Posterior Reversible Encephalopathy Syndrome Resolving Within 48 Hours in a Normotensive Patient Who Underwent Thoracic Spine Surgery

Perioperative Cerebrovascular Accidents in Spine Surgery: A Retrospective Descriptive Study and A Systematic Review with Meta-Analysis

Introduction

Perioperative cerebrovascular accidents (CVAs) related to spine surgery, although rare, can lead to significant disabilities. More studies on spine surgeries are required to identify those at risk of perioperative CVAs. The characteristics and outcomes of patients that experienced CVAs during spine surgery were assessed through a retrospective descriptive study and meta-analysis.

Methods

Patients aged ≥18 years who underwent spine surgery under general anesthesia at a hospital between April 2011 and March 2023 were examined. Of the 2,391 initially identified patients, 2,346 were included after excluding 45 who underwent debridement for surgical site infections. Subsequently, a meta-analysis including the present retrospective descriptive study was conducted. Databases such as PubMed and Google Scholar were searched for original peer-reviewed articles written in English.

Results

Of the 2,346 patients, 4 (0.17%) (three men, one woman) exhibited perioperative CVAs associated with spine surgery. The CVAs were diverse in nature: one case of cerebral hemorrhage resulting from dural injury during posterior occipitocervical fusion, two cases of cerebral infarctions after lumbar laminectomy and anterior thoracic fusion due to anticoagulant discontinuation, and one case of posterior reversible encephalopathy syndrome following microscopic lumbar discectomy due to gestational hypertension. The subsequent meta-analysis included three studies (n=186,860). It showed several risk factors for perioperative CVAs, including cervical level (pooled odds ratio [OR]=1.33), hypertension (pooled OR=2.27), atrial fibrillation (pooled OR=8.78), history of heart disease (pooled OR=2.47), and diabetes (pooled OR=2.13).

Conclusions

It was speculated that the potential risk factors for the four perioperative CVA cases of spine surgery in this retrospective descriptive study were intraoperative dural injury, preoperative anticoagulant discontinuation, and gestational hypertension history. The meta-analysis revealed that cervical spine surgery, hypertension, atrial fibrillation, heart disease, and diabetes increased the CVA risk. This highlights the need for risk assessment, preoperative optimization, and postoperative care to reduce spine surgery-associated perioperative CVAs.

Can Post-Operative Posterior Reversible Encephalopathy Syndrome (PRES) Be Considered an Insidious Rare Surgical Complication?

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.

Posterior reversible encephalopathy syndrome following cervical spine surgery: insights from an interesting case

A 14-month child presenting with complaints of spastic paraplegia was diagnosed with C6-D1 intramedullary cyst. A cysto-subarachnoid shunt was performed; the patient was clinically stable in the immediate post-operative period. On post-operative day 2, the patient developed multiple episodes of generalized tonic-clonic seizures (GTCS) with altered sensorium, NCCT head revealed bilateral diffuse parieto-occipital hypodensities. MRI brain showed on T2WI and FLAIR, diffuse hyperintensities in bilateral parieto-occipital region suggestive of posterior reversible encephalopathy syndrome (PRES). The patient never experienced hypertensive episodes and was treated with anti-epileptics. The patient's symptoms improved and repeat MRI after 10 weeks revealed normal signal intensity in bilateral parieto-occipital areas. PRES after spinal surgeries is very rare and more so in pediatric cases, CSF hypotension may contribute to PRES in such cases.

Cortical Blindness after Cervical Spine Surgery in Supine Position - A Rare Case Report and Review of the Literature

We report the first case of perioperative visual loss due to cortical blindness after supine cervical spine surgery. A 46-year-old female presented with severe right-sided brachialgia of 1½ years' duration. Her magnetic resonance imaging (MRI) (cervical spine) showed severe right foraminal stenosis at C5–6. She underwent C5–6 anterior cervical discectomy and fusion. Nine hours after surgery, during a routine postoperative round, the patient complained of complete bilateral visual loss. The fundus examination and pupillary light reflex were normal. MRI of the brain showed the posterior cerebral artery infarct with hypoplasia of the left vertebral artery. She was transferred to the neurointensive care unit where antiplatelet treatment was started along with heparin. Her vision slowly began to improve, and at the end of 1 year, she had a reasonable visual acuity in both eyes. It is now standard practice in our institution to check patients' vision immediately after surgery.

Posterior reversible encephalopathy syndrome in the setting of trauma: A case report

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Posterior reversible encephalopathy syndrome (PRES) in the setting of trauma and acute care surgery.

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Posterior reversible encephalopathy syndrome (PRES) in trauma patients with a specific pattern of neuroimaging and clinical symptoms.

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T2 weighted diffusion hyperintensities were present on MRI of the brain in both cases.

Reports of posterior reversible encephalopathy syndrome (PRES) in the setting of trauma and acute care surgery are scarce. PRES presents rapidly with a variety of symptoms including headaches, visual disturbances, altered consciousness, and seizures. It is associated with acute hypertensive episodes. PRES is diagnosed with a specific neuroimaging pattern and a constellation of clinical symptoms. This case report presents two traumatically injured patients with one confirmed case of PRES and the other with a potential case of PRES. The diagnosis was made through neuroimaging showing patchy T2 and diffusion hyperintensity in the periphery of both occipital lobes and adjacent cerebellar hemispheres on MRI in one case. The other case highlights extensive stable white matter disease without evidence of acute infarct on MRI, as well as diminished attenuation within the cerebral white matter in the occipital lobes on CT scan. There was resolution of visual symptoms in one patient while the other patient's neurologic status did not allow for evaluation of symptom resolution. This report aims to emphasize the possibility of PRES in trauma patients with a specific pattern of neuroimaging and clinical symptoms, and to increase the index of suspicion in acute care providers.

Unusual Delayed Presentation of Posterior Reversible Encephalopathy Syndrome Following Vestibular Schwannoma Surgery: A Rare Neurologic Emergency

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) is a rare neurologic condition that manifests with heterogeneous clinical findings, including altered mental status, seizure, vision loss, and vomiting. It characteristically leads to diffuse subcortical vasogenic edema, most commonly in the parieto-occipital regions. Although frequently reported with conditions such as hypertension, eclampsia, sepsis, electrolyte imbalances, autoimmune diseases, and immunosuppressive therapy, PRES may rarely occur after surgery for posterior fossa tumors. In the postsurgical setting, clinical features of PRES usually develop intraoperatively or in the immediate postoperative period. Delayed presentation months after the surgery has not been reported earlier.

CASE DESCRIPTION

A 23-year-old woman who underwent surgery for vestibular schwannoma 8 months earlier presented with altered sensorium, generalized seizures, and high blood pressure. Common possibilities were ruled out by clinical history, diagnostic imaging, and appropriate blood tests. Radiologic imaging revealed rapid recurrence of tumor with diffuse subcortical edema involving both hemispheres. The patient showed complete neurologic recovery with antihypertensive and antiepileptic drugs.

CONCLUSIONS

PRES is a rare but important cause of acute neurologic deterioration following posterior fossa tumor surgery. Prompt diagnosis and aggressive treatment often lead to complete neurologic recovery.

Posterior Reversible Encephalopathy Syndrome with Status Epilepticus Following Surgery for Lumbar Stenosis and Spondylolisthesis

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiologic condition encountered in many different clinical settings; it generally occurs in the context of hypertensive crisis, immunosuppressive therapy, or autoimmune diseases. It is characterized by headache, stupor, seizures, and visual alterations. Magnetic resonance imaging findings include white matter changes preferentially in the parieto-occipital regions. Although pathogenesis is not fully elucidated, vasoconstriction and brain hypoperfusion seem to be the cause of brain ischemia and vasogenic edema. Cerebrospinal fluid hypotension is also a reported plausible pathogenic mechanism.

CASE DESCRIPTION

We present a case of PRES following laminectomy and fixation for L4-5 lumbar stenosis and spondylolisthesis. The patient presented with status epilepticus immediately after surgery that lasted 5 days. Brain magnetic resonance imaging showed fluid attenuated inversion recovery and T2 hyperintensities in the bilateral parietal and occipital lobes and external capsules. On the basis of postoperative lumbar images, we hypothesized that an unnoticed cerebrospinal fluid leak might have contributed to development of PRES. The patient developed multiple postoperative complications but ultimately recovered after treatment for severe hypertension and seizures.

CONCLUSIONS

Prompt recognition and treatment of this potentially life-threatening syndrome is necessary to increase the likelihood of favorable outcome. Spinal surgeons need to be aware of the possibility of neurologic deterioration after spinal surgery and be alert about the occurrence of a dural leak, either recognized or unnoticed, as the plausible mechanism triggering PRES.