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

A case study of posterior reversible encephalopathy syndrome: Not always reversible with detrimental consequences

ABSTRACT

Posterior reversible encephalopathy syndrome, or PRES, is often an unrecognized sequela of uncontrolled hypertension that is associated with a significant risk of mortality. It is poorly understood and can lead to endothelial dysfunction with disturbance of the blood-brain barrier and subsequent brain edema. Headache, seizures, encephalopathy, and visual disturbances are among the most common symptoms associated with PRES. Testing and evaluation should be quickly initiated not only to solidify the diagnosis but also to rule out others such as infection or stroke. Prompt identification of the symptoms of PRES can potentially reverse long-term side effects such as life-long seizures or visual deficits.

Posterior reversible encephalopathy syndrome and acute ischemic stroke: an underreported association

INTRODUCTION

Posterior reversible encephalopathy syndrome (PRES) is a rare and complex disorder with variable clinical presentation and a typical magnetic resonance imaging (MRI) pattern of vasogenic edema with typical and atypical locations. It is often triggered by other diseases and drugs and the most prototypical association is with persistently elevated arterial pressure values. Among the potential cerebrovascular complications, intracranial bleeding has been described, but ischemic stroke is uncommonly reported.

METHODS

We are presenting a case of a male patient with prolonged and sustained arterial hypertension acutely presenting with lacunar ischemic stroke involving the right corona radiata and composite MRI findings with the association of chronic small vessel disease (SVD) markers, acute symptomatic lacunar stroke, and atypical, central variant, posterior fossa dominant PRES. In the MRI follow-up, the white matter hyperintensities in T2-fluid attenuated inversion recovery (FLAIR sequences) due to PRES.

DISCUSSION

The pathophysiology of PRES is not yet fully known, but the association with markedly increased values of arterial pressure is typical. In this context, ischemic stroke has not been considered in the clinical and neuroradiological manifestations of PRES and it has been only occasionally reported in the literature. In this case, the main hypothesis is that sustained hypertension may have triggered both manifestations, PRES, and ischemic stroke and the last one allowed to diagnose the first one.

CONCLUSIONS

Atypical variants of PRES are not so rare and it may also occur in typical triggering situations. The association with ischemic stroke is even rarer and it may add some clues to the pathomechanisms of PRES.

Simultaneous Presentation of Brainstem and Cerebellar Posterior Reversible Encephalopathy Syndrome With Acute Cerebral Infarction

Posterior reversible encephalopathy syndrome (PRES) and cerebral infarction are both caused by hypertension, but they rarely occur together. If they do coexist, the selection of a management strategy is difficult because of their pathologic differences. Here, we present an uncommon case of brainstem and cerebellar PRES combined with acute lacunar infarction. For this patient, we used an aggressive blood pressure-lowering regimen during the acute phase of his condition. Once the cerebral edema caused by PRES began to improve, antiplatelet therapy was initiated. The treatment was ultimately successful, and the patient was discharged home. A return to work is now planned. Given the rarity of this combination of conditions and a lack of published evidence for management, our report will contribute to the literature concerning the treatment for this combination of conditions.

The pathophysiologic, diagnostic, and therapeutic aspects of posterior reversible encephalopathy syndrome during pregnancy

Posterior reversible encephalopathy syndrome (PRES) is a neurological condition with a wide range of symptoms, including visual disturbances, headache, vomiting, seizures, and altered consciousness. This review describes the pathophysiology of PRES, as well as the clinical, diagnostic, and therapeutic intervention during pregnancy. The gold standard for diagnosis of PRES is Magnetic Resonance Imaging (MRI), helping to differentiate it from other similar conditions. The aim of this paper is to review the principal aspects of PRES, general care, blood pressure control, and seizures prevention while avoiding potential injuries to the mother and fetus in the event of pregnancy. We concluded that PRES can be effectively treated and reversed if prompt diagnostic action is made, and adequate care is initiated.