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Trent AR, Parry JW, Yokley JE, Grathwohl KW. Posterior Reversible Encephalopathy Syndrome and Pre-eclampsia/Eclampsia: Anesthetic Implications and Management. Cureus 2022; 14:e23659. [PMID: 35505705 PMCID: PMC9054029 DOI: 10.7759/cureus.23659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2022] [Indexed: 11/17/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a rare neurologic disorder that has recently become more frequently diagnosed. While the exact etiology of PRES remains unclear, multiple diseases are associated with PRES. Moreover, there is increasing recognition of the association of PRES in pre-eclampsia/eclampsia with advancements in imaging techniques and increased awareness of the disorder. While pre-eclampsia/eclampsia alone presents unique perioperative challenges, PRES further complicates anesthetic management. Unfortunately, the anesthetic management for these critically ill and complex patients is not well elucidated and it is unclear whether the anesthetic choice may actually worsen neurologic symptoms. We describe two different presentations of PRES with pre-eclampsia/eclampsia, their anesthetic implications, and management.
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Parasher A, Jhamb R. Posterior reversible encephalopathy syndrome (PRES): presentation, diagnosis and treatment. Postgrad Med J 2020; 96:623-628. [PMID: 32467104 DOI: 10.1136/postgradmedj-2020-137706] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/09/2020] [Accepted: 05/10/2020] [Indexed: 11/03/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a neurological disorder which is characterised by variable symptoms, which include visual disturbances, headache, vomiting, seizures and altered consciousness. The exact pathophysiology of PRES has not been completely explained, but hypertension and endothelial injury seem to be almost always present. Vasoconstriction resulting in vasogenic and cytotoxic edema is suspected to be responsible for the clinical symptoms as well as the neuro-radiological presentation. On imaging studies, Symmetrical white matter abnormalities suggestive of edema are seen in the computer tomography (CT) and magnetic resonance imaging (MRI) scans, commonly but not exclusively in the posterior parieto-occipital regions of the cerebral hemispheres. The management is chiefly concerned with stabilization of the patient, adequate and prompt control of blood pressure, prevention of seizures and timely caesarean section in obstetric cases with pre-eclampsia/eclampsia. In conclusion, persistently elevated blood pressures remain the chief culprit for the clinical symptoms as well as the neurological deficits. Early diagnosis by diffusion weighted MRI scans, and differentiation from other causes of altered sensorium i.e. seizures, meningitis and psychosis, is extremely important to initiate treatment and prevent further complications. Although most cases resolve successfully and carry a favorable prognosis, patients with inadequate therapeutic support or delay in treatment may not project a positive outcome.
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Affiliation(s)
- Anant Parasher
- Medicine, Guru Teg Bahadur Hospital, New Delhi, India .,Medicine, Guru Teg Bahadur Hospital, New Delhi, India
| | - Rajat Jhamb
- Medicine, Guru Teg Bahadur Hospital, New Delhi, India
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Katsevman GA, Turner RC, Cheyuo C, Rosen CL, Smith MS. Post-partum posterior reversible encephalopathy syndrome requiring decompressive craniectomy: case report and review of the literature. Acta Neurochir (Wien) 2019; 161:217-224. [PMID: 30659351 DOI: 10.1007/s00701-019-03798-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 01/04/2019] [Indexed: 10/27/2022]
Abstract
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.
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Sesar A, Cavar I, Sesar AP, Sesar I. Transient cortical blindness in posterior reversible encephalopathy syndrome after postpartum eclampsia. Taiwan J Ophthalmol 2018; 8:111-114. [PMID: 30038892 PMCID: PMC6055316 DOI: 10.4103/tjo.tjo_5_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinical condition that can cause different ophthalmological and neurological symptoms. Preeclampsia toxemia or eclampsia is one of the leading causes of PRES. Herein, we present a study of a 35-year old woman who gave birth to healthy twins at 35 weeks of gestation by cesarean section because of threatened preterm delivery. On the 1st postoperative day, the woman developed a severe headache, arterial hypertension, tachycardia, generalized tonic-clonic seizures, and loss of consciousness that persisted for about 2 min. A provisional diagnosis of eclampsia was made, and the woman was then quickly transferred to the intensive care unit where she was treated with antihypertensive therapy, magnesium sulphate, and diazepam. Following stabilization of the general condition, the patient noticed sudden bilateral blindness. An ophthalmological examination revealed significant bilateral loss of vision at the level of insecured light perception, normal pupillary responses to a light stimulus, and normal fundus findings. On this basis, an ophthalmologist made the diagnosis to cortical blindness. Radiographic analysis showed an edematous change in the occipital and parietal brain regions, thus suggesting a diagnosis of PRES. In conclusion, cortical blindness is a clinically striking ophthalmic disorder that may occur in PRES associated with postpartum eclampsia.
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Affiliation(s)
- Antonio Sesar
- Department of Ophthalmology, University Clinical Hospital Mostar, Mostar, Bosnia and Herzegovina
| | - Ivan Cavar
- Department of Ophthalmology, University Clinical Hospital Mostar, Mostar, Bosnia and Herzegovina.,Department of Physiology, School of Medicine, University of Mostar, Mostar, Bosnia and Herzegovina
| | - Anita Pusic Sesar
- Department of Ophthalmology, University Clinical Hospital Mostar, Mostar, Bosnia and Herzegovina
| | - Irena Sesar
- Department of Ophthalmology, University Clinical Hospital Mostar, Mostar, Bosnia and Herzegovina
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Vandenbossche G, Maquet J, Vroonen P, Lambert G, Nisolle M, Kridelka F, Emonts E. A reversible posterior leucoencephalopathy syndrome including blindness caused by preeclampsia. Facts Views Vis Obgyn 2016; 8:173-177. [PMID: 28003872 PMCID: PMC5172574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Complications of (pre)eclampsia may involve multiple systems and organs. Neurological symptoms may occur. Visual symptoms concern up to 25% the of patients with severe preeclampsia and 50% of the patients with eclampsia. An uncommon effect of severe preeclampsia is sudden blindness. Blindness may be part of a clinical and radiological presentation named Posterior Reversible Encephalopathy Syndrome (PRES). PRES may lead to permanent neurological deficit, recurrences or death. We report the case of a 24-year-old Caucasian patient, gravida 5 para 2 who developed preeclampsia and PRES complicated with blindness at 32 weeks of gestation. Optimal care allowed visual symptoms to resolve within 24 hours and a favourable maternal outcome and no long- term sequelae. We describe different causes and manifestations of PRES and highlight the need for immediate care in order to optimize the chance of symptoms reversibility.
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Affiliation(s)
- G Vandenbossche
- CHU of Liège, Department of Obstetrics and Gynaecology, 4000 Liège, Belgium
| | - J Maquet
- University of Liège, Medical School, Liege, Belgium
| | - P Vroonen
- CHU of Liège, Department of Emergencies, Liège, Belgium
| | - G Lambert
- CHR de la Citadelle, Department of Anesthesiology, 4000 Liège, Belgium
| | - M Nisolle
- CHR de la Citadelle, Department of Obstetrics and Gynecology, Liège, Belgium
| | - F Kridelka
- CHU of Liège, Department of Obstetrics and Gynaecology, 4000 Liège, Belgium
| | - E Emonts
- CHU of Liège, Department of Obstetrics and Gynaecology, 4000 Liège, Belgium
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Demirel İ, Kavak BS, Özer AB, Bayar MK, Erhan ÖL. An intensive care approach to posterior reversible encephalopathy syndrome (PRES): An analysis of 7 cases. J Turk Ger Gynecol Assoc 2014; 15:217-21. [PMID: 25584029 DOI: 10.5152/jtgga.2014.14072] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 09/19/2014] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The aim of this study was to retrospectively evaluate the intensive care unit treatments applied to obstetrics patients with a diagnosis of posterior reversible encephalopathy syndrome (PRES). MATERIAL AND METHODS The cases of 7 pregnant patients who had been diagnosed with PRES between July 2011 and July 2013 were retrospectively reviewed. The patients' clinical data, brain magnetic resonance imaging (MRI) images before and after treatment, and neuropsychological tests were evaluated. RESULTS Five out of 7 patients had eclampsia, 1 patient had severe preeclampsia, and 1 patient developed HELLP syndrome secondary to PRES. Calcium channel blockers and β-blockers were used as antihypertensive treatment. All patients were treated with parenteral magnesium sulfate. In addition, sodium thiopental was given to control sedation and convulsions in all patients except 1. The neurological and radiological findings of all cases treated in the intensive care unit improved. CONCLUSION Posterior reversible encephalopathy syndrome is a clinical condition with a multifactorial etiology and can result in different clinical findings. Radiological imaging techniques can be used for the diagnosis of PRES. Pregnancy and the postpartum period often lead to this syndrome. In some cases, PRES can cause irreversible neurological deficits or death. For patients with severe radiological findings, early diagnosis and thiopental infusion, in addition to treatment with antihypertensive agents and magnesium sulfate, may lead to quicker and more effective recovery from clinical manifestations. We suggest supplementation of standard treatment with early thiopental infusion.
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Affiliation(s)
- İsmail Demirel
- Department of Anesthesiology and Reanimation, Fırat University Faculty of Medicine, Elazığ, Turkey
| | - Burçin Salih Kavak
- Department of Obstetric and Gynecology, Fırat University Faculty of Medicine, Elazığ, Turkey
| | - Ayşe B Özer
- Department of Anesthesiology and Reanimation, Fırat University Faculty of Medicine, Elazığ, Turkey
| | - Mustafa K Bayar
- Department of Anesthesiology and Reanimation, Fırat University Faculty of Medicine, Elazığ, Turkey
| | - Ömer L Erhan
- Department of Anesthesiology and Reanimation, Fırat University Faculty of Medicine, Elazığ, Turkey
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Poma S, Delmonte MP, Gigliuto C, Imberti R, Delmonte M, Arossa A, Iotti GA. Management of posterior reversible syndrome in preeclamptic women. Case Rep Obstet Gynecol 2014; 2014:928079. [PMID: 25506009 PMCID: PMC4254080 DOI: 10.1155/2014/928079] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Revised: 10/30/2014] [Accepted: 11/01/2014] [Indexed: 11/17/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a neurological syndrome associated with a number of conditions including preeclampsia. It is characterized by seizures, alteration of consciousness, visual disturbances, and symmetric white matter abnormalities, typically in the posterior parietooccipital regions of the cerebral hemispheres, at computed tomography (CT) and magnetic resonance (MRI). We report three new cases of PRES in preeclamptic patients and describe the management of these patients. We present a brief review of other cases in the literature, with particular attention to the anesthetic management.
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Affiliation(s)
- S. Poma
- Unit of Obstetric Anesthesia, Department of Anesthesia and Intensive Care, Fondazione Policlinico San Matteo Hospital, Viale Golgi 19, 27100 Pavia, Italy
| | - M. P. Delmonte
- Unit of Obstetric Anesthesia, Department of Anesthesia and Intensive Care, Fondazione Policlinico San Matteo Hospital, Viale Golgi 19, 27100 Pavia, Italy
| | - C. Gigliuto
- Department of Anesthesia and Intensive Care, Fondazione Policlinico San Matteo Hospital, Viale Golgi 19, 27100 Pavia, Italy
| | - R. Imberti
- Direzione Scientifica, Fondazione Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
| | - M. Delmonte
- Dipartimento di Medicina Diagnostica e Servizi, Servizio di Radiodiagnostica, Fondazione Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
| | - A. Arossa
- Department of Obstetrics and Gynecology, Fondazione Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
| | - G. A. Iotti
- Department of Anesthesia and Intensive Care, Fondazione Policlinico San Matteo Hospital, Viale Golgi 19, 27100 Pavia, Italy
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