalopathy Syndrome: Clinical Features and Outcome

Background: Posterior reversible encephalopathy syndrome (PRES) is an acute neurotoxic syndrome that is characterized by a spectrum neurological and radiological feature from various risk factors. Common neurological symptoms includes headache, impairment in level of consciousness, seizures, visual disturbances, and focal neurological deficits. Common triggering factors include blood pressure fluctuations, renal failure, eclampsia, exposure to immunosuppressive or cytotoxic agents and autoimmune disorders. The classic radiographic findings include bilateral subcortical vasogenic edema predominantly affecting the parieto-occipital regions but atypical features include involvement of other regions, cortical involvement, restricted diffusion, hemorrhage, contrast enhancement. This review is aimed to summarize the updated knowledge on the typical and atypical clinical and imaging features, prognostic markers and identify gaps in literature for future research.

Methods: Systematic literature review using PUBMED search from 1990 to 2019 was performed using terms PRES was performed.

Results: While clinical and radiographic reversibility is common, long-standing morbidity and mortality can occur in severe forms. In patients with malignant forms of PRES, aggressive care has markedly reduced mortality and improved functional outcomes. Although seizures were common, epilepsy is rare. Various factors that have been associated with poor outcome include altered sensorium, hypertensive etiology, hyperglycemia, longer time to control the causative factor, elevated C reactive protein, coagulopathy, extensive cerebral edema, and hemorrhage on imaging.

Conclusion: Large prospective studies that accurately predict factors that are associated with poor outcomes, determine the pathophysiology, and targeted therapy are required.

Childhood Posterior Reversible Encephalopathy Syndrome: Clinicoradiological Characteristics, Managements, and Outcome

Posterior reversible encephalopathy syndrome (PRES) is a novel clinicoradiological syndrome characterized by convulsions, headache, altered mentality, and impaired vision, which are usually accompanied by hypertension. As its nomination, PRES is usually diagnosed according to the presence of typical neuroimage showing vasogenic edema predominately involving the posterior brain area. With the widespread utilization of magnetic resonance imaging (MRI), PRES is becoming more perceptible in different medical fields. Compared to adult cases, childhood PRES seems to have a broader clinical and neuroradiological spectrum. PRES can be associated with various underlying comorbidities, medication use, and therapeutic modalities in children with diverse neurological manifestations. Moreover, pediatric patients with PRES have a more significant propensity for atypical MRI findings beyond the typically posterior cerebral areas. The knowledge of typical and atypical presentations in children is essential to avoid misdiagnosing or missing PRES, which is a potentially treatable entity. Early supportive care is the mainstay of treatment, with particular attention to the treatment of hypertension with rigorous attention to all body systems. Prompt identification and symptom-directed management are imperative to achieve a reversible prognosis in childhood PRES. Future studies specially designed for the child population are required to determine potential outcome predictors, and further, to develop novel strategies of neuroprotection in childhood PRES.

Childhood Posterior Reversible Encephalopathy Syndrome: Clinicoradiological Characteristics, Managements, and Outcome

Posterior reversible encephalopathy syndrome (PRES) is a novel clinicoradiological syndrome characterized by convulsions, headache, altered mentality, and impaired vision, which are usually accompanied by hypertension. As its nomination, PRES is usually diagnosed according to the presence of typical neuroimage showing vasogenic edema predominately involving the posterior brain area. With the widespread utilization of magnetic resonance imaging (MRI), PRES is becoming more perceptible in different medical fields. Compared to adult cases, childhood PRES seems to have a broader clinical and neuroradiological spectrum. PRES can be associated with various underlying comorbidities, medication use, and therapeutic modalities in children with diverse neurological manifestations. Moreover, pediatric patients with PRES have a more significant propensity for atypical MRI findings beyond the typically posterior cerebral areas. The knowledge of typical and atypical presentations in children is essential to avoid misdiagnosing or missing PRES, which is a potentially treatable entity. Early supportive care is the mainstay of treatment, with particular attention to the treatment of hypertension with rigorous attention to all body systems. Prompt identification and symptom-directed management are imperative to achieve a reversible prognosis in childhood PRES. Future studies specially designed for the child population are required to determine potential outcome predictors, and further, to develop novel strategies of neuroprotection in childhood PRES.

Posterior reversible encephalopathy syndrome

PURPOSE OF REVIEW

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological syndrome characterized by acute cerebral endotheliopathy with consecutive disruption of the blood-brain barrier and vasogenic edema. Since its first description in 1996, PRES is increasingly recognized. However, many aspects of this syndrome with its wide spectrum of clinical and radiological features are still incompletely understood. In this review, possible pathophysiological mechanisms, approaches to diagnosis, recent study results on outcome, and future directions of research are described.

RECENT FINDINGS

Clinical manifestations of PRES include seizures, headache, visual disturbances, altered mental state, and more rarely hemiparesis or aphasia. Vasogenic edema predominantly occurs in the parieto-occipital region, but lesions affecting formerly called 'atypical' regions such as frontal lobe, cerebellum, or basal ganglia are common. If treated early and adequately, that is by removal of the underlying cause, PRES has a favorable prognosis, but neurological residual symptoms and even mortality can occur, particularly in patients with complications such as intracranial hemorrhage.

SUMMARY

In summary, validated diagnostic criteria and algorithms are warranted to standardize the diagnosis of PRES. This is essential for further research and future prospective studies that should investigate risk factors for unfavorable outcome and identify the roles of imaging features, clinical symptoms, and other biomarkers in predicting outcome.

Clinical features, outcomes and risk factors for posterior reversible encephalopathy syndrome in systemic lupus erythematosus: a case-control study

OBJECTIVE

The objective of this paper is to investigate the clinical features, outcomes, and risk factors for posterior reversible encephalopathy syndrome (PRES) in systemic lupus erythematosus (SLE).

METHODS

From 2011 to October 2017, SLE patients with PRES were identified from the First Affiliated Hospital of Zhengzhou University, China. Patients presenting with neuropsychiatric lupus hospitalized in the same period were included as controls. Additionally, survival status was acquired via telephone follow-up in March 2018.

RESULTS

Thirty episodes of PRES were identified in 29 SLE patients from a total of 7059 SLE patients (prevalence 0.43%). Patients with PRES had a younger age at onset than controls, with seizures more commonly the initial clinical manifestation (80.00% vs 42.37%, p = 0.001). Multiple logistic regression yet again confirmed several known risk factors, including younger age (odds ratio (OR) 1.15 (95% confidence interval (CI) 1.13-1.16)), nephritis (OR 20.74 (18.10-23.75)), history of hypertension (OR 1.17 (1.05-1.31)), SLE Disease Activity Index without neurologic symptoms (SLEDAI-N) score >12 (OR 1.14 (1.11-1.18)) and eclampsia (OR 9.38 (7.84-11.23)). Furthermore, we identified two novel independent risk factors for PRES in SLE: white blood cells >9 × 10⁹/l (OR 2.33 (2.05-2.64)) and heart failure (OR 2.10 (1.18-2.42)). At follow-up, SLE patients with PRES had higher mortality than controls (30.77% vs 8.33%, respectively, p = 0.012).

CONCLUSIONS

PRES may be a reversible neurological deficit in patients with SLE other than neuropsychiatric lupus. Our results indicate two new risk factors for PRES and that PRES is associated with a higher mortality rate.

Post-partum posterior reversible encephalopathy syndrome requiring decompressive craniectomy: case report and review of the literature

Posterior reversible encephalopathy syndrome (PRES) is an uncommon but potentially devastating syndrome if not recognized and treated appropriately. As the name implies, recognition of the condition and proper management may reverse the clinical and radiological findings. However, diagnosis is not always straightforward. We present the case of a 24-year-old female who was 4 days post-partum and presented with headache, neck pain, and new-onset seizures. She had undergone epidural anesthesia during labor, and initial imaging was suggestive of intracranial hypotension versus pachymeningitis. Despite initial conservative therapy including anti-epileptic drugs, magnesium therapy, empiric antibiotics, and Trendelenburg positioning, the patient continued to deteriorate. Follow-up imaging was suggestive of PRES with signs of intracranial hypertension. The patient underwent a decompressive suboccipital craniectomy for refractory and severe PRES and later fully recovered. This case highlights the sometimes difficult diagnosis of PRES, possible association with pregnancy, eclampsia/preeclampsia and/or cerebrospinal fluid drainage, and the rare but life-saving need for decompression in severe cases.

Cerebrospinal Fluid in Posterior Reversible Encephalopathy Syndrome: Implications of Elevated Protein and Pleocytosis

Background and Purpose

Patients with posterior reversible encephalopathy syndrome (PRES) sometimes undergo analysis of cerebrospinal fluid (CSF) to exclude alternative diagnoses. This study's objectives were to describe the CSF characteristics in patients with PRES and to identify clinical and radiologic findings associated with distinct CSF abnormalities.

Methods

We identified a retrospective cohort of patients with PRES. We compared clinical and radiographic characteristics of those who did versus did not undergo lumbar puncture, described the observed range of CSF findings, and analyzed clinical and radiographic features associated with specific CSF abnormalities.

Results

A total of 188 patients were included. Patients with (n = 77) and without (n = 111) CSF analysis had similar clinical and radiographic characteristics. Cerebrospinal fluid protein was elevated in 46 (60%) of 77, with median CSF protein 53 mg/dL (upper limit of normal 45 mg/dL). Protein elevation was significantly associated with radiographic severity (P = .0058) but not with seizure, time from symptom onset, radiographic evidence of diffusion restriction, or contrast enhancement. Five (7%) patients had elevated CSF white blood cells, all of whom had infarction and/or hemorrhage on neuroimaging, and 4 of whom had eclampsia.

Conclusion

The CSF of most patients with PRES shows a mild protein elevation commensurate with radiographic severity. Cerebrospinal fluid pleocytosis may mark a distinct subtype of PRES with predisposition toward infarction and/or hemorrhage. These findings help clinicians interpret CSF findings in these patients and generate new hypotheses about the pathophysiology of this syndrome.

Late recovery from unconsciousness in a patient with severe posterior reversible encephalopathy syndrome

This study describes a patient case presenting with severe posterior reversible encephalopathy syndrome (PRES) who needed 3 months to recover impaired consciousness. We discuss the protracted time course needed to deal with severe PRES cases. Positive prognoses can emerge from these situations if treatment is prompt and precise.

Risk factors for poor outcome in posterior reversible encephalopathy syndrome: systematic review and meta-analysis

Background

The roles of clinical etiology and symptoms, imaging findings and biochemical parameters in predicting the prognosis of posterior reversible encephalopathy syndrome (PRES) have not been well-characterized. We perform a meta-analysis of all published studies to assess the value of various risk factors in predicting the prognosis of PRES.

Methods

Searches of the PubMed, EMBASE, Cochrane Library, and Web of Science databases were performed to identify the eligible studies. The odds ratios (ORs) with their corresponding 95% confidence interval (CI) for related risk factors were used to calculate the pooled estimates of the outcomes.

Results

Six studies with 448 cases were included in the meta-analysis. Hemorrhage was associated with high risk for poor outcome in patients with PRES. Toxemia of pregnancy (pre-eclampsia/eclampsia) was associated with improved outcome in PRES patients. Cytotoxic edema was noted to be related to poor outcome, but did not show statistical significance. The pooled OR for hemorrhage, pre-eclampsia/eclampsia, cytotoxic edema was 4.93 (95% CI: 3.94-6.17; P<0.00001), 0.24 (95% CI: 0.15-0.40; P<0.00001) and 2.59 (95% CI: 0.84-7.99; P=0.10), respectively.

Conclusions

PRES patients with hemorrhage or cytotoxic edema are likely to have poor outcomes. Pre-eclampsia/eclampsia is associated with reduced risk of poor outcome in patients with PRES.

Controversy of posterior reversible encephalopathy syndrome: what have we learnt in the last 20 years?

Over two decades have passed since posterior reversible encephalopathy syndrome (PRES) was first described in 1996. It has becoming increasingly recognised because of improved and more readily available imaging modality. The exact pathophysiological mechanism is not completely understood and remains controversial at present. Precise diagnosis is essential to guide prompt, proper management. Our ability of differentiating it from other acute neurological disorders is likely to improve as we learnt more about the spectrum of this entity in the last 20 years. We emphasise the importance of recognising its diagnostic criteria and biomarker, which would be of great relevance to either outcome evaluation or study design. PRES has a favourable prognosis generally, but neurological sequelae and even fatalities can occur, especially in severe forms that might cause substantial morbidity and even mortality, particularly when the syndrome is complicated by intracranial haemorrhage or brain infarction. In this review, the pathophysiology, approach to diagnosis, some controversies as to the prognosis, as well as the future research direction of PRES are described.

Posterior Reversible Encephalopathy Syndrome Presenting as Stroke Mimic

We present the case of a 33-year-old male with end stage renal disease presenting to the emergency department (ED) with headache, dizziness, and unilateral weakness. Initial concern was for ischemic or hemorrhagic stroke. Magnetic resonance imaging confirmed posterior reversible encephalopathy syndrome (PRES). The patient was treated appropriately and made a full neurologic recovery. PRES is an under-recognized diagnosis in the ED. As a stroke mimic, PRES can lead the clinician on an incorrect diagnostic pathway with potential for iatrogenic harm.

Predictors of intensive care unit utilization in patients with posterior reversible encephalopathy syndrome

Posterior reversible encephalopathy syndrome (PRES) is an acute neurological syndrome that requires prompt, aggressive management to improve outcomes. Our aim was to identify factors that would necessitate care in the intensive care unit (ICU) in patients with PRES and the outcomes on discharge following ICU stay. We retrospectively reviewed the medical records and radiological data of adult PRES patients admitted to our tertiary care medical center. We dichotomized them into two groups based on their need for ICU care and compared their clinical, laboratory, imaging characteristics and discharge outcomes. Outcomes were defined using the modified Rankin Score (mRS) and Glasgow Outcome Score (GOS) on discharge. Out of 100 patients, 67 % required admission to the ICU. On univariate analysis, factors associated with ICU admission were atrial fibrillation (19.4 vs 0 %; p ≤ 0.05), encephalopathy from PRES (89.6 vs 66.7 %; p < 0.05), low Glasgow Coma Score (GCS) (11 ± 4 vs 14 ± 2; p = 0.01) and cortical involvement on imaging (89.6 vs 72.7 %, p = 0.03). On multivariate logistic regression analysis, encephalopathy (odds ratio 10.22; 95 % CI (1.14-91.55; p = 0.04) was the sole predictor of ICU utilization. This correlated with a GCS <12 (odds ratio 5.53; 95 % CI (1.05-29.22; p = 0.04). Despite worse functional outcomes following ICU care based on mRS (2.3 ± 2.1 vs 1.3 ± 1.4, p = 0.02) and GOS (3.9 ± 1.3 vs 4.6 ± 0.7, p ≤ 0.05), only a borderline increase in mortality was observed (10.4 vs 0 %, p = 0.05). The presence of PRES-related encephalopathy might aid in prompt identification of patients who require ICU care.

Neuropathological findings from an autopsied case showing posterior reversible encephalopathy syndrome-like neuroradiological findings associated with premedication including tacrolimus for autologous peripheral blood stem cell transplantation

Posterior reversible encephalopathy syndrome (PRES) is diagnosed based on neuroradiological findings. Typically, PRES is reversible and presents with a good outcome; however, fatal outcomes have been reported. We report an autopsied case showing PRES-like neuroradiological findings associated with premedication including tacrolimus for autologous peripheral blood stem cell transplantation in a 28-year-old woman with a 2-year history of acute myeloid sarcoma/acute myeloid leukemia. Neurological examination revealed disturbed consciousness, muscle weakness in all extremities, and bilaterally diminished tendon reflexes. Brain fluid attenuated inversion recovery MRI showed multiple bilateral hyper-intensity areas in the posterior white matter and left corona radiate. She died of respiratory arrest within 24h after PRES diagnosis. Neuropathological examination revealed diffuse cerebral edema, multiple cerebral hematomas that extended into the lateral ventricles and subarachnoid cavities, and multiple microbleeds predominantly in the inferior surface of the occipital white matter. Microscopic findings revealed paler myelin sheaths, enlargement of the vascular endothelium, leakage of plasma components and red blood cells, and clasmatodendrosis within the occipital white matter. Cerebral herniation and diffuse cerebral edema due to vascular endothelial dysfunction were concluded to be the cause of death. These pathological findings may aid in the pathophysiological recognition of acute-stage PRES.

Posterior reversible encephalopathy in the intensive care unit

Posterior reversible encephalopathy syndrome (PRES) is increasingly diagnosed in the emergency department, and medical and surgical intensive care units. PRES is characterized by acute onset of neurologic symptoms in the setting of blood pressure fluctuations, eclampsia, autoimmune disease, transplantation, renal failure, or exposure to immunosuppressive or cytotoxic drugs, triggers known to admit patients to the intensive care unit (ICU). Although the exact pathophysiology remains unknown, there is growing consensus that PRES results from endothelial dysfunction. Because of the heterogeneous nature of the disorder, it is probable that different mechanisms of endothelial injury are etiologically important in different clinical situations. The presence of bilateral vasogenic edema on brain imaging, particularly in parieto-occipital regions, is of great diagnostic utility but PRES remains a clinical diagnosis. Although largely reversible, PRES can result in irreversible neurologic injury and even death. The range of clinical and radiographic manifestations of the syndrome is probably broader than previously thought, and it is imperative that clinicians become familiar with the full spectrum of the disorder, as prompt recognition and elimination of an inciting factor improve outcome. PRES may be the most frequent toxic-metabolic encephalopathy seen in the ICU.

Spectrum of cerebral spinal fluid findings in patients with posterior reversible encephalopathy syndrome

The purpose of this study is to characterize the spectrum of cerebrospinal fluid (CSF) findings in patients with posterior reversible encephalopathy syndrome (PRES)and determine its associations with severity of edema. In this retrospective cross-sectional study electronic medical reports were screened for patients with PRES. Clinical and laboratory data closest to onset of clinical symptoms were collected. Neuroimaging reports from all patients were categorized according to the presence of vasogenic edema,cytotoxic edema and contrast enhancement. From Jan 1999to Feb 2015, 87 patients with PRES and CSF findings were included. Mean total protein levels were 793 ± 929 mg/l. Median cell counts were 2/μl (IQR 1-4). Eight patients had cell counts[6/μl with a maximum of 41/μl. In 31 patients with extended CSF analysis, mean CSF/serum albuminquotient (QAlb) was 10.1 (IQR 6-17.3). An elevated QAlb (age-adjusted) was found in 74 % of these 31 patients. PRES patients with severe edema had higher mean total protein levels in CSF (mean difference = 407 mg/l; 95 %CI 187-628). Significant correlations were found for edema severity with levels of CSF protein (r = 0.48, p<0.001) as well with QAlb (r = 0.44, p = 0.013). This study shows that total protein in CSF and QAlb are elevated and correlate with severity of edema in PRES patients, whereas pleocytosis was rare in our cohort. This supports the theory that PRES is caused by a dysfunctional blood brain barrier.

Acute Kidney Injury, Recurrent Seizures, and Thrombocytopenia in a Young Patient with Lupus Nephritis: A Diagnostic Dilemma

Introduction. Posterior reversible encephalopathy syndrome (PRES) is a constellation of clinical and radiologic findings. Fluctuations in blood pressure, seizures, and reversible brain MRI findings mainly in posterior cerebral white matter are the main manifestations. PRES has been associated with multiple conditions such as autoimmune disorders, pregnancy, organ transplant, and thrombotic microangiopathy (TMA). Case Presentation. A 22-year-old woman with history of Systemic Lupus Erythematous complicated with chronic kidney disease secondary to lupus nephritis class IV presented with recurrent seizures and uncontrolled hypertension. She was found to have acute kidney injury and thrombocytopenia. Repeat kidney biopsy showed diffuse endocapillary and extracapillary proliferative and membranous lupus nephritis (ISN-RPS class IV-G+V) and endothelial swelling secondary to severe hypertension but no evidence of TMA. Brain MRI showed reversible left frontal and parietal lesions that resolved after controlling the blood pressure, making PRES the diagnosis. Conclusion. PRES is an important entity that must be recognized and treated early due to the potential reversibility in the early stages. Physicians must have high suspicion for these unusual presentations. We present a case where performing kidney biopsy clinched the diagnosis in our patient with multiple confounding factors.

Factors associated with fatal outcome in posterior reversible encephalopathy syndrome: a retrospective analysis of the Berlin PRES study

Although often reversible, fatal outcome in posterior reversible encephalopathy syndrome (PRES) is well known. However, data on predictors of PRES-associated in-hospital death are scarce. In this study, we aimed to investigate predictors of in-hospital death in a large cohort. Radiological report databases between January 1999 and February 2015 were retrospectively searched for patients with PRES. Patients were included if they met criteria for PRES after detailed investigation of clinical charts and imaging studies. Various clinical, paraclinical and brain MRI data as well as data on in-hospital mortality were analyzed. 151 patients were included into the study, 64% were female. Seventeen (11.2%) patients died during hospital stay. In univariate analyses, higher age (p = 0.04), higher levels of C-reactive protein (p < 0.001), etiology of PRES (sepsis and chemotherapy; p = 0.02), altered coagulation (p = 0.002), altered mental state at onset (p = 0.03), and subarachnoid hemorrhage (SAH; p = 0.01) were related to in-hospital death. In multivariate analyses adjusted for age and sex, elevated CRP levels (OR 1.1 95% CI 1.1-1.2), altered coagulation (OR 5.1 95% CI 1.8-14.7), subarachnoid hemorrhage (OR 10.1 95% CI 2.2-46.1) and altered mental state (OR 3.3; 95% CI 1.1-9.4) were independently associated with in-hospital death. Altered mental state, subarachnoid hemorrhage as well as the higher levels of CRP and altered coagulation were significantly more frequent in patients who died in hospital. However, prospective studies are warranted to establish predictors of fatality in patients with PRES.

[Posterior reversible encephalopathy syndrome due to hypocalcemia: a description of a case and an analysis of a pathogenic role of electrolyte disturbances]

Afemale patient with recurrent posterior reversible encephalopathy syndrome, severe hypocalcemia due to extirpation of the parathyroid glands is described. The disease was characterized by the acute development of headache, seizures, cognitive and behavioral disorders, mental confusion, transitory blood pressure increasing. The vasogenic edema in the posterior parts of the brain, detected by CT at the first exacerbation,was completely regressed. The residual neurological deficit and MRI changes remained after the recurrent exacerbations. Main clinical features of PRESare explained by hypocalcemia and accompanying electrolyte disturbances.The reported case shows the necessity to study blood electrolytes in patients with PRES to clarify their pathogenic role and the necessity of drug correction.

Predictors of poor outcome in patients with posterior reversible encephalopathy syndrome

PURPOSE

Posterior reversible encephalopathy syndrome (PRES) is an acute neurotoxic syndrome that, although characteristically reversible, can be fatal or result in long-term disability in a subset of patients. Our aim was to identify factors associated with poor discharge outcome in PRES patients.

MATERIALS AND METHODS

We retrospectively reviewed the clinical and radiological records of all patients with PRES admitted at our tertiary care medical center from 2007 to 2014. They were divided based their modified Rankin Score at discharge and compared for their baseline variables, clinical, laboratory and imaging features. Poor outcome was defined by a modified Rankin scale 2-6 and was subdivided based on the primary mechanism that led to poor outcome.

RESULTS

Out of 100 PRES subjects, 36% had poor discharge outcomes. Factors associated with poor outcomes on univariate analysis were history of diabetes mellitus, coma, high Charlson comorbidity index, post-transplantation, autoimmune condition, lack of systolic or diastolic hypertension, elevated blood urea nitrogen and involvement of the corpus callosum. On multivariate analysis, only prior diabetes mellitus odd ratio (OR) = 6.8 (95% CI 1.1-42.1, p = 0.04), corpus callosum involvement (OR = 11.7; 95% CI 2.4-57.4, p = 0.00) were associated with poor outcome. Poor outcome also correlated with increased length of hospital stay (OR = 7.9; 95% CI 1.3-49.7, p = 0.03).

CONCLUSION

Large prospective studies incorporating serial blood glucose values and advanced imaging studies are required to validate these findings.

Posterior reversible encephalopathy syndrome: clinical and radiological manifestations, pathophysiology, and outstanding questions

Almost two decades have elapsed since posterior reversible encephalopathy syndrome (PRES) was described in an influential case series. This usually reversible clinical syndrome is becoming increasingly recognised, in large part because of improved and more readily available brain imaging. Although the pathophysiological changes underlying PRES are not fully understood, endothelial dysfunction is a key factor. A diagnosis of PRES should be considered in the setting of acute neurological symptoms in patients with renal failure, blood pressure fluctuations, use of cytotoxic drugs, autoimmune disorders, or eclampsia. Characteristic radiographic findings include bilateral regions of subcortical vasogenic oedema that resolve within days or weeks. The presence of haemorrhage, restricted diffusion, contrast enhancement, and vasoconstriction are all compatible with a diagnosis. In most cases, PRES resolves spontaneously and patients show both clinical and radiological improvements. The range of symptoms that can comprise the syndrome might be broader than usually thought. In its mild form, this disorder might cause only one clinical symptom (headache or seizure) and radiographically might show few areas of vasogenic oedema or even normal brain imaging in some rare cases. In severe forms, PRES might cause substantial morbidity and even mortality, most often as a result of acute haemorrhage or massive posterior fossa oedema causing obstructive hydrocephalus or brainstem compression.

Clinical and radiological spectrum of posterior reversible encephalopathy syndrome: does age make a difference?--A retrospective comparison between adult and pediatric patients

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.