Spectrum of radiological changes in hypertensive children with reversible posterior leucoencephalopathy

Posterior Reversible Encephalopathy Syndrome in a Patient with Post Streptococcal Glomerulonephritis: A Case Report

Posterior reversible encephalopathy syndrome is a clinical-radiological syndrome neurological disorder with varied symptoms which include headache, visual field defects, seizures, altered consciousness. It is a rare complication of post-streptococcal glomerulonephritis and results in life-threatening manifestations if not managed on time. Although reversible by definition, complications like status epilepticus, intracranial hemorrhage, and ischemic infarction may lead to mortality and morbidity. We report a case of a 9-year-old female patient with posterior reversible encephalopathy syndrome who presented with multiple episodes of seizures and bilateral painless loss of vision for 1 day. Due to her severity, a computed tomography scan was sent which revealed a hypodense lesion in the brain. She was admitted to the pediatric intensive care unit and managed with supportive care for 6 days where she died on the 6th day. Vital signs are simple but important and if overlooked can lead to a series of complicated events.

Relapsing Demyelinating Syndromes in Children: A Practical Review of Neuroradiological Mimics

Relapsing demyelinating syndromes (RDS) in children encompass a diverse spectrum of entities including multiple sclerosis (MS) acute disseminated encephalomyelitis (ADEM), aquaporin-4 antibody associated neuromyelitis optica spectrum disorder (AQP4-NMOSD) and myelin oligodendrocyte glycoprotein antibody disease (MOG-AD). In addition to these, there are “antibody-negative” demyelinating syndromes which are yet to be fully characterized and defined. The paucity of specific biomarkers and overlap in clinical presentations makes the distinction between these disease entities difficult at initial presentation and, as such, there is a heavy reliance on magnetic resonance imaging (MRI) findings to satisfy the criteria for treatment initiation and optimization. Misdiagnosis is not uncommon and is usually related to the inaccurate application of criteria or failure to identify potential clinical and radiological mimics. It is also notable that there are instances where AQP4 and MOG antibody testing may be falsely negative during initial clinical episodes, further complicating the issue. This article illustrates the typical clinico-radiological phenotypes associated with the known pediatric RDS at presentation and describes the neuroimaging mimics of these using a pattern-based approach in the brain, optic nerves, and spinal cord. Practical guidance on key distinguishing features in the form of clinical and radiological red flags are incorporated. A subsection on clinical mimics with characteristic imaging patterns that assist in establishing alternative diagnoses is also included.

Posterior Reversible Encephalopathy Syndrome after Head Trauma Surgery in Pediatric Patient without Any Underlying Disease

Posterior reversible encephalopathy syndrome (PRES) is a neurological disorder characterized by signs of posterior cerebral edema upon radiographic examination. A 16-year-old girl was involved in motorcycle accident and depressed frontal fracture was presented. She had generalized seizures 3 days after dural repair and fracture reduction. Signal changes was noted on both parietal lobes in the magnetic resonance images and it was completely resolved in 3 months follow-up. We would like to present the case that demonstrated PRES related hypertension after head trauma surgery for cerebrospinal fluid leakage in pediatric patient without any underlying disease.

Indications for the performance of neuroimaging in children

Pediatric neurology relies on ultrasound, computed tomography (CT), and magnetic resonance (MR) imaging. CT prevails in acute neurologic presentations, including traumatic brain injury (TBI), nontraumatic coma, stroke, and status epilepticus, because of easy availability, with images of diagnostic quality, e.g., to exclude hemorrhage, usually completed quickly enough to avoid sedation. Concerns over the risks of ionizing radiation mean re-imaging and higher-dose procedures, e.g., arteriography and venography, require justification. T1/T2-weighted imaging (T1/T2-WI) MR with additional sequences (arteriography, venography, T2*, spectroscopy, diffusion tensor, perfusion, diffusion- (DWI) and susceptibility-weighted imaging (SWI)) often clarifies the diagnosis, which may alter management in acute settings, as well as chronic conditions, e.g., epilepsy. Clinical acumen remains essential to avoid imaging, e.g., in genetic epilepsies or migrainous headaches responding to treatment, or to target sequences to specific diagnosis, e.g., T1/T2-WI for shunt dysfunction (with SWI for TBI); DWI, arteriography including neck vessels, and venography for acute hemiplegia or coma; coronal temporal cuts for partial epilepsy; or muscle imaging for motor delay. The risk of general anesthesia is low; "head-only" scanners may allow rapid MRI without sedation. Timely and accurate reporting, with discrepancy discussion between expert neuroradiologists, is important for management of the child and the family's expectations.

Posterior Reversible Encephalopathy Syndrome in Two Omani Children with Underlying Renal Diseases

Posterior reversible encephalopathy syndrome (PRES) is a neurological condition with a combination of clinical and radiological features. Clinical symptoms include headaches, confusion, seizures, disturbed vision or an altered level of consciousness. Classic magnetic resonance imaging (MRI) findings indicate subcortical and cortical oedema, affecting mainly the posterior cerebral region. We report two paediatric cases of PRES with underlying renal diseases presenting at the Sultan Qaboos University Hospital in Muscat, Oman, in April 2010 and August 2011. The first case was an 11-year-old girl diagnosed with systemic lupus erythematosus and the second was a six-and-a-half-year-old boy on peritoneal dialysis due to multi-drug-resistant nephrotic syndrome. Both patients were hypertensive and treated with blood pressure control medications. No residual neurological dysfunction was noted in the patients at a one-year follow-up and at discharge, respectively. The role of hypertension in paediatric PRES cases, among other important risk factors, is emphasised. Additionally, MRI is an important diagnostic and prognostic tool. Prompt diagnosis and aggressive management is fundamental to preventing permanent neurological damage.

Clinical Utility of Computed Tomography and Magnetic Resonance Imaging for Diagnosis of Posterior Reversible Encephalopathy Syndrome after Stem Cell Transplantation in Children and Adolescents

Posterior reversible encephalopathy syndrome (PRES) is a clinical syndrome characterized by vision changes, altered mental status, and seizures, typically caused by an acute rise in blood pressure. PRES has been reported after hematopoietic stem cell transplantation (HSCT) in association with hypertension from calcineurin inhibitors and corticosteroids. The imaging evaluation of PRES after HSCT in children and young adults has not been well described. We performed a retrospective review of all HSCT recipients presenting to the intensive care unit with new neurologic symptoms. A neuroradiologist reviewed all radiologic images and compared computed tomography (CT) versus magnetic resonance imaging (MRI) findings indicative of diagnosis of PRES. Alternative imaging diagnoses explaining the patients' symptoms were also recorded. Fifty-four transplant recipients were admitted to the intensive care unit with new neurologic symptoms. Thirty-nine percent (21 of 54) of subjects had imaging findings consistent with PRES, 24% (13 of 54) had imaging findings consistent with an alternative diagnosis, 9% (5 of 54) had a nonspecific finding, and 28% (15 of 54) had no acute imaging findings. PRES was diagnosed at a median of 49 days (interquartile range, 29 to 94) after HSCT. The presenting symptom for the majority of patients with PRES was seizures (86%), whereas 14% presented with acute encephalopathy. Ninety-five percent of subjects diagnosed with PRES (20 of 21) underwent a head CT as their initial imaging evaluation. CT scan was diagnostic of PRES in 40% (8 of 20). Subsequently, 16 patients underwent brain MRI with 12 additional patients being diagnosed with PRES on MRI. The median time elapsed between negative CT and a positive MRI examination was 20 hours (range, 3.6 hours to 9 days). CT serves as an excellent screening test for acute pathology, such as intracranial hemorrhage; however, it lacks sensitivity for the diagnosis of PRES. Patients with clinical symptoms suggestive of PRES who have a negative CT should be treated appropriately for PRES and should undergo MRI of the brain as soon as clinically stable to confirm the diagnosis.

A case of acute post-streptococcal glomerulonephritis that developed posterior reversible encephalopathy syndrome

A 10-year male patient presented with swelling in the face, legs and scrotal area which developed 8 days after tonsillitis treatment. Acute post-sterotococcal glomerulonephritis (APSGN) was considered in the patient whose urinalysis revealed hematuria and proteinuria at nephrotic level, whose urea, creatinine, lipid profile and anti-streptolysine O antibody levels were increased, albumin and C3 value were decreased and whose 24-hour urine test revealed proteinuria. Renal biopsy was found to be compatible with APSGN. In the follow-up, severe headache, vomiting and convulsion were observed under antihypertensive and diuretic treatment and when the blood pressure was 130/80 mmHg (the 99(th) percentile for the patient: 129/88 mmHg). During the follow-up, the blood pressure values increased to 160/90 mmHg. The electroencephalogram (EEG) performed was found to be normal and magnetic resonance imaging (MRI) findings were compatible with posterior reversible encephalopathy syndrome (PRES). MRI was found to be normal at the first month following antihypertensive and anticonvulsive treatment. In the first year of the follow-up, the blood pressure, neurological examination and urinalysis findings were found to be normal. This patient was presented to draw attention to the fact that PRES can also present with a blood pressure tending to increase and with blood pressure values which are not so high.

Posterior reversible encephalopathy syndrome and the pediatric population

Posterior reversible encephalopathy syndrome presents with neurological and imaging features that are reversible, if prompt diagnosis and treatment is undertaken. However, the disease has been more commonly described in adult population, especially in eclampsia. In the background of predisposing factors like renal disease or chemotherapy, the pediatric population is also at equal risk for this condition, as we would like to present through this case and also demonstrate the potential for complete reversal of symptoms and imaging findings if diagnosed without delay.

Severe neurological symptoms in a patient with advanced renal cell carcinoma treated with sunitinib

Neurological symptoms are uncommon in patients administered sunitinib therapy; however, a few cases of dramatic neurotoxicity attributable to the development of reversible posterior leukoencephalopathy syndrome have been reported. Here, we report a case of a 71-year old woman with severe neurological symptoms occurring during sunitinib therapy for metastatic renal cell carcinoma. The clinical symptoms were typical for reversible posterior leukoencephalopathy syndrome, but there were no accompanying neuroimaging abnormalities. A Naranjo probability score of 3 indicates the adverse drug reaction was possible, but we discuss other potential causes of this event.

Transient subcortical high-signal lesions in Kawasaki syndrome

Kawasaki syndrome is an acute systemic vasculitis in children. The pathophysiology of Kawasaki syndrome presumably involves vascular inflammation, causing plasma leakage from systemic microvessels. From 1-30% of patients with Kawasaki syndrome exhibit central nervous system involvement, e.g., aseptic meningitis, epileptic seizures, transient hemiplegia, facial palsy, ataxia, chorea, ischemia, hearing loss, abnormal vision, disturbed consciousness, and behavioral changes. Neuroradiologically, Kawasaki syndrome demonstrates subdural effusion, infarction, atrophy, and reversible splenial lesions on magnetic resonance imaging. A 25-month-old boy developed transient hypertension with generalized seizure in the subacute phase of Kawasaki syndrome. Fluid-attenuated inversion recovery imaging, performed 5 hours and 2 days postseizure, indicated subtle, subcortical, high-signal-intensity lesions. Acute transient hypertension in this patient may have triggered the onset of lesions because of the increased permeability of brain microvessels, attributable to systemic vasculitis in Kawasaki syndrome. To our knowledge, subcortical lesions in Kawasaki syndrome were not previously reported.

A case of reversible posterior leukoencephalopathy syndrome with acute hypotension

Reversible posterior leukoencephalopathy syndrome (RPLS) is theoretically associated with hypertensive encephalopathy because the most patients demonstrate abrupt increasing of blood pressure (BP). A 59-year-old woman, who had undergone cholecystectomy 4 days before, complained of a headache and rapidly progressing visual disturbance. Her BP was postoperatively controlled at around 150/80, but her BP was 89/46 when she noticed her symptoms. Magnetic resonance imaging showed vasogenic edema in bilateral occipital and right parietal lobes, and intracranial magnetic resonance angiography revealed bilateral diffuse peripheral vasoconstriction. After discontinuing ropivacaine administration via epidural catheter, her BP rose to 114/62 and her symptoms completely disappeared within a few days. Except for hypotension, the clinical course and the radiological evidences in our case were consistent with RPLE. This case supports another hypothesis of RPLS mechanism that arterial endothelial injury by toxic drug effect results in transudation of fluid from blood vessels causing vasogenic brain edema.

Posterior reversible encephalopathy syndrome in a patient with hepatitis B induced type 1 membranoproliferative glomerulonephritis

Posterior reversible encephalopathy syndrome (PRES) is a rare complication of nephrotic syndrome and corticosteroid therapy. Here, we discuss an 18 year old man with type 1 membranoproliferative glomerulonephritis (MPGN) secondary to hepatitis B infection who developed posterior leukoencephalopathy while on therapy with lamivudine and prednisone. He developed seizures and vision loss. He also had hypertension, but no sudden elevation was recorded at any time. Magnetic resonance imaging revealed patchy areas of altered signal intensity involving cortical gray and subcortical white matter in the bilateral frontoparietal regions, occipital cortices, temporal cortices and cerebellar hemispheres, and hyperintensity on T2W and FLAIR sequences. Tapering of prednisone and controlling hypertension resulted in clinical improvement within a few days, and in a month MRI was normal. Diagnosing PRES requires a high index of suspicion when treating similarly susceptible patients. PRES as a complication during the treatment of MPGN secondary to hepatitis B has, to our knowledge, never been reported previously in the literature.

Reversible posterior leucoencephalopathy syndrome in post streptococcal glomerulonephritis

Reversible posterior leukoencephalopathy syndrome is characterized by an acute, usually reversible encephalopathy, with radiological findings that mainly involve the white or grey matter of the parieto-occipital lobes. We report a case of post streptococcal glomerulonephritis presenting as reversible leukoencephalopathy syndrome. Immediate control of hypertension resulted in rapid and complete neurological recovery.

Reversible posterior leuko-encephalopathy in children with sickle cell disease

Children with sickle cell disease (SCD) have high risk of neurologic morbidity and mortality, such as strokes, silent infarcts and TIA's. A retrospective review of magnetic resonance imaging and magnetic resonance angiography identified eight children with radiological and clinical characteristics of reversible posterior encephalopathy (RPLS). These patients had no evidence of previous cerebral infarcts or vasculopathy. Three have died during the 5-year follow up; one developed a stroke and one a conditional TCD. RPLS needs to be considered in the differential diagnosis of children with SCD that present with acute neurological changes, especially if they are already been hospitalized.