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Jeong DY, Shin YN, Ha SH, Chang JY, Kang DW, Kwon SU, Kim BJ. Association between renal insufficiency and lesion characteristics of posterior reversible encephalopathy syndrome. Neurol Sci 2024; 45:3907-3915. [PMID: 38480646 DOI: 10.1007/s10072-024-07446-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 03/03/2024] [Indexed: 07/18/2024]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is characterized by cerebral blood flow dysregulation and the blood-brain barrier (BBB) disruption. While renal insufficiency has been considered a factor in BBB fragility, the relationship between renal insufficiency and the PRES lesions volume remains unclear. METHODS This observational study was performed retrospectively. PRES patients were categorized into two groups with renal insufficiency, defined as an estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73m2 on the day of symptom occurrence. Lesion volume was measured using fluid-attenuated inversion recovery (FLAIR) imaging, and the brain was divided into nine regions. The volume of the parietal-occipital-temporal lobe was considered typical, while the other six regions were labeled as atypical. RESULTS The study included 200 patients, of whom 94 (47%) had renal insufficiency. Patients with renal insufficiency had a larger lesion volume (144.7 ± 125.2 cc) compared to those without renal insufficiency (110.5 ± 93.2 cc; p = 0.032); particularly in the atypical lesions volume (49.2 ± 65.0 vs. 29.2 ± 44.3 cc; p = 0.013). However, there was no difference in the reversibility of the lesions (35.2 ± 67.5 vs. 18.8 ± 33.4 cc; p = 0.129). Multiple regression analysis revealed that decreases in eGFR (β = -0.34, 95% CI -0.62-0.05, p = 0.020) were positively associated with total lesion volume. CONCLUSION Our findings suggest that PRES patients with renal insufficiency experience more severe lesion volumes, likely due to the atypical brain regions involvement. The lesions involving atypical regions may have a similar pathophysiology to typical lesions, as the PRES lesions reversibility was found to be similar between individuals with and without renal insufficiency.
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Affiliation(s)
- Dong Young Jeong
- School of Convergence Science and Technology, Pohang University of Science and Technology (POSTECH), Pohang, Republic of Korea
| | - Yea Na Shin
- Department of Family Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang Hee Ha
- Department of Neurology, Gil Medical Center, Gachon College of Medicine, Incheon, Republic of Korea
| | - Jun Young Chang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong-Wha Kang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sun U Kwon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Bum Joon Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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Rajiah PS, Suman G, Vijay K, Venugopal N, Mansoori B, Chalian M, Agarwal AK. Multisystem Imaging Manifestations of Kidney Failure. Radiographics 2024; 44:e230124. [PMID: 39052499 DOI: 10.1148/rg.230124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Kidney failure (KF) refers to a progressive decline in glomerular filtration rate to below 15 ml/min per 1.73 m2, necessitating renal replacement therapy with dialysis or renal transplant. The hemodynamic and metabolic alterations in KF combined with a proinflammatory and coagulopathic state leads to complex multisystemic complications. The imaging hallmark of systemic manifestations of KF is bone resorption caused by secondary hyperparathyroidism. Other musculoskeletal complications include brown tumor, osteosclerosis, calcinosis, soft-tissue calcification, and amyloid arthropathy. Cardiovascular complications and infections are the leading causes of death in KF. Cardiovascular complications include accelerated atherosclerosis, cardiomyopathy, pericarditis, myocardial calcinosis, and venous thromboembolism. Neurologic complications such as encephalopathy, osmotic demyelination, cerebrovascular disease, and opportunistic infections are also frequently encountered. Pulmonary complications include edema and calcifications. Radiography and CT are used in assessing musculoskeletal and thoracic complications, while MRI plays a key role in assessing neurologic and cardiovascular complications. CT iodinated contrast material is generally avoided in patients with KF except in situations where the benefit of contrast-enhanced CT outweighs the risks and in patients already undergoing maintenance dialysis. At MRI, group II gadolinium-based contrast material can be safely administered in patients with KF. The authors discuss the extrarenal systemic manifestations of KF, the choice of imaging modality in their assessment, and imaging findings of complications. ©RSNA, 2024 Supplemental material is available for this article.
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Affiliation(s)
- Prabhakar Shantha Rajiah
- From the Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 559905 (P.S.R., G.S.); UT Southwestern Medical Center, Dallas, Tex (K.V.); University of Washington, Seattle, Wash (N.V., B.M., M.C.); and Mayo Clinic, Jacksonville, Fla (A.K.A.)
| | - Garima Suman
- From the Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 559905 (P.S.R., G.S.); UT Southwestern Medical Center, Dallas, Tex (K.V.); University of Washington, Seattle, Wash (N.V., B.M., M.C.); and Mayo Clinic, Jacksonville, Fla (A.K.A.)
| | - Kanupriya Vijay
- From the Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 559905 (P.S.R., G.S.); UT Southwestern Medical Center, Dallas, Tex (K.V.); University of Washington, Seattle, Wash (N.V., B.M., M.C.); and Mayo Clinic, Jacksonville, Fla (A.K.A.)
| | - Nitin Venugopal
- From the Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 559905 (P.S.R., G.S.); UT Southwestern Medical Center, Dallas, Tex (K.V.); University of Washington, Seattle, Wash (N.V., B.M., M.C.); and Mayo Clinic, Jacksonville, Fla (A.K.A.)
| | - Bahar Mansoori
- From the Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 559905 (P.S.R., G.S.); UT Southwestern Medical Center, Dallas, Tex (K.V.); University of Washington, Seattle, Wash (N.V., B.M., M.C.); and Mayo Clinic, Jacksonville, Fla (A.K.A.)
| | - Majid Chalian
- From the Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 559905 (P.S.R., G.S.); UT Southwestern Medical Center, Dallas, Tex (K.V.); University of Washington, Seattle, Wash (N.V., B.M., M.C.); and Mayo Clinic, Jacksonville, Fla (A.K.A.)
| | - Amit Kumar Agarwal
- From the Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 559905 (P.S.R., G.S.); UT Southwestern Medical Center, Dallas, Tex (K.V.); University of Washington, Seattle, Wash (N.V., B.M., M.C.); and Mayo Clinic, Jacksonville, Fla (A.K.A.)
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3
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Battal B, Castillo M. Imaging of Reversible Cerebral Vasoconstriction Syndrome and Posterior Reversible Encephalopathy Syndrome. Neuroimaging Clin N Am 2024; 34:129-147. [PMID: 37951698 DOI: 10.1016/j.nic.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
PRES and RCVS are increasingly recognized due to the wider use of brain MRI and increasing clinical awareness. Imaging plays a crucial role in confirming the diagnosis and guiding clinical management for PRES and RCVS. Imaging also has a pivotal role in determining the temporal progression of these entities, detecting complications, and predicting prognosis. In this review, we aim to describe PRES and RCVS, discuss their possible pathophysiological mechanisms, and discuss imaging methods that are useful in the diagnosis, management, and follow-up of patients.
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Affiliation(s)
- Bilal Battal
- Division of Neuroradiology, Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, NC 27599, USA.
| | - Mauricio Castillo
- Division of Neuroradiology, Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, NC 27599, USA
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Anandan S, Rajendran SS, Kumar JP, Shajee DS. Posterior Reversible Encephalopathy Syndrome without Encephalopathy. Neurol India 2024; 72:165-167. [PMID: 38443025 DOI: 10.4103/neurol-india.neurol-india-d-23-00475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 02/02/2024] [Indexed: 03/07/2024]
Affiliation(s)
| | | | | | - Divine S Shajee
- Department of Neurology, St. Joseph Hospital, Anchal, Kerala, India
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Zerweck L, Bombach P, Hucker S, Tabatabai G, Ernemann U, Bender B. MR Spectroscopy in a Patient With Isolated Brainstem Posterior Reversible Encephalopathy Syndrome. Neurology 2023; 101:1075-1076. [PMID: 37816635 PMCID: PMC10752642 DOI: 10.1212/wnl.0000000000207860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 09/20/2023] [Indexed: 10/12/2023] Open
Affiliation(s)
- Leonie Zerweck
- From the Department of Diagnostic and Interventional Neuroradiology (L.Z., U.E., B.B.); Department of Neurology and Interdisciplinary Neuro-Oncology (P.B., S.H., G.T.), University Hospital Tuebingen; and Center for CNS Tumors (P.B., S.H., G.T.), Comprehensive Cancer Center Tuebingen-Stuttgart.
| | - Paula Bombach
- From the Department of Diagnostic and Interventional Neuroradiology (L.Z., U.E., B.B.); Department of Neurology and Interdisciplinary Neuro-Oncology (P.B., S.H., G.T.), University Hospital Tuebingen; and Center for CNS Tumors (P.B., S.H., G.T.), Comprehensive Cancer Center Tuebingen-Stuttgart
| | - Svenja Hucker
- From the Department of Diagnostic and Interventional Neuroradiology (L.Z., U.E., B.B.); Department of Neurology and Interdisciplinary Neuro-Oncology (P.B., S.H., G.T.), University Hospital Tuebingen; and Center for CNS Tumors (P.B., S.H., G.T.), Comprehensive Cancer Center Tuebingen-Stuttgart
| | - Ghazaleh Tabatabai
- From the Department of Diagnostic and Interventional Neuroradiology (L.Z., U.E., B.B.); Department of Neurology and Interdisciplinary Neuro-Oncology (P.B., S.H., G.T.), University Hospital Tuebingen; and Center for CNS Tumors (P.B., S.H., G.T.), Comprehensive Cancer Center Tuebingen-Stuttgart
| | - Ulrike Ernemann
- From the Department of Diagnostic and Interventional Neuroradiology (L.Z., U.E., B.B.); Department of Neurology and Interdisciplinary Neuro-Oncology (P.B., S.H., G.T.), University Hospital Tuebingen; and Center for CNS Tumors (P.B., S.H., G.T.), Comprehensive Cancer Center Tuebingen-Stuttgart
| | - Benjamin Bender
- From the Department of Diagnostic and Interventional Neuroradiology (L.Z., U.E., B.B.); Department of Neurology and Interdisciplinary Neuro-Oncology (P.B., S.H., G.T.), University Hospital Tuebingen; and Center for CNS Tumors (P.B., S.H., G.T.), Comprehensive Cancer Center Tuebingen-Stuttgart
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6
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Fujii N, Fujii H, Matsuki M, Doi S, Isozaki T, Watanabe Y, Nakamata A, Fujita A, Mori H. Optic pathway involvement in the posterior reversible encephalopathy syndrome: A case report and review of the literature. Radiol Case Rep 2023; 18:3769-3772. [PMID: 37649724 PMCID: PMC10462788 DOI: 10.1016/j.radcr.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 07/29/2023] [Accepted: 08/01/2023] [Indexed: 09/01/2023] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiological condition characterized by reversible vasogenic edema of the white matter and acute neurological symptoms. PRES typically affects the parieto-occipital regions but rarely affects the optic pathway. Herein, we describe a case of central-variant PRES in a 57-year-old man with abnormal signal intensities in the optic pathway on magnetic resonance imaging (MRI). The patient underwent hemodialysis, initiated diuretics and antihypertensive medications, and the abnormal signal intensities of the brainstem and optic pathway on MRI improved. Although rare, PRES can affect the optic pathway, thus suggesting the possibility of fragility of the optic pathway itself to hyperperfusion.
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Affiliation(s)
- Nana Fujii
- Department of Radiology, Jichi Medical University, Tochigi, Japan
| | - Hiroyuki Fujii
- Department of Radiology, Jichi Medical University, Tochigi, Japan
| | - Mitsuru Matsuki
- Department of Radiology, Jichi Medical University, Tochigi, Japan
| | - Shugo Doi
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Takenori Isozaki
- Department of Radiology, Jichi Medical University, Tochigi, Japan
| | - Yuriko Watanabe
- Department of Radiology, Jichi Medical University, Tochigi, Japan
| | - Akihiro Nakamata
- Department of Radiology, Jichi Medical University, Tochigi, Japan
| | - Akifumi Fujita
- Department of Radiology, Haga Red Cross Hospital, Tochigi, Japan
| | - Harushi Mori
- Department of Radiology, Jichi Medical University, Tochigi, Japan
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7
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Hwang J, Cho WH, Cha SH, Ko JK. Posterior reversible encephalopathy syndrome following uneventful clipping of an unruptured intracranial aneurysm: A case report. World J Clin Cases 2023; 11:4723-4728. [PMID: 37469736 PMCID: PMC10353519 DOI: 10.12998/wjcc.v11.i19.4723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/10/2023] [Accepted: 06/06/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is characterized mainly by occipital and parietal lobe involvement, which can be reversible within a few days. Herein, we report a rare case of PRES that developed after craniotomy for an unruptured intracranial aneurysm (UIA).
CASE SUMMARY A 59-year-old man underwent clipping surgery for the treatment of UIA arising from the left middle cerebral artery. Clipping surgery was performed uneventfully, and he regained consciousness quickly immediately after the surgery. At the 4th hour after surgery, he developed a disorder of consciousness and aphasia. Magnetic resonance imaging revealed cortical and subcortical T2/FLAIR hyperintensities in the parietal, occipital, and frontal lobes ipsilaterally, without restricted diffusion, consistent with unilateral PRES. With conservative treatment, his symptoms and radiological findings almost completely disappeared within weeks. In our case, the important causative factor of PRES was suspected to be a sudden increase in cerebral perfusion pressure associated with temporary M1 occlusion.
CONCLUSION Our unique case highlights that, to our knowledge, this is the second report of PRES developing after craniotomy for the treatment of UIA. Surgeons must keep PRES in mind as one of the causes of perioperative neurological abnormality following clipping of an UIA.
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Affiliation(s)
- Joseph Hwang
- Department of Neurosurgery, Biomedical Research Institute, Pusan National University Hospital, School of Medicine, Pusan National University, Busan 49241, South Korea
| | - Won-Ho Cho
- Department of Neurosurgery, Biomedical Research Institute, Pusan National University Hospital, School of Medicine, Pusan National University, Busan 49241, South Korea
| | - Seung-Heon Cha
- Department of Neurosurgery, Biomedical Research Institute, Pusan National University Hospital, School of Medicine, Pusan National University, Busan 49241, South Korea
| | - Jun-Kyueng Ko
- Department of Neurosurgery, Biomedical Research Institute, Pusan National University Hospital, School of Medicine, Pusan National University, Busan 49241, South Korea
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Matsumoto N, Ogawa T, Hishikawa N, Takao Y, Fujii S. Dramatic Amelioration in Serial Magnetic Resonance Imaging in an "Isolated Brainstem" Reversible Encephalopathy Syndrome Case. Yonago Acta Med 2023; 66:297-299. [PMID: 37229371 PMCID: PMC10203647 DOI: 10.33160/yam.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/28/2023] [Indexed: 05/27/2023]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is characterized by transient vasogenic edema predominantly in supratentorial areas within the posterior circulation regions. Although PRES with only brainstem involvement is quite rare, accurate diagnosis is important because prompt antihypertensive therapy contributes to a favorable outcome. Herein, we report a case with isolated brainstem PRES showing dramatical improvement in an apparent diffusion coefficient (ADC) value of the lesion in magnetic resonance imaging (MRI) after clinical remission. The present case suggests the association between favorable clinical course and complete amelioration on MRI.
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Affiliation(s)
- Namiko Matsumoto
- Department of Neurology, Kurashiki Heisei Hospital, Kurashiki 710-0826, Japan
| | - Toshihide Ogawa
- Neuroradiology Center, Kurashiki Heisei Hospital, Kurashiki 710-0826, Japan
| | - Nozomi Hishikawa
- Department of Neurology, Kurashiki Heisei Hospital, Kurashiki 710-0826, Japan
| | - Yoshiki Takao
- Department of Neurology, Kurashiki Heisei Hospital, Kurashiki 710-0826, Japan
| | - Shinya Fujii
- Division of Radiology, Department of Multidisciplinary Internal Medicine, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
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Kachi S, Nomura T, Yamada K, Oshima Y, Ura S. Atypical posterior reversible encephalopathy syndrome associated with Sjögren's syndrome: a case report. Rinsho Shinkeigaku 2023; 63:159-162. [PMID: 36843087 DOI: 10.5692/clinicalneurol.cn-001809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
Abstract
Sjögren's syndrome (SJS) is a common autoimmune disease. Generally, posterior reversible encephalopathy syndrome (PRES) is often concomitant with autoimmune disease; however, PRES rarely complicates SJS. Thus, the detailed clinical course of cases with SJS and PRES remains unknown. We present the case of a 71-year-old female patient with primary SJS, whose magnetic resonance (MR) images showed bilateral vasogenic edema in the basal ganglia, brainstem, and cerebellum. Cerebrospinal fluid (CSF) examination revealed increased IgG index and higher interleukin-6 and anti-SSA-autoantibody levels. Management of her blood pressure combined with corticosteroid therapy improved her neurological symptoms, including abnormal CSF and MR imaging findings.
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Affiliation(s)
- Shion Kachi
- Department of Neurology, Japanese Red Cross Asahikawa Hospital
| | - Taichi Nomura
- Department of Neurology, Japanese Red Cross Asahikawa Hospital
| | - Kazuki Yamada
- Department of Neurology, Japanese Red Cross Asahikawa Hospital
| | - Yuki Oshima
- Department of Neurology, Japanese Red Cross Asahikawa Hospital
| | - Shigehisa Ura
- Department of Neurology, Japanese Red Cross Asahikawa Hospital
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Pischik E, Baumann K, Karpenko A, Kauppinen R. Pathogenesis of acute encephalopathy in acute hepatic porphyria. J Neurol 2023; 270:2613-2630. [PMID: 36757574 PMCID: PMC10129990 DOI: 10.1007/s00415-023-11586-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 01/20/2023] [Accepted: 01/22/2023] [Indexed: 02/10/2023]
Abstract
Acute encephalopathy (AE) can be a manifestation of an acute porphyric attack. Clinical data were studied in 32 patients during AE with or without polyneuropathy (PNP) together with 12 subjects with PNP but no AE, and 17 with dysautonomia solely. Brain neuroimaging was done in 20 attacks during AE, and PEPT2 polymorphisms were studied in 56 subjects, 24 with AE. AE manifested as a triad of seizures, confusion and/or blurred vision. Symptoms lasting 1-5 days manifested 3-19 days from the onset of an attack. 55% of these patients had acute PNP independent of AE. Posterior reversible encephalopathy syndrome (PRES) was detected in 42% of the attacks. These patients were severely affected and hyponatremic (88%). Reversible segmental vasoconstriction was rare. There was no statistical difference in hypertension or urinary excretion of porphyrin precursors among the patients with or without AE. In 94% of the attacks with AE, liver transaminases were elevated significantly (1.5 to fivefold, P = 0.034) compared to a normal level in 87% of the attacks with dysautonomia, or in 25% of patients with PNP solely. PEPT2*2/2 haplotype was less common among patients with AE than without (8.3% vs. 25.8%, P = 0.159) and in patients with PNP than without (9.5% vs. 22.9%, P = 0.207), suggesting a minor role, if any, in acute neurotoxicity. In contrast, PEPT2*2/2 haplotype was commoner among patients with chronic kidney disease (P = 0.192). Acute endothelial dysfunction in porphyric encephalopathy could be explained by a combination of abrupt hypertension, SIADH, and acute metabolic and inflammatory factors of hepatic origin.
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Affiliation(s)
- Elena Pischik
- Department of Neurology, Consultative and Diagnostic Center with Polyclinics, St. Petersburg, Russia.,Department of Medicine, University Central Hospital of Helsinki, Helsinki, Finland
| | - Katrin Baumann
- Department of Gynecology and Obstetrics, University Central Hospital of Helsinki, Helsinki, Finland
| | - Alla Karpenko
- Department of Radiology, Consultative and Diagnostic Center with Polyclinics, St. Petersburg, Russia.,High Technology Institution, North-Western State Medical University, St. Petersburg, Russia
| | - Raili Kauppinen
- Department of Medicine, University Central Hospital of Helsinki, Helsinki, Finland. .,Biomedicum-Helsinki2, Tukholmankatu 8C, 00029 HUS, Helsinki, Finland.
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John KJ, Pillai DP, Roy RA, Mathew P, Chacko KP, John JK. Central Variant Posterior Reversible Encephalopathy Syndrome in a Pregnant Woman With Eclampsia: A Case Report. Neurohospitalist 2022; 12:682-686. [PMID: 36147753 PMCID: PMC9485688 DOI: 10.1177/19418744221110360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023] Open
Abstract
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.
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Affiliation(s)
- Kevin John John
- Department of Critical Care, Believers Church Medical College Hospital, Thiruvalla, India
| | - Deep P Pillai
- Department of Neurology, Believers Church Medical College Hospital, Thiruvalla, India
| | - Rhea Anne Roy
- Department of Neurology, Believers Church Medical College Hospital, Thiruvalla, India
| | - Philip Mathew
- Department of Critical Care, Believers Church Medical College Hospital, Thiruvalla, India
| | - Kuruvilla P Chacko
- Department of Gynecology, Believers Church Medical College Hospital, Thiruvalla, India
| | - John K John
- Department of Neurology, Believers Church Medical College Hospital, Thiruvalla, India
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Ohashi E, Hayakawa I, Tsutsumi Y, Kamei K, Ide K, Abe Y. Central-variant posterior reversible encephalopathy syndrome in an infant with mid-aortic syndrome: A rare case of symmetric basal ganglia lesions. Radiol Case Rep 2022; 17:3475-3480. [PMID: 35912291 PMCID: PMC9334930 DOI: 10.1016/j.radcr.2022.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 07/05/2022] [Indexed: 10/24/2022] Open
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Role of MRI and CT in the Evaluation of Headache in Pregnancy and the Postpartum Period. Neurol Clin 2022; 40:661-677. [PMID: 35871790 DOI: 10.1016/j.ncl.2022.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Approximately 35% of acute headaches in pregnant women are secondary to an underlying condition. Headaches are also common in the postpartum period where they occur in 30% to 40% of patients. The majority of secondary headaches are due to hypertensive disorders: preeclampsia-eclampsia, posterior reversible encephalopathy syndrome, and acute arterial hypertension. Other causes include reversible cerebral vasoconstriction syndrome and pituitary apoplexy, as well as life-threatening conditions such as cerebral venous thrombosis. In this article, we review general recommendations for imaging the pregnant patients and discuss the imaging findings of common causes of headaches in pregnancy and the postpartum period.
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Fazeli S, Noorbakhsh A, Imbesi SG, Bolar DS. Cerebral perfusion in posterior reversible encephalopathy syndrome measured with arterial spin labeling MRI. Neuroimage Clin 2022; 35:103017. [PMID: 35584601 PMCID: PMC9119826 DOI: 10.1016/j.nicl.2022.103017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/12/2022] [Accepted: 04/22/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE The pathophysiologic basis of posterior reversible encephalopathy syndrome (PRES) remains controversial. Hypertension (HTN)-induced autoregulatory failure with subsequent hyperperfusion is the leading hypothesis, whereas alternative theories suggest vasoconstriction-induced hypoperfusion as the underlying mechanism. Studies using contrast-based CT and MR perfusion imaging have yielded contradictory results supporting both ideas. This work represents one of the first applications of arterial spin labeling (ASL) to evaluate cerebral blood flow (CBF) changes in PRES. MATERIALS AND METHODS After obtaining Institutional Review Board approval, MRI reports at our institution from 07/2015 to 09/2020 were retrospectively searched and reviewed for mention of "PRES" and "posterior reversible encephalopathy syndrome." Of the resulting 103 MRIs (performed on GE 1.5 Tesla or 3 Tesla scanners), 20 MRIs in 18 patients who met the inclusion criteria of clinical and imaging diagnosis of PRES and had diagnostic-quality pseudocontinuous ASL scans were included. Patients with a more likely alternative diagnosis, technically non-diagnostic ASL, or other intracranial abnormalities limiting assessment of underlying PRES features were excluded. Perfusion in FLAIR-affected brain regions was qualitatively assessed using ASL and characterized as hyperperfusion, normal, or hypoperfusion. Additional quantitative analysis was performed by measuring average gray matter CBF in abnormal versus normal brain regions. RESULTS HTN was the most common PRES etiology (65%). ASL showed hyperperfusion in 13 cases and normal perfusion in 7 cases. A hypoperfusion pattern was not identified. Quantitative analysis of gray matter CBF among patients with visually apparent hyperperfusion showed statistically higher perfusion in affected versus normal appearing brain regions (median CBF 100.4 ml/100 g-min vs. 61.0 ml/ 100 g-min, p < 0.001). CONCLUSION Elevated ASL CBF was seen in the majority (65%) of patients with PRES, favoring the autoregulatory failure hypothesis as a predominant mechanism. Our data support ASL as a practical way to assess and noninvasively monitor cerebral perfusion in PRES that could potentially alter management strategies.
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Affiliation(s)
- Soudabeh Fazeli
- Department of Radiology, University of California San Diego, 200 W. Arbor Drive, San Diego, CA 92103, United States
| | - Abraham Noorbakhsh
- Department of Radiology, University of California San Diego, 200 W. Arbor Drive, San Diego, CA 92103, United States
| | - Steven G Imbesi
- Department of Radiology, University of California San Diego, 200 W. Arbor Drive, San Diego, CA 92103, United States
| | - Divya S Bolar
- Department of Radiology, University of California San Diego, 200 W. Arbor Drive, San Diego, CA 92103, United States; Center for Functional Magnetic Resonance Imaging, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, United States.
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15
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Chaudhari DM, Renjen PN, Goyal N, Mishra A. Central variant reversible encephalopathy syndrome. BMJ Case Rep 2022; 15:e245636. [PMID: 35131777 PMCID: PMC8823040 DOI: 10.1136/bcr-2021-245636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
| | | | - Nidhi Goyal
- Radio Diagnosis, Indraprastha Apollo Hospital, New Delhi, Delhi, India
| | - Anjali Mishra
- Critical Care Medicine, Holy Family Hospital, Okhla Road, New Delhi, Delhi, India
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16
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Chen X, Zhao JG, Gao B, Yu H, Yu YL, Shen GQ, McKinney AM. Posterior reversible encephalopathy syndrome with a special focus on seizures. J Clin Neurosci 2021; 95:38-43. [PMID: 34929649 DOI: 10.1016/j.jocn.2021.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 11/06/2021] [Accepted: 11/11/2021] [Indexed: 12/18/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a neurological disorder characterized by headache, seizures, confusion and visual disturbances, as well as potentially reversible neuroimaging findings in most patients after proper treatment. Seizures is one of the most common clinical presentations of PRES. This review summarizes the potential pathophysiology and clinical features of PRES, as well as a multimodal approach to imaging and also briefly discusses the phenomenon of seizures in paediatric population.
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Affiliation(s)
- Xin Chen
- Department of Radiology, The Affiliated Hospital of Guizhou Medical University, 550001 Guizhou, China
| | - Jun-Guo Zhao
- Department of Radiology, The Affiliated Hospital of Guizhou Medical University, 550001 Guizhou, China
| | - Bo Gao
- Department of Radiology, The Affiliated Hospital of Guizhou Medical University, 550001 Guizhou, China; Key Laboratory of Brain Imaging, Guizhou Medical University, Guiyang, China.
| | - Hui Yu
- Department of Radiology, The Affiliated Hospital of Guizhou Medical University, 550001 Guizhou, China; Key Laboratory of Brain Imaging, Guizhou Medical University, Guiyang, China
| | - Yun-Li Yu
- Department of Neurology, The Affiliated Hospital of Guizhou Medical University, 550001 Guizhou, China
| | - Gui-Quan Shen
- Department of Radiology, The Affiliated Hospital of Guizhou Medical University, 550001 Guizhou, China; Key Laboratory of Brain Imaging, Guizhou Medical University, Guiyang, China
| | - Alexander M McKinney
- Department of Radiology, University of Miami Miller School of Medicine, Miami, FL, USA
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17
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Sharma M, Menon B, Manam G. Postpartum Reversible Cerebral Vasoconstriction Syndrome Presenting with Radiological Plethora. Indian J Radiol Imaging 2021; 31:764-767. [PMID: 34790334 PMCID: PMC8590535 DOI: 10.1055/s-0041-1735923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) is a clinicoradiological syndrome characterized by segmental vasoconstriction of cerebral arteries with resolution in most patients within 1 to 3 months. It has been known to be a benign uniphasic reversible illness but cases of fulminant RCVS with mortality have also been reported. The symptoms can be varied with presentations like transient ischemic attack (TIA), ischemic stroke (IS), intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), and posterior reversible encephalopathy syndrome (PRES). We report a postpartum female with RCVS with radiological features of ICH, SAH, atypical PRES, and atypical clinical presentation as well. RCVS can be frequently missed unless there is a high index of suspicion. Hence clinicians should be aware of the typical and the atypical presentation of RCVS along with the radiological findings with the potential complications. Early suspicion and detection in the emergency help in recovery and reducing morbidity.
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Affiliation(s)
- Manisha Sharma
- Department of Neurology, Apollo Speciality Hospital, Nellore, Andhra Pradesh, India
| | - Bindu Menon
- Department of Neurology, Apollo Speciality Hospital, Nellore, Andhra Pradesh, India
| | - Gayatri Manam
- Department of Radiology, Apollo Speciality Hospital, Nellore, Andhra Pradesh, India
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18
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Yamamoto S, Nagashima T, Akiyama Y, Nagatani K, Iwamoto M, Minota S. Fatal Thrombotic Microangiopathy and Posterior Reversible Encephalopathy Syndrome in a Patient with Anti-melanoma Differentiation-associated Gene 5 Antibody-positive Dermatomyositis. Intern Med 2021; 60:3329-3333. [PMID: 33896869 PMCID: PMC8580758 DOI: 10.2169/internalmedicine.7309-21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 56-year-old woman presented with dermatomyositis positive for anti-melanoma differentiation-associated gene 5 antibody. No interstitial lung disease was detected. Despite treatment with methylprednisolone pulse therapy and cyclosporine, dysphagia developed. Furthermore, the presence of thrombocytopenia, elevated lactate dehydrogenase levels, and an undetectable haptoglobin level suggested the possibility of thrombotic microangiopathy (TMA). Disturbed consciousness developed shortly after TMA onset, and brain magnetic resonance imaging revealed hyperintensity lesions in the bilateral basal ganglia, thalami, and brainstem. The patient was diagnosed with atypical posterior leukoencephalopathy syndrome before dying of heart failure later that day. In conclusion, early TMA recognition and prompt intensive treatment are critical in such cases.
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Affiliation(s)
- Shotaro Yamamoto
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Japan
| | - Takao Nagashima
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Japan
| | - Yoichiro Akiyama
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Japan
| | - Katsuya Nagatani
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Japan
| | - Masahiro Iwamoto
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Japan
| | - Seiji Minota
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Japan
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19
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Ribeiro BNDF, Marchiori E. Evaluation of neuroimaging findings in thalamic lesions: what can we think? Radiol Bras 2021; 54:341-347. [PMID: 34602671 PMCID: PMC8475170 DOI: 10.1590/0100-3984.2020.0129] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 10/31/2020] [Indexed: 11/22/2022] Open
Abstract
The diseases that affect the thalamus are heterogeneous in their etiologies, including infectious, inflammatory, vascular, toxic-metabolic, and neoplastic causes. It is often difficult to make the clinical differentiation between different entities. Within this context, computed tomography and magnetic resonance imaging have come to be of fundamental importance for defining the etiology and planning the treatment. In this pictorial essay, we will illustrate the main causes of diseases affecting the thalamus, discussing the possible differential diagnoses, as well as the most relevant imaging aspects.
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Affiliation(s)
- Bruno Niemeyer de Freitas Ribeiro
- Department of Radiology, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, RJ, Brazil.,Department of Radiology, Hospital Casa de Portugal / 3D Diagnóstico por Imagem, Rio de Janeiro, RJ, Brazil
| | - Edson Marchiori
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
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20
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Efficacy of renin-angiotensin-aldosterone system blockades for acute phase hypertensive emergencies in patient complicating severe acute kidney injury. CEN Case Rep 2021; 11:105-109. [PMID: 34420196 DOI: 10.1007/s13730-021-00639-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 08/16/2021] [Indexed: 10/20/2022] Open
Abstract
Renin-angiotensin-aldosterone system (RAAS) is primarily involved with pathological mechanism of developing hypertensive emergencies. However, none of clinical practice guidelines mention RAAS blockers for the treatment of hypertensive emergencies. A 44 year-old woman presented with severe hypertension, brain stem posterior reversible encephalopathy syndrome and severe acute kidney injury (AKI). We started anti-hypertensive therapy with continuous intravenous nitroglycerin and oral calcium channel blocker (CCB) and spironolactone. Since severe AKI persisted despite this therapy, we administered losartan potassium, which resulted in improvement in her blood pressure and creatinine. Clinical course of our patient suggests that timely initiation of ARB and spironolactone for hypertensive emergencies could be beneficial in terms of blood pressure control and for protection of target organs from this condition.
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21
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Arinuma Y, Asakura H, Yamaoka K. Reversible basal ganglia lesions in a patient with systemic lupus erythematosus. Rheumatology (Oxford) 2021; 60:e447-e449. [PMID: 34329406 DOI: 10.1093/rheumatology/keab621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/26/2021] [Accepted: 07/26/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Yoshiyuki Arinuma
- Department of Rheumatology and Infectious diseases, Kitasato University School of Medicine
| | - Hirotomo Asakura
- Department of Rheumatology and Infectious diseases, Kitasato University School of Medicine
| | - Kunihiro Yamaoka
- Department of Rheumatology and Infectious diseases, Kitasato University School of Medicine
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22
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Jesrani G, Gupta S, Arya Y, Syal A, Gupta M. Systemic Lupus Erythematosus Induced Central Variant of Posterior Reversible Encephalopathy Syndrome: A Rare Association. Cureus 2021; 13:e13431. [PMID: 33758718 PMCID: PMC7978386 DOI: 10.7759/cureus.13431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Involvement of the posterior cerebral structures is well established in patients with posterior reversible encephalopathy syndrome (PRES). In striking contrast to this, a subset of patients may have an atypical presentation characterized by the involvement of central structures. This is usually seen in the backdrop of systemic lupus erythematosus (SLE), a rare but known cause of PRES. Timely diagnosis with judicious use of radiological modalities and therapeutic intervention is key for successful recovery; however, the prognosis of PRES in patients with SLE is not very promising. We are describing an extremely rare case of a patient diagnosed with a central variant of PRES with previously undiagnosed SLE.
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Affiliation(s)
- Gautam Jesrani
- Internal Medicine, Government Medical College and Hospital, Chandigarh, IND
| | - Samiksha Gupta
- Internal Medicine, Government Medical College and Hospital, Chandigarh, IND
| | - Yajur Arya
- Internal Medicine, Government Medical College and Hospital, Chandigarh, IND
| | - Arshi Syal
- Internal Medicine, Government Medical College and Hospital, Chandigarh, IND
| | - Monica Gupta
- Internal Medicine, Government Medical College and Hospital, Chandigarh, IND
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23
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Central-variant posterior reversible encephalopathy syndrome with bilateral corticospinal tract involvement: a case report. Acta Neurol Belg 2021; 121:265-268. [PMID: 32666507 DOI: 10.1007/s13760-020-01394-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 06/02/2020] [Indexed: 10/23/2022]
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24
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Rodrigues SG, Saraiva P, Marques IB. Optic pathways and brainstem involvement in posterior reversible encephalopathy syndrome. BMJ Case Rep 2021; 14:14/1/e239130. [PMID: 33431522 PMCID: PMC7802660 DOI: 10.1136/bcr-2020-239130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a neurological syndrome manifesting with acute focal signs, and concomitant neuroimaging findings of vasogenic oedema. It affects the parieto-occipital regions in a vast majority of cases, although atypical variants have been described comprising the brainstem, basal ganglia or spinal cord. We report the case of a 41-year-old woman, admitted for persistent headache and inferior altitudinal field defect in the right eye. She presented with severe, non-medicated, hypertension. Brain MRI showed findings compatible with atypical PRES, involving the brainstem and optic pathways. With antihypertensive therapy the headache remitted, although visual field remained and was interpreted in the context of a vascular aetiology-non-arteritic anterior ischaemic optic neuropathy. MRI was repeated 3 weeks later and showed almost complete reversal of the previous changes.
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Affiliation(s)
| | - Paulo Saraiva
- Neuroradiology Department, Hospital da Luz Lisboa, Lisboa, Lisboa, Portugal
| | - Inês Brás Marques
- Neurology Department, Hospital da Luz Lisboa, Lisboa, Lisboa, Portugal
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25
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Liu L, Zhang L. Posterior reversible encephalopathy syndrome coexists with acute cerebral infarction: challenges of blood pressure management. Quant Imaging Med Surg 2020; 10:2356-2365. [PMID: 33269231 DOI: 10.21037/qims-20-392] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Luji Liu
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Lihong Zhang
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
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26
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Khan IR, Pai V, Mundada P, Sitoh YY, Purohit B. Detecting the Uncommon Imaging Manifestations of Posterior Reversible Encephalopathy Syndrome (PRES) in Adults: a Comprehensive Illustrated Guide for the Trainee Radiologist. Curr Probl Diagn Radiol 2020; 51:98-111. [PMID: 33257096 DOI: 10.1067/j.cpradiol.2020.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/28/2020] [Accepted: 11/09/2020] [Indexed: 12/11/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) has traditionally been described as a reversible leukoencephalopathy with a distinct pattern of posteriorly distributed vasogenic oedema involving the subcortical regions of parietal and occipital lobes. PRES commonly occurs in the setting of hypertensive emergencies, pre-eclampsia/eclampsia, impaired renal function, and immunosuppressive therapy. The various clinical presentations of PRES include encephalopathy, seizures, headache, visual, and focal neurological deficits. As knowledge of this entity grows, the range of clinical, and radiological features is seen to be much broader than originally described. The brain oedema may not always be posteriorly distributed and the syndrome may not be uniformly reversible. Of special note are some uncommon imaging features (unilateral cerebral involvement, and isolated posterior fossa involvement) and also some uncommon complications (haemorrhage, cytotoxic oedema, and vasoconstriction). These red herrings may lead to potential diagnostic challenges and pitfalls especially for trainee radiologists, who often read these scans in an emergency setting. Early and accurate diagnosis is crucial for prompt optimum management, thereby avoiding residual morbidity. This review article focusses on the atypical radiological features of PRES in adults with extensive case-based imaging examples. A brief description of the pathophysiology, clinical, and classic radiological features of PRES has also been included. A tabulated summary of potential mimics with diagnostic pearls is provided to highlight pertinent take home points and to serve as an easy guide for day-to-day clinical practice.
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Affiliation(s)
- Iram R Khan
- Department of Neuroradiology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore
| | - Vivek Pai
- Department of Neuroradiology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore
| | - Pravin Mundada
- Department of Diagnostic and Interventional Radiology, Raffles Hospital, 585 North Bridge Rd, Singapore
| | - Yih Yian Sitoh
- Department of Neuroradiology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore
| | - Bela Purohit
- Department of Neuroradiology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore.
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27
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Cox M, Rodriguez P, Mohan S, Sedora-Roman NI, Pukenas B, Choudhri O, Kurtz RM. Tentorial Dural Arteriovenous Fistulas as a Cause of Thalamic Edema: 2 Cases of an Important Differential Diagnosis to Consider. Neurohospitalist 2020; 11:33-39. [PMID: 33868554 DOI: 10.1177/1941874420944333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The differential diagnosis for bilateral thalamic edema is extensive and includes vascular, neoplastic, metabolic, and infectious causes. Of the vascular causes of thalamic edema, arterial and venous infarctions are well-documented, but dural arteriovenous fistulas (dAVFs) are a relatively uncommon and widely underrecognized cause of thalamic edema. Dural AVFs are notoriously difficult to diagnose clinically, especially in the absence of hemorrhage, and cross-sectional imaging findings can be subtle. This can result in a delayed diagnosis, and occasionally, an invasive biopsy for further clarification of a purely vascular disease. In this review, we detail our experience with the imaging diagnosis of dAVF as a cause of thalamic edema and present a short differential of other vascular causes.
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Affiliation(s)
- Mougnyan Cox
- Section of Neurointerventional Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Pavel Rodriguez
- Neurointerventional Radiology, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Suyash Mohan
- Division of Neuroradiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Neda I Sedora-Roman
- Section of Neurointerventional Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Bryan Pukenas
- Section of Neurointerventional Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Omar Choudhri
- Section of Neurointerventional Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Robert M Kurtz
- Division of Neuroradiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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28
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Van Cauter S, Severino M, Ammendola R, Van Berkel B, Vavro H, van den Hauwe L, Rumboldt Z. Bilateral lesions of the basal ganglia and thalami (central grey matter)-pictorial review. Neuroradiology 2020; 62:1565-1605. [PMID: 32761278 PMCID: PMC7405775 DOI: 10.1007/s00234-020-02511-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/30/2020] [Indexed: 12/11/2022]
Abstract
The basal ganglia and thalami are paired deep grey matter structures with extensive metabolic activity that renders them susceptible to injury by various diseases. Most pathological processes lead to bilateral lesions, which may be symmetric or asymmetric, frequently showing characteristic patterns on imaging studies. In this comprehensive pictorial review, the most common and/or typical genetic, acquired metabolic/toxic, infectious, inflammatory, vascular and neoplastic pathologies affecting the central grey matter are subdivided according to the preferential location of the lesions: in the basal ganglia, in the thalami or both. The characteristic imaging findings are described with emphasis on the differential diagnosis and clinical context.
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Affiliation(s)
- Sofie Van Cauter
- Department of Medical Imaging, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium. .,Department of Radiology, University Hospitals Leuven, Herestraat 39, 3000, Leuven, Belgium.
| | - Mariasavina Severino
- Neuroradiology Unit, IRCCS Instituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genoa, Italy
| | - Rosamaria Ammendola
- Neuroradiology Unit, IRCCS Instituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genoa, Italy
| | - Brecht Van Berkel
- Department of Medical Imaging, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.,Department of Radiology, University Hospitals Leuven, Herestraat 39, 3000, Leuven, Belgium
| | - Hrvoje Vavro
- Department of Diagnostic and Interventional Radiology, University Hospital Dubrava, Avenija Gojka Šuška 6, Zagreb, Croatia
| | - Luc van den Hauwe
- Department of Radiology, University Hospital Antwerp, Wilrijkstraat 10, 2650, Edegem, Belgium.,Department of Medical Imaging, AZ KLINA, Augustijnslei 100, 2930, Brasschaat, Belgium
| | - Zoran Rumboldt
- Department of Radiology, University of Rijeka School of Medicine, Ulica Braće Branchetta 20, 51000, Rijeka, Croatia.,Department of Radiology, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC, 29425, USA
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29
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Koksel Y, McKinney A. Potentially Reversible and Recognizable Acute Encephalopathic Syndromes: Disease Categorization and MRI Appearances. AJNR Am J Neuroradiol 2020; 41:1328-1338. [PMID: 32616580 PMCID: PMC7658879 DOI: 10.3174/ajnr.a6634] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 04/26/2020] [Indexed: 01/21/2023]
Abstract
"Encephalopathy" is a vague term that encompasses varying definitions, often with a nonspecific clinical presentation and numerous possible pathophysiologic causes. Hence, MR imaging plays a crucial role in the early diagnosis and treatment by identifying imaging patterns when there is limited clinical history in such patients with acute encephalopathy. The aim of this review was to aid in remembrance of etiologies of potentially reversible acute encephalopathic syndromes on MR imaging. The differential includes vascular (reversible cerebral vasoconstriction syndrome, transient global amnesia, disseminated intravascular coagulation, and thrombotic microangiopathy), infection (meningitis, encephalitis), toxic (posterior reversible encephalopathy syndrome, acute toxic leukoencephalopathy; carbon monoxide, alcohol-related, medication- and illicit drug-related toxic encephalopathies), autoimmune, metabolic (osmotic demyelination syndrome, uremic, acute hepatic encephalopathy), idiopathic/inflammatory (stroke-like migraine attacks after radiation therapy syndrome), neoplasm-related encephalopathy, and seizure-related encephalopathy.
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Affiliation(s)
- Y. Koksel
- From the Department of Radiology (Y.K.), Division of Neuroradiology, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - A.M. McKinney
- Department of Radiology (A.M.M.), University of Miami School of Medicine, Miami, Florida
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30
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Chen H, Xu Z, Yuan Y. Posterior reversible encephalopathy syndrome and reversible cerebral vasoconstriction syndrome associated spinal subdural hematoma: A case report. Medicine (Baltimore) 2020; 99:e21522. [PMID: 32756193 PMCID: PMC7402904 DOI: 10.1097/md.0000000000021522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS) are separate clinical entities with distinct pathophysiological features. But in some special conditions PRES and RCVS can occur simultaneously. PATIENT CONCERNS We report the unique case of a 40-year-old female presented with crescendo headache, blurred vision, and recurrent generalized tonic-clonic seizure. She had a minor neck injury 1 week before but attracted no more attention. Neurological tests on admission yielded a Glasgow Coma Scale score of 13. No obvious focal neurological deficit apart from positive signs of meningeal irritation was presented. DIAGNOSES Xanthochromia and hemorrhagic cerebrospinal fluid with pleocytosis was found on lumbar puncture. Cranial computed tomography was negative but magnetic resonance imaging demonstrated bilateral areas of vasogenic edema in the parieto-occipital lobes and cerebellum consistent with PRES. An incidental subacute spinal subdural hematoma extending from the level of C6 to T1 was depicted by spinal magnetic resonance imaging, presumably as a complication of negligible neck trauma. Spinal digital subtraction angiography showed no evidence of spinal aneurysm, arteriovenous malformation, or dural arteriovenous fistula. Cerebral digital subtraction angiography showed segmental narrowing and dilatation of vessels, a potential feature of RCVS, involving the circle of Willis and their branches. INTERVENTIONS The patient was treated with nimodipine for vasodilation and other symptomatic therapies. The spinal subdural hematoma was not warranted for surgical intervention and managed with simple analgesics. OUTCOMES The patient experienced a dramatic improvement in neurological symptoms and was discharged without sequelae. Follow-up imaging showed complete resolution of all radiological changes. LESSONS Clinician should be aware of spinal subdural hematoma as the potential trigger in development of PRES and RCVS. We speculate that endothelial dysfunction and vascular tone dysregulation may be implicated to play the major pathophysiologic role.
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Abraham P, Longardner K, Chen P, Huisa B, Handwerker J. Case 279: Central-Variant Posterior Reversible Encephalopathy Syndrome. Radiology 2020; 296:239-243. [DOI: 10.1148/radiol.2020181547] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Peter Abraham
- From the School of Medicine (P.A.) and Departments of Neurosciences (K.L., P.C., B.H.) and Radiology (J.H.), University of California San Diego Medical Center, 200 West Arbor Dr, San Diego, CA 92103
| | - Katie Longardner
- From the School of Medicine (P.A.) and Departments of Neurosciences (K.L., P.C., B.H.) and Radiology (J.H.), University of California San Diego Medical Center, 200 West Arbor Dr, San Diego, CA 92103
| | - Patrick Chen
- From the School of Medicine (P.A.) and Departments of Neurosciences (K.L., P.C., B.H.) and Radiology (J.H.), University of California San Diego Medical Center, 200 West Arbor Dr, San Diego, CA 92103
| | - Branko Huisa
- From the School of Medicine (P.A.) and Departments of Neurosciences (K.L., P.C., B.H.) and Radiology (J.H.), University of California San Diego Medical Center, 200 West Arbor Dr, San Diego, CA 92103
| | - Jason Handwerker
- From the School of Medicine (P.A.) and Departments of Neurosciences (K.L., P.C., B.H.) and Radiology (J.H.), University of California San Diego Medical Center, 200 West Arbor Dr, San Diego, CA 92103
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Chruickshank T, Thoresen H, Benjaminsen E, Odeh F. Posterior reversible encephalopathy syndrome, a clinically diverse and challenging disorder. Clin Case Rep 2020; 8:798-803. [PMID: 32477520 PMCID: PMC7250976 DOI: 10.1002/ccr3.2745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 12/30/2019] [Accepted: 01/21/2020] [Indexed: 11/05/2022] Open
Abstract
The characterizing features of Posterior reversible encephalopathy syndrome (PRES) are broad and diverse, making early recognition and diagnosis challenging tasks. To illustrate the heterogeneous nature of PRES, we present three cases and discuss their clinical and radiological presentation.
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Affiliation(s)
| | - Hanne Thoresen
- Department of RadiologyNordland Hospital TrustBodøNorway
| | | | - Francis Odeh
- Department of NeurologyNordland Hospital TrustBodøNorway
- Institue Clinical MedicineUiTThe Arctic University of TromsøTromsøNorway
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Li K, Yang Y, Guo D, Sun D, Li C. Clinical and MRI Features of Posterior Reversible Encephalopathy Syndrome With Atypical Regions: A Descriptive Study With a Large Sample Size. Front Neurol 2020; 11:194. [PMID: 32265829 PMCID: PMC7105821 DOI: 10.3389/fneur.2020.00194] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 03/03/2020] [Indexed: 12/12/2022] Open
Abstract
Background: Accurate diagnosis and timely treatment for posterior reversible encephalopathy syndrome (PRES) with atypical regions are very important in clinical practice. However, until now, little has been known about the clinical and MRI manifestations of this disease. Therefore, the aim of this study is to investigate the clinical and MRI features of PRES to promote clinical management and deepen our understanding of this disease. Materials and Methods: Data from six PRES patients with atypical regions were collected from our hospital. Data from another 550 cases were obtained by searching the PubMed, EMBASE and Web of Science databases with the keywords "posterior reversible encephalopathy syndrome" "PRES" "reversible posterior leukoencephalopathy" "RPLS" "hypertensive encephalopathy" "hyperperfusion encephalopathy" or "reversible posterior cerebral edema encephalopathy." The clinical and MRI features of these 556 cases were analyzed together. Results: A total of 305 patients were female, and 248 were male, with a median age of 34 years. The information on sex and age of three patients was not available. The most common symptom was headache (282/556, 50.7%), followed by altered mental status (243/556, 43.7%), seizures (233/556, 41.9%), visual disturbances (194/556, 34.9%), nausea/vomiting (130/556, 23.4%), and focal neurological deficits (101/556, 18.2%). Hypertension (425/556, 76.4%), renal diseases (152/556, 27.3%), immunosuppressant drugs (79/556, 14.2%), and chemotherapy/chemoradiotherapy (59/556, 10.6%) were the major predisposing factors. The atypical regions of the lesions were the cerebellum (331/556, 59.5%), basal ganglia (135/556, 24.3%), periventricular/deep white matter (125/556, 22.5%), pons (124/556, 22.3%), brainstem (115/556, 20.7%), thalamus (114/556, 20.5%), midbrain (48/556, 8.6%), spinal cord (33/556, 5.9%), and medulla (29/556, 5.2%). Additionally, the following typical regions were observed: occipital (278/556, 50.0%), parietal (234/556, 42.1%), frontal (150/556, 27.0%), and temporal (124/556, 22.3%) lobes. The major treatments were antihypertensives (358/515, 69.5%), antiepileptics/sedation (126/515, 24.5%), discontinuation/switching agents (67/515, 13.0%), and steroids (54/515, 10.5%). The median time of the clinical state improved and abnormal neuroimaging resolved is 2-3 weeks after appropriate treatment. Conclusion: The common symptoms of PRES with atypical regions include headaches, altered mental status, seizures, visual disturbances, nausea or vomiting, and focal neurological deficits. The frequent predisposing factors include hypertension, renal diseases, immunosuppressant drugs and chemotherapy/chemoradiotherapy. MRI features are mainly characterized by vasogenic edema in central zones always accompanied by typical regions. Most cases can be reversed in 2-3 weeks when promptly recognized and properly treated.
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Affiliation(s)
- Kunhua Li
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yang Yang
- Department of Radiology, Chongqing Prevention and Treatment Center for Occupational Diseases, Chongqing, China
| | - Dajing Guo
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dong Sun
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chuanming Li
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Brainstem Posterior Reversible Encephalopathy Syndrome in an Asymptomatic Patient. Can J Neurol Sci 2020; 47:267-269. [PMID: 31915091 DOI: 10.1017/cjn.2020.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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35
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Hinduja A. Posterior Reversible Encephalopathy Syndrome: Clinical Features and Outcome. Front Neurol 2020; 11:71. [PMID: 32117030 PMCID: PMC7034490 DOI: 10.3389/fneur.2020.00071] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/21/2020] [Indexed: 01/24/2023] Open
Abstract
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.
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Affiliation(s)
- Archana Hinduja
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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36
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Molema F, Williams M, Langendonk J, Darwish-Murad S, van de Wetering J, Jacobs E, Onkenhout W, Brusse E, van der Eerden A, Wagenmakers M. Neurotoxicity including posterior reversible encephalopathy syndrome after initiation of calcineurin inhibitors in transplanted methylmalonic acidemia patients: Two case reports and review of the literature. JIMD Rep 2020; 51:89-104. [PMID: 32071844 PMCID: PMC7012740 DOI: 10.1002/jmd2.12088] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 10/15/2019] [Accepted: 11/15/2019] [Indexed: 12/20/2022] Open
Abstract
Introduction New neurological symptoms in methylmalonic acidemia (MMA) patients after liver and/or kidney transplantation (LKT) are often described as metabolic stroke‐like‐events. Since calcineurin inhibitors (CNIs) are a well‐known cause of new neurological symptoms in non‐MMA transplanted patients, we investigated the incidence of CNI‐induced neurotoxicity including posterior reversible encephalopathy syndrome (PRES) in post‐transplanted MMA patients. Methods We report the two MMA patients treated with LKT in our center. Additionally, we performed a systematic review of case reports/series of post‐transplanted MMA patients and determined if CNI‐induced neurotoxicity/PRES was a likely cause of new neurological symptoms. Definite CNI‐induced neurotoxicity was defined as new neurological symptoms during CNI treatment with symptom improvement after CNI dose reduction/discontinuation. PRES was defined as CNI‐induced neurotoxicity with signs of vasogenic edema on brain magnetic resonance imaging (MRI)‐scan post‐transplantation. Results Our two MMA patients both developed CNI‐induced neurotoxicity, one had PRES. In literature, 230 transplanted MMA patients were identified. Neurological follow‐up was reported in 54 of them, of which 24 were excluded from analysis since no anti‐rejection medication was reported. Thirty patients, all using CNI, were included. Sixteen patients (53%) had no new neurological symptoms post‐transplantation and five patients (17%) had definite CNI neurotoxicity of whom two had PRES. Including our cases this results in a pooled incidence of 22% (7/32) definite CNI neurotoxicity and 9% PRES (3/32) in post‐transplanted MMA patients on CNI. Conclusion In MMA post‐transplanted patients with new neurological symptoms CNI‐induced neurotoxicity/PRES should be considered. Early recognition of CNI‐induced neurotoxicity is essential to initiate dose reduction/discontinuation of CNI to minimize persistent neurologic damage and improve outcome. Concise one sentence take home message In all post‐transplanted MMA patients with new neurological symptoms CNI‐induced neurotoxicity/PRES should be considered, and directly reducing the dose/discontinuation of CNI is essential.
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Affiliation(s)
- Femke Molema
- Department of Pediatrics, Center for Lysosomal and Metabolic Disease Erasmus - Sophia Children's Hospital, University Medical Center Rotterdam The Netherlands
| | - Monique Williams
- Department of Pediatrics, Center for Lysosomal and Metabolic Disease Erasmus - Sophia Children's Hospital, University Medical Center Rotterdam The Netherlands
| | - Janneke Langendonk
- Department of Internal Medicine, Erasmus University Medical Center Center for Lysosomal and Metabolic Disease Rotterdam The Netherlands
| | - Sarwa Darwish-Murad
- Department of Gastroenterology and Hepatology Erasmus University Medical Center Rotterdam The Netherlands
| | - Jacqueline van de Wetering
- Department of Internal Medicine Erasmus University Medical Center, Nephrology and Transplantation, Rotterdam Transplant Group Rotterdam The Netherlands
| | - Ed Jacobs
- Department of Pediatrics, Center for Lysosomal and Metabolic Disease Erasmus - Sophia Children's Hospital, University Medical Center Rotterdam The Netherlands.,Department of Clinical Genetics Erasmus University Medical Center Rotterdam The Netherlands
| | - Willem Onkenhout
- Department of Pediatrics, Center for Lysosomal and Metabolic Disease Erasmus - Sophia Children's Hospital, University Medical Center Rotterdam The Netherlands.,Department of Clinical Genetics Erasmus University Medical Center Rotterdam The Netherlands
| | - Esther Brusse
- Department of Neurology Erasmus University Medical Center Rotterdam The Netherlands
| | - Anke van der Eerden
- Department of Radiology Erasmus University Medical Center Rotterdam The Netherlands
| | - Margreet Wagenmakers
- Department of Internal Medicine, Erasmus University Medical Center Center for Lysosomal and Metabolic Disease Rotterdam The Netherlands
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37
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Di Stefano V, Rispoli MG, Onofrj M, De Angelis MV. Tumour-like presentation of atypical posterior reversible encephalopathy syndrome with prominent brainstem involvement. BMJ Case Rep 2020; 13:13/1/e231687. [PMID: 31919058 DOI: 10.1136/bcr-2019-231687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Typical posterior reversible encephalopathy syndrome (PRES) is a clinical-neuroradiological entity characterised by bilateral white matter oedema, which is usually symmetrical and totally reversible in 2-3 weeks. A 46-year-old man presented with a persistent headache and visual blurring in the right eye. On admission, the clinical examination revealed minimal unsteadiness of gait and elevated blood pressure. A brain MRI showed a hyperintense signal on T2-weighted sequences in the whole brainstem, extended to the spinal cord (C2-C6), the left insula and the right cerebellum. When his blood pressure was controlled, his symptoms gradually improved. The follow-up MRI scan at 3 weeks revealed a dramatic regression of the hyperintense lesions on T2-weighted sequences. The differential diagnosis of PRES is very wide, especially in the case of conspicuous brainstem involvement. Treatable causes of white matter oedema should be always kept in mind to avoid misdiagnosis and prevent complications, such as intracranial haemorrhage.
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Affiliation(s)
- Vincenzo Di Stefano
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University, Chieti, Italy
| | | | - Marco Onofrj
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University, Chieti, Italy
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38
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Canedo-Antelo M, Baleato-González S, Mosqueira AJ, Casas-Martínez J, Oleaga L, Vilanova JC, Luna-Alcalá A, García-Figueiras R. Radiologic Clues to Cerebral Venous Thrombosis. Radiographics 2019; 39:1611-1628. [DOI: 10.1148/rg.2019190015] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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39
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Saad AF, Chaudhari R, Wintermark M. Imaging of Atypical and Complicated Posterior Reversible Encephalopathy Syndrome. Front Neurol 2019; 10:964. [PMID: 31551919 PMCID: PMC6738024 DOI: 10.3389/fneur.2019.00964] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 08/22/2019] [Indexed: 12/26/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a condition clinically characterized by headache, altered mental status, seizures, and visual loss and may be associated with systemic hypertension, preeclampsia/eclampsia, chemotherapy, immunosuppressive therapies in the setting of organ transplantation, and uremic encephalopathy. While brain imaging in patients with PRES typically reveals symmetric vasogenic edema within the parietal and occipital lobes, PRES may present with atypical imaging findings such as central brainstem and deep gray involvement without subcortical edema, and even spinal cord involvement. Additionally, PRES may be complicated in some cases by the presence of cytotoxic edema and hemorrhage. This review will serve to summarize the pathophysiologic theories and controversies underlying PRES, imaging features encountered in atypical and complicated PRES, and the implications these findings may have on patient prognosis.
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Affiliation(s)
- Amin F Saad
- Department of Radiology, Baylor University Medical Center, Dallas, TX, United States
| | - Ruchir Chaudhari
- Department of Radiology, Stanford University, Stanford, CA, United States
| | - Max Wintermark
- Department of Radiology, Stanford University, Stanford, CA, United States
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40
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Tetsuka S, Ogawa T. Posterior reversible encephalopathy syndrome: A review with emphasis on neuroimaging characteristics. J Neurol Sci 2019; 404:72-79. [DOI: 10.1016/j.jns.2019.07.018] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 06/25/2019] [Accepted: 07/16/2019] [Indexed: 01/24/2023]
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41
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Strother R, Wong H, Miller NE. Posterior Reversible Encephalopathy Syndrome Secondary to Hypertensive Encephalopathy Brought on by a MAO Inhibitor: A Case Report. J Prim Care Community Health 2019; 10:2150132719869539. [PMID: 31423884 PMCID: PMC6698996 DOI: 10.1177/2150132719869539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
An elderly woman was admitted to the Family Medicine inpatient service for altered mental status after being brought to the emergency room by a concerned neighbor, who had come across the patient speaking incoherently. Initial evaluation was notable for elevated blood pressures, but extensive lab testing and head computed tomographic imaging were within normal limits. However, subsequent magnetic resonance imaging showed white matter changes consistent with posterior reversible encephalopathy syndrome (PRES), a neurologic syndrome characterized by headache, altered mental status, loss of vision, and seizures as well as radiographic findings of posterior cerebral white matter edema. Multiple etiologies of PRES have been described and include hypertensive encephalopathy, immunosuppressant medications, and eclampsia. This case describes an episode of PRES secondary to hypertensive encephalopathy brought about by an inappropriate dose of a monoamine oxidase (MAO) inhibitor. The patient had significant improvement in symptoms with removal of the offending agent and control of her blood pressure. While PRES generally has a good prognosis, prompt recognition, and management are important in preventing significant disease morbidity and mortality.
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Affiliation(s)
- Robert Strother
- Mayo Clinic, Rochester, MN, USA,Robert Strother, Department of Family
Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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42
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Hong JH. Cerebrovascular complications during pregnancy and postpartum. JOURNAL OF NEUROCRITICAL CARE 2019. [DOI: 10.18700/jnc.190087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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43
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Maier S, Monica C, Romaniuc A, Andone S, Bălaşa R. Central-variant posterior reversible encephalopathy syndrome in a young patient with systemic lupus erythematosus. Acta Neurol Belg 2019; 119:269-271. [PMID: 30467758 DOI: 10.1007/s13760-018-1046-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 11/13/2018] [Indexed: 10/27/2022]
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44
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Samara A, Berry B, Ghannam M. Posterior reversible encephalopathy syndrome with isolated infratentorial involvement: A case report. Radiol Case Rep 2019; 14:576-580. [PMID: 30886669 PMCID: PMC6402429 DOI: 10.1016/j.radcr.2019.02.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 02/10/2019] [Accepted: 02/11/2019] [Indexed: 11/07/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiological entity of acute neurological symptoms associated with characteristic MRI finding. Vasogenic edema in the white matter of parieto-occipital regions is the classical MRI findings. Spinal cord involvement in PRES is extremely rare and frequently underrecognized condition. Recently, a variant-type PRES with isolated involvement of infratentorial structures is getting more attention. Herein, we present a case of hypertensive emergency and associated radiological features of PRES with isolated involvement of the brain stem, cerebellum, and spinal cord.
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Affiliation(s)
- Amjad Samara
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Brent Berry
- Neurology Department, University of Minnesota, Minneapolis, MN, USA
| | - Malik Ghannam
- Neurology Department, University of Minnesota, Minneapolis, MN, USA
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45
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Hebant B, Guegan-Massardier E, Triquenot-Bagan A, Ozkul-Wermester O. Atypical MRI presentation of posterior reversible encephalopathy syndrome with predominant brainstem involvement. Acta Neurol Belg 2019; 119:123-125. [PMID: 30498887 DOI: 10.1007/s13760-018-1055-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 11/26/2018] [Indexed: 11/27/2022]
Abstract
We report here the case of a 80-year-old woman for the assessment of an acute confusional state since 2 days asssociated with diffuse and gradual headache. Brain MRI disclosed isolated hyperintense signal on fluid-attenuated inversion recovery sequence involving the medulla and the right inferior cerebellar peduncle with moderate swelling, consistent with vasogenic oedema, without abnormalities on diffusion-weighted imaging sequence. PRES diagnosis was suspected and antihypertensive therapy was introduced to achieve a blood pressure goal < 140/90 mmHg, allowing a quickly favourable clinical course. Three months later, brain MRI demonstrated a complete clearance of the abnormalities, confirming the PRES diagnosis. Atypical MRI findings are possible with involvement of basal ganglia, brainstem or cerebellum, but in these cases, oedema is most of the time accompanied by the classical parieto-occipital region involvement. Vasogenic oedema strictly unilateral or involving exclusively the brainstem or the cerebellum are very rare and should prompt suspicion for an alternative diagnosis. That constitutes a crucial diagnosis challenge in neurology.
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Affiliation(s)
- Benjamin Hebant
- Department of Neurology, Rouen University Hospital and University of Rouen, 76031, Rouen Cedex, France.
| | - Evelyne Guegan-Massardier
- Department of Neurology, Rouen University Hospital and University of Rouen, 76031, Rouen Cedex, France
| | - Aude Triquenot-Bagan
- Department of Neurology, Rouen University Hospital and University of Rouen, 76031, Rouen Cedex, France
| | - Ozlem Ozkul-Wermester
- Department of Neurology, Rouen University Hospital and University of Rouen, 76031, Rouen Cedex, France
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46
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Chiang WF, Chen PT, Chen YL, Chen MH. Atypical posterior reversible encephalopathy syndrome in a noncompliant hemodialysis patient: Case report and literature review. Hemodial Int 2019; 23:E100-E103. [PMID: 30735291 DOI: 10.1111/hdi.12735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 11/26/2018] [Indexed: 10/27/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a reversible vasogenic brain edema in patients who present with seizure, headache, visual disturbance, and altered mental status, and a characteristic neuroimaging profile. Although PRES predominantly affects the bilateral parieto-occipital areas, involvement of the frontal and temporal lobes, basal ganglia, brainstem, and cerebellum is not uncommon. Isolated involvement of the brainstem and cerebellum sparing the parieto-occipital lobe is rarely reported. Here, we describe a 47-year-old man with end-stage renal disease on chronic hemodialysis who presented with prominent hypertension and coma after missing three dialysis sessions. On examination, there was paucity of focal neurologic signs. Diagnosis of PRES was based on brain magnetic resonance imaging findings that were consistent with vasogenic edema of the pons and cerebellum without involvement of other areas. With antihypertensive therapy and intense ultrafiltration during hemodialysis, the patient's blood pressure and consciousness returned to normal, along with complete resolution of the abnormal imaging findings. This case stresses that noncompliance with dialysis should be considered a risk factor for PRES. This case is considered relative to the available literature on three patients with brainstem variant of PRES.
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Affiliation(s)
- Wen-Fang Chiang
- Division of Nephrology, Armed Forces Taoyuan General Hospital, Taoyuan, Taiwan.,Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Pei-Ti Chen
- Department of Radiology, Armed Forces Taoyuan General Hospital, Taoyuan, Taiwan.,Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yen-Lin Chen
- Department of Radiology, Armed Forces Taoyuan General Hospital, Taoyuan, Taiwan.,Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ming-Hua Chen
- Division of Neurology, Department of Medicine, Armed Forces Taoyuan General Hospital, Taoyuan, Taiwan.,Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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47
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Gowan JM, Liu A. Isolated pan-pontine posterior reversible encephalopathy syndrome in a patient with uncontrolled hypertension. Clin Case Rep 2019; 7:32-36. [PMID: 30656003 PMCID: PMC6332822 DOI: 10.1002/ccr3.1888] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 09/26/2018] [Accepted: 10/05/2018] [Indexed: 11/11/2022] Open
Abstract
Recognition of central variant PRES is key to avoiding detrimental treatment. The pons may be the most vulnerable area in central PRES, and delayed presentation may result in greater damage. CSF reporting may lead to eventual recognition of a common profile, and possible aid in future diagnosis.
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Affiliation(s)
| | - Antonio Liu
- Department of NeurologyCalifornia Hospital Medical CenterLos AngelesCalifornia
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Wittgrove C, Kaur H, Siddiqui JH. Atypical Variant of Posterior Reversible Encephalopathy Syndrome in the Setting of Renovascular Hypertension: Case Report and Review of Literature. Cureus 2018; 10:e3573. [PMID: 30656077 PMCID: PMC6333264 DOI: 10.7759/cureus.3573] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiologic syndrome resulting in subcortical vasogenic edema appreciated on T2/fluid-attenuated inversion recovery (FLAIR) sequence of magnetic resonance imaging (MRI). PRES classically involves bilateral parieto-occipital lobes and is usually reversible. Atypical variant of PRES includes the involvement of brainstem, basal ganglia, thalami, or periventricular white matter. We report an unusual case of PRES with isolated brainstem involvement with periventricular white matter changes in a patient with renovascular hypertension from unilateral renal artery stenosis. To our knowledge, this is the first case of secondary hypertension from renal artery stenosis resulting in the atypical variant of PRES.
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Affiliation(s)
| | - Harleen Kaur
- Neurology, Univeristy of Missouri, Columbia, USA
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Ou S, Xia L, Wang L, Xia L, Zhou Q, Pan S. Posterior Reversible Encephalopathy Syndrome With Isolated Involving Infratentorial Structures. Front Neurol 2018; 9:843. [PMID: 30356684 PMCID: PMC6189285 DOI: 10.3389/fneur.2018.00843] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 09/19/2018] [Indexed: 11/13/2022] Open
Abstract
Typical neuroimaging findings of posterior reversible encephalopathy syndrome include symmetrical white matter edema in subcortical white matter of bilateral occipital and parietal lobes, although variations do occur and more and more attention is being focused upon disease of infratentorial-isolated involved posterior reversible encephalopathy syndrome. In this article, we described 1 case of posterior reversible encephalopathy syndrome with isolated infratentorial brain involvement and reviewed the literature to identify an additional 36 cases in the PubMed database. We used various search terms, such as "brainstem/cerebella/spinal posterior reversible encephalopathy syndrome," "brainstem/cerebella/spinal reversible posterior leukoencephalopathy syndrome," "brainstem/cerebella/spinal hypertensive encephalopathy," "infratentorial posterior reversible encephalopathy syndrome," and "posterior reversible encephalopathy syndrome variant." Then, we systematically analyzed the clinical and imaging characteristics of the 37 cases and found that posterior reversible encephalopathy syndrome with isolated involving infratentorial structures predominantly affect male patients compared with typical posterior reversible encephalopathy syndrome. The presence of extremely high blood pressure at onset is essential to the development of infratentorial-isolated involved posterior reversible encephalopathy syndrome. A relatively high rate of hydrocephalus and spinal cord involvement can be a distinctive feature of this kind of variant. Symptoms and outcomes are basically similar to typical posterior reversible encephalopathy syndrome.
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Affiliation(s)
- Shuchun Ou
- Department of neurology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Lu Xia
- Department of neurology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Li Wang
- Department of neurology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Li Xia
- Department of neurology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Qin Zhou
- Department of neurology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Songqing Pan
- Department of neurology, Renmin Hospital of Wuhan University, Wuhan, China
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Abe Y, Narita K, Kobayashi H, Kitadate A, Takeuchi M, Kikuchi Y, Ouchi T, Takeuchi K, Matsue K. Clinical value of abnormal findings on brain magnetic resonance imaging in patients with intravascular large B-cell lymphoma. Ann Hematol 2018; 97:2345-2352. [DOI: 10.1007/s00277-018-3481-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 08/19/2018] [Indexed: 12/18/2022]
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