Posterior reversible encephalopathy syndrome: a truly treatable neurologic illness

Cerebral hypometabolism in a pediatric patient with clinically resolved posterior reversible encephalopathy syndrome

A 4-year-old boy with Nuclear factor-kappa B Essential Modulator deficiency syndrome presented with encephalopathy post haematopoietic stem cell transplantation. MRI demonstrated T2/FLAIR-hyperintensities in the posterior cerebral cortex concerning for posterior reversible encephalopathy syndrome. Clinical improvement was appreciated following withdrawal of the suspected offending pharmacological agent (Cyclosporine). An 18F-FDG PET/CT performed 2 months later to screen for post-transplant lymphoproliferative disease demonstrated markedly reduced FDG uptake in the posterior cerebral cortex, involving the parietal and occipital lobes. We describe, to the best of our knowledge, the first case of profound cerebral hypometabolism in a child with clinically resolved posterior reversible encephalopathy syndrome.

Amyloid-related imaging abnormalities (ARIA): diagnosis, management, and care in the setting of amyloid-modifying therapy

Amyloid-related imaging abnormalities, were originally described by dementia care experts. The wider use of aducanumab and now lecanemab warrant broader understanding by the health care provider continuum. The optimal care approach for patients with Alzheimer's dementia, treated with amyloid-targeted therapy, includes proper clinical diagnosis, complication surveillance, specific imaging protocols, expert specialty consultation, integrated treatment strategies, and proper facility system planning. Improved awareness and understanding of amyloid-modifying therapy, both benefits and potential complications, among the health care provider continuum is paramount to the success of complex care programs. Specifically, recognition of treatment high risk, high benefit groups, and the interface of concurrent antiplatelet and anticoagulation. This integrated acute, specialty, and primary care approach should improve patient care quality and outcome.

Analysis of drug-induced posterior reversible encephalopathy syndrome using the food and drug administration adverse drug events reporting system database

OBJECTIVE

In this retrospective pharmacovigilance study, we gathered data on drug-induced posterior reversible encephalopathy syndrome (PRES). Our goal was to identify the primary suspect drugs in PRES by analyzing the Food and Drug Administration Adverse Events Reporting System (FAERS) database.

METHODS

We identified and analyzed reports of PRES listed in the FAERS database between 2004 and 2021. Using the reporting odds ratio and 95% confidence interval, we evaluated the safety signals for each of the drugs associated with PRES.

RESULTS

We reviewed 11,077 reports of adverse events corresponding to PRES. The primary suspect drug categories were antineoplastics, immunosuppressants, and glucocorticoids. PRES was 24.77% more likely to occur in females than in males. Drug-induced PRES usually occurs in individuals with cancer, those who have undergone an organ/stem cell transplant, and those with autoimmune conditions.

CONCLUSION

Our results show that the drugs most commonly suspected to cause PRES were antineoplastics, immunosuppressants, and glucocorticoids. Future studies are needed to illuminate the pathophysiological alterations that underlie PRES. In the meantime, prescribers and patients should be made aware of the potential risks of PRES associated with pharmaceutical therapy, and the summaries of product characteristics for individual drugs should be updated to include this information.

Cocaine-Induced Toxic Leukoencephalopathy: A Case Report

We present a case here where a 57-year-old South Asian male with disturbed mental status developed multifocal leukoencephalopathy, which we believe was caused by cocaine usage. Cocaine was detected in the urine toxicological sample. Non-acute CT head, with a follow-up brain MRI demonstrating hyperintensity of the T2 FLAIR signal corresponding to diffusion restriction throughout the whole supratentorial white matter, involving semiovale and subcortical U fibres in the occipital lobes as well as posterior frontal and parietal centrum. It was less likely that the patient had posterior reversible encephalopathy syndrome (PRES), which can potentially manifest similarly in a clinical and imaging context because there was no abrupt rise of blood pressure at presentation or during the patient's stay. Extensive examinations were conducted to exclude additional factors that may contribute to the patient's appearance, including autoimmune, vasculitis, and infectious diseases. Levamisole, a significant chemical that is frequently used to increase the volume of cocaine samples and has been linked to neuronal damage, should be examined in individuals who use cocaine and exhibit these kinds of clinical symptoms. The patient was prescribed 250 mg of methylprednisolone twice daily for five days after it was determined that cocaine-induced neuronal toxicity was the cause of his symptoms. Although no improvement was seen right away, over the course of the next few days, he did exhibit a gradual, albeit slight, improvement in his mental status while residing in the nursing home. It is crucial to comprehend the possible connection between cocaine usage, a commonly abused drug, and people exhibiting similar clinical symptoms. To have a better understanding of the pathophysiology and possible treatment approach, more research is necessary as there is now no recommended therapy regimen.

Posterior Reversible Encephalopathy Syndrome in a Patient with Septic Shock: A Case Report

INTRODUCTION

Posterior reversible encephalopathy syndrome (PRES) is a reversible condition with nonspecific neurologic and characteristic radiologic findings. Clinical presentation may include headache, nausea, vomiting, altered mental status, seizures, and vision changes. Diagnosis is confirmed through T2-weighted brain magnetic resonance imaging (MRI) showing bilateral hyperintensities in the white matter of posterior circulatory regions.

CASE REPORT

We report a case of PRES in a patient suffering from complicated diverticulitis. Following medical management in the emergency department, the patient deteriorated, becoming hypotensive and altered. Bowel resection under general anesthesia was performed. Postoperative brain MRI demonstrated bilateral and symmetric T2 signal hyperintensities suggestive of PRES. Following supportive treatment, the patient was discharged from the surgical intensive care unit on postoperative day 21 with no residual deficits.

CONCLUSION

It is important to recognize the nonspecific neurologic symptoms associated with PRES. Emergency physicians should suspect acute PRES when managing patients with prolonged or unexplained encephalopathy, while recognizing that hypertension need not be present.

The effect of induced hypertension in aneurysmal subarachnoid hemorrhage: A narrative review

Aneurysmal subarachnoid hemorrhage ‎(aSAH) ‎accounts for 2-5% of all strokes, and 10%-15% of ‎aSAH patients will not survive until hospital admission. Induced hypertension (IH) is an emerging therapeutic option being used for the treatment of vasospasm in ‎aSAH. For patients with cerebral vasospasm (CVS) consequent to SAH, IH is implemented to increase systolic blood pressure (SBP) in order to optimize cerebral blood flow (CBF) and prevent delayed cerebral ischemia (DCI). Prophylactic use of IH has been associated with the development of vasospasm and cerebral ischemia in SAH patients. Various trials have defined several different parameters to help clinicians decide when to initiate IH in a SAH patient. However, there is insufficient evidence to recommend therapeutic IH in aSAH due to the possible serious complications like myocardial ischemia, development of posterior reversible encephalopathy syndrome (PRES), pulmonary edema, and even rupture of another unsecured aneurysm. This narrative review showed the favorable impact of IH therapy on aSAH patients; however, it is crucial to conduct further clinical and molecular experiments to shed more light on the effects of IH in aSAH.

Posterior Reversible Encephalopathy Syndrome as an Adverse Effect of Lenvatinib in a Patient with Papillary Thyroid Carcinoma: A Case Report

Posterior reversible encephalopathy syndrome (PRES) is an uncommon transient neuroradiological phenomenon that develops vasogenic cerebral edema and could be caused by some pharmacological agents, such as molecular-specific target agents. Lenvatinib belongs to the tyrosine kinase inhibitors and was approved in 2015 for progressive locally advanced or metastatic thyroid cancer refractory to radioactive iodine (I-131) treatment. Herein, we present the case of a 65-year-old woman who, while receiving treatment with lenvatinib for radioiodine-refractory metastatic papillary thyroid carcinoma, developed PRES without hypertension at the initial evaluation. Her clinical and radiological findings improved after withdrawing from the mentioned therapy, and later it was possible to re-incorporate lower doses of the medication, as described in the other three case reports found in the worldwide medical literature. The recognition of this entity is essential to timely suspend the drug and avoid greater comorbidity. This is the first paper reporting this kind of adverse event using lenvatinib in a Hispanic population.

Cerebral Amyloid Angiopathy-Related Inflammation (CAA-ri): Presentation at an Unusual Age

Cerebral amyloid angiopathy-related inflammation (CAA-ri) is a less common but aggressive manifestation of CAA caused by an autoimmune reaction to the amyloid-beta (Ab) deposits in affected vessels. Here, we report the case of a 96-year-old patient, with a history of Alzheimer's disease, who presented to our hospital due to a sudden onset of high-intensity holocranial headache followed by dysarthria, left hemiplegia, and gaze deviation to the right. MRI of the brain was performed, which revealed a heterogeneous hypointense signal on the right frontal T2 and fluid-attenuated inversion recovery (FLAIR) sequences, with an asymmetric hyperintensity surrounding the lesion compatible with perilesional vasogenic edema. Given the clinical radiographic findings, a diagnosis of CAA-ri was established and immediate treatment with intravenous corticosteroids was started, with a rapid clinical response and remarkable improvement in follow-up neuroimaging.

Fever, Cognitive Decline, and Multifocal T2 Hyperintensities on Brain MRI: A Case Report of Cytokine Release Syndrome

Cytokine release syndrome (CRS) is a systemic inflammatory response characterized by fever, constitutional symptoms, and multiorgan dysfunction. While most commonly associated with immunotherapy, CRS can also be incited by infections or drugs. This case details the presentation and evaluation of a 71-year-old woman with a history of primary myelofibrosis and breast cancer who presented with acute onset of altered mental status. Initial vital signs were notable for severe hypertension, tachycardia, and fever. The patient was alert and oriented only to self, with little verbal output, and spontaneously moving all extremities. The patient had a submandibular gland abscess that had been diagnosed prior to presentation via a computed tomography scan of the neck. A comprehensive analysis, including blood tests, cerebrospinal fluid (CSF) analysis, electroencephalogram (EEG), and neuroimaging, was performed. Severe leukocytosis was noted and brain MRI demonstrated scattered areas of diffusion restriction and diffuse T2 white matter hyperintensities. Serial imaging demonstrated the progression of T2 hyperintensities. Ultimately, CRS was the most likely diagnosis. In this case, the inciting event was likely an infectious etiology, suspected to be the submandibular gland abscess that was present at the time of admission. It is vital to have a high index of suspicion for CRS in patients with recent infection, drug exposure, or immune dysregulation.

Posterior Reversible Leucoencephalopathy Syndrome: Case Series, Comments, and Diagnostic Dilemma

PURPOSE OF REVIEW

To report a series of patients with clinical and radiological features suggestive of posterior reversible encephalopathy syndrome (PRES) related to diverse etiologies emphasizing its pathophysiological basis.

RECENT FINDINGS

Posterior reversible encephalopathy syndrome (PRES) may present with a broad range of clinical symptoms from headache and visual disturbances to seizure and altered mentation. Typical imaging findings include posterior-circulation predominant vasogenic edema. Although there are many well-documented diseases associated with PRES, the exact pathophysiologic mechanism has yet to be fully elucidated. Generally accepted theories revolve around disruption of the blood-brain barrier secondary to elevated intracranial pressures or endothelial injury induced by ischemia from a vasoconstrictive response to rising blood pressure or toxins/cytokines. 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. 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. Reversible cerebral vasoconstriction syndromes (RCVS) and primary angiitis of the central nervous system (PACNS) are invariably considered in the differential diagnosis of new cerebral arteriopathies. Recurrent thunderclap headache (TCH), and single TCH combined with either normal neuroimaging, border zone infarcts, or vasogenic edema, have 100% positive predictive value for diagnosing RCVS or RCVS-spectrum disorders. Diagnosis of PRES in some circumstances can be challenging and structural imaging may not be sufficient to distinguish it from other differential diagnostic considerations like ADEM. Advanced imaging techniques, such as MR spectroscopy or positron emission tomography (PET) can provide additional information to determine the diagnosis. Such techniques are more useful to understand the underlying vasculopathic changes in PRES and may answer some of the unresolved controversies in pathophysiology of this complex disease. Eight patients with PRES resulting from different etiologies varying from pre-eclampsia/eclampsia, post-partum headache with seizures, neuropsychiatric systemic lupus erythematosus, snake bite, Dengue fever with encephalopathy, alcoholic liver cirrhosis with hepatic encephalopathy, and lastly reversible cerebral vasoconstriction syndrome (RCVS). Additionally, a diagnostic dilemma between PRES and acute disseminated encephalomyelitis (ADEM) was notable in one patient. Some of these patients did not have or only very transiently had arterial hypertension. PRES may underlie the clinical conundrum of headache, confusion, altered sensorium, seizures, and visual impairment. PRES need not necessarily be always associated with high blood pressure. Imaging findings may also be variable. Both clinicians and radiologists need to familiarize themselves with such variabilities.

Alcohol-related posterior reversible encephalopathy syndrome: a case report of a patient managed with a benzodiazepine-sparing regimen for alcohol withdrawal

We report a case of posterior reversible encephalopathy syndrome (PRES) during treatment for alcohol withdrawal syndrome with gabapentin and clonidine. The patient developed severe hypertension, confusion and tremor, culminating in bilateral vision loss and a seizure. Imaging revealed posterior cerebral edema. Treatment with benzodiazepines, antihypertensives, and anti-seizure medications led to resolution. One year later, imaging showed resolution of the findings. We review the associated literature and propose the recognition of a PRES sub-entity, Alcohol-Related PRES (ARPRES), which can appear in the setting of alcohol withdrawal syndrome, chronic alcohol use, and acute alcohol intoxication, with or without hypertension.

Eclampsia-Associated Posterior Reversible Encephalopathy Syndrome (PRES) Complicated by Intracerebral Hemorrhage: A Case Report and Review of Management Strategies

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological syndrome that is being increasingly recognized due to the advancements in brain imaging, specifically MRI. This syndrome is characterized by symptoms including, but not limited to, headache, seizures, altered mental status, and vision loss. There are various underlying etiologies which lead to PRES occurrence; the etiology of focus in this report is preeclampsia and eclampsia. PRES is associated with the development of various types of intracerebral hemorrhage which can lead to detrimental and even fatal consequences in a patient. In our case, a 22-year-old female developed PRES within one week postpartum, which was complicated by parenchymal hemorrhage development in the fronto-parietal lobe. MRI findings were characteristic for PRES with multiple subcortical hyperintensities within the bilateral occipital lobe. The patient improved symptomatically after management with intravenous fluids, antihypertensives, antiepileptics, and antibiotics. This report aims to explore the association between preeclampsia/eclampsia (PE/E) and PRES and underscore the importance of prompt diagnosis and treatment, which can lead to recovery within a week and significantly reduce morbidity and mortality.

Nivolumab-Induced PRES (Posterior Reversible Encephalopathy Syndrome)

PRES (posterior reversible encephalopathy syndrome) is a clinical-radiographic syndrome comprising clinical symptoms, including headache, vision abnormalities, nausea/vomiting, seizures, and posterior cerebral white matter edema seen as radiographic changes. Commonly, PRES is known to occur with severely elevated blood pressure, or eclampsia. However, in recent times, increasing cases of PRES have been observed in patients being treated with immunotherapy or chemotherapy. Nivolumab is an immunotherapy used in the treatment of various cancers and is an increasingly identified cause of PRES. A few case reports exist in the literature. We report a case of nivolumab-induced PRES.

Posterior reversible encephalopathy syndrome: A rare complication of rituximab therapy in rheumatoid arthritis

Rituximab, a murine-human chimeric monoclonal antibody targeting CD20-positive B lymphocytes, has established itself as an effective and relatively safe biologic therapy for patients with refractory rheumatoid arthritis. Most common side effects associated with its use include infusion related reactions and cytopenia. Rare adverse effects such as progressive multifocal leukoencephalopathy and posterior reversible encephalopathy syndrome (PRES) have also been reported. Diagnosis of PRES following rituximab treatment requires a high index of suspicion correlated with clinical and radiological features in individuals at risk. Early diagnosis and prompt treatment is associated with a favorable prognosis. We present a case of a young man who developed PRES following rituximab administration on account of active rheumatoid arthritis. Timely diagnosis and prompt treatment ensured his uneventful recovery without residual neurological deficit.

A Case of Posterior Reversible Encephalopathy Due to Takotsubo Cardiomyopathy Triggered by Aerophobia

A 37-year-old woman, previously known to have severe airplane phobia, develops panic disorder-like symptoms in the second hour of the flight. After a while, panic disorder was accompanied by chest pain and syncope. An ECG showed no abnormalities. Transthoracic echocardiogram demonstrated decreased left ventricular ejection fraction (EF: 30), large apical akinesis, and characteristic regional wall motion abnormalities involving the middle and apical segments of the left ventricle. Findings were consistent with Takotsubo cardiomyopathy. But in the emergency department, Brain Diffusion MRI showed cortical and subcortical vasogenic edema in the posterior regions, predominantly on the left, bilaterally, compatible with posterior reversible encephalopathy. This case highlights the Takotsubo cardiomyopathy-related posterior reversible encephalopathy syndrome (PRES) syndrome and managing the disease.

Posterior reversible encephalopathy syndrome: A conundrum of nephrotic syndrome complication

Nephrotic syndrome is a kidney disease with proteinuria, hypoalbuminemia, and edema. One rare, potentially life-threatening complication of nephrotic syndrome is posterior reversible encephalopathy syndrome (PRES). Sudden episodes of neurological symptoms such as headache, confusion, seizures, or focal neurological deficits with radiological findings of white matter abnormalities in the parietal and occipital lobes characterize it. Multiple factors predispose an individual with nephrotic syndrome to PRES, such as uncontrolled hypertension, reduced serum albumin levels, administration of drugs (cyclosporine, tacrolimus), anasarca, disturbed body fluid status and renal insufficiency. Here, we report a case of PRES in a seven-year-old girl with nephrotic syndrome who presented with high blood pressure while admitted to the ward. Her neurological symptom rapidly recovered after the control of hypertension. Recurrence of acute severe hypertension, nephrotic state (edema/ hypoalbuminemia), and renal insufficiency may lead to recurrent PRES. Thus, early treatment of trigger factors, especially of hypertension, is vital to reduce the episodes of PRES.

Preeclampsia: Recent Advances in Predicting, Preventing, and Managing the Maternal and Fetal Life-Threatening Condition

Preeclampsia accounts for one of the most common documented gestational complications, with a prevalence of approximately 2 to 15% of all pregnancies. Defined as gestational hypertension after 20 weeks of pregnancy and coexisting proteinuria or generalized edema, and certain forms of organ damage, it is life-threatening for both the mother and the fetus, in terms of increasing the rate of mortality and morbidity. Preeclamptic pregnancies are strongly associated with significantly higher medical costs. The maternal costs are related to the extra utility of the healthcare system, more resources used during hospitalization, and likely more surgical spending due to an elevated rate of cesarean deliveries. The infant costs also contribute to a large percentage of the expenses as the babies are prone to preterm deliveries and relevant or causative adverse events. Preeclampsia imposes a considerable financial burden on our societies. It is important for healthcare providers and policy-makers to recognize this phenomenon and allocate enough economic budgets and medical and social resources accordingly. The true cellular and molecular mechanisms underlying preeclampsia remain largely unexplained, which is assumed to be a two-stage process of impaired uteroplacental perfusion with or without prior defective trophoblast invasion (stage 1), followed by general endothelial dysfunction and vascular inflammation that lead to systemic organ damages (stage 2). Risk factors for preeclampsia including race, advanced maternal age, obesity, nulliparity, multi-fetal pregnancy, and co-existing medical disorders, can serve as warnings or markers that call for enhanced surveillance of maternal and fetal well-being. Doppler ultrasonography and biomarkers including the mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI), and serum pregnancy-associated plasma protein A (PAPP-A) can be used for the prediction of preeclampsia. For women perceived as high-risk individuals for developing preeclampsia, the administration of low-dose aspirin on a daily basis since early pregnancy has proven to be the most effective way to prevent preeclampsia. For preeclamptic females, relevant information, counseling, and suggestions should be provided to facilitate timely intervention or specialty referral. In pregnancies complicated with preeclampsia, closer monitoring and antepartum surveillance including the Doppler ultrasound blood flow study, biophysical profile, non-stress test, and oxytocin challenge test can be arranged. If the results are unfavorable, early intervention and aggressive therapy should be considered. Affected females should have access to higher levels of obstetric units and neonatal institutes. Before, during, and after delivery, monitoring and preparation should be intensified for affected gravidas to avoid serious complications of preeclampsia. In severe cases, delivery of the fetus and the placenta is the ultimate solution to treat preeclampsia. The current review is a summary of recent advances regarding the knowledge of preeclampsia. However, the detailed etiology, pathophysiology, and effect of preeclampsia seem complicated, and further research to address the primary etiology and pathophysiology underlying the clinical manifestations and outcomes is warranted.

Posterior Reversible Encephalopathy Syndrome in a Male With Polysubstance Abuse: A Case Report

Posterior reversible encephalopathy syndrome (PRES) is a neurologic disorder with multiple etiologies. The signs and symptoms of PRES are non-specific, making the differential diagnosis broad. Although PRES is suspected clinically, a diagnosis requires characteristic findings on imaging. In patients with undiagnosed PRES, the coexistence of substance abuse can divert the care provider from pursuing imaging studies, leading to a missed diagnosis. We describe the case of a 51-year-old male who presented with altered mental status and was diagnosed with PRES despite having a positive urine drug screen.

Ustekinumab-Associated Posterior Reversible Encephalopathy Syndrome in a Patient With Crohn's Disease

Ustekinumab is a common biologic therapy for the treatment of inflammatory bowel disease. Posterior reversible encephalopathy syndrome (PRES) is an uncommon condition consisting of a constellation of neurologic findings and characteristic findings on imaging. The association between ustekinumab and PRES is not well defined. We present a case of PRES in a patient with Crohn's disease on ustekinumab and a brief review of the literature. Clinicians should be aware of this rare complication with high morbidity in patients with inflammatory bowel disease on ustekinumab and be able to recognize clinical symptoms.

Characteristics and predictors of ICU-mortality in critically ill patients with hyperlactatemia requiring CRRT: A retrospective cohort study

BACKGROUND

Hyperlactatemia is a common complication in critically ill patients with high morbidity and mortality. Hyperlactatemia patients who require continuous renal replacement therapy (CRRT) constitute a subgroup with increased mortality risk. The clinical significance of serum lactate in these patients was not well understood and clearance of lactate using CRRT shown no survival benefits. The aim of this study is to investigate the incidence and non-lactate risk factors for ICU mortality in hyperlactatemia patients who underwent CRRT.

METHOD

Hyperlactatemia patients with a serum lactate level >2 μmol/L who underwent CRRT between January, 2014 and May, 2021 were retrospectively investigated. Demographic characteristics and clinical data were collected from the electronic medical record system. The primary endpoint was predictors for ICU mortality which were identified by using multivariate logistic regression analysis.

RESULTS

A total of 178 eligible patients were finally included with a mean age of 56.6 ± 17.9 years and a median APACHE II score of 18 (IQR (14-22)). The multivariate regression results showed that male gender (OR 0.55 (95%CI 0.27-1.12), p = 0.1), mechanical ventilation (OR 2.60 (95%CI 1.27-5.34), p = 0.008), history of hypertension (OR 2.40 (95%CI 1.12-5.14), p = 0.02), SOFA score (OR 1.16 (95%CI 1.05-1.28), p = 0.002), AST (OR 1.0005 (95%CI 0.99-1.001), p = 0.08), and PT (OR 1.08 (95%CI 0.99-1.17), p = 0.06) were independently associated with ICU mortality. After adjusting for age, illness severity (APACHE II score), and serum lactate level, the statistical significances of SOFA score (OR 1.16 (95%CI 1.04-1.29), p = 0.005), hypertension (OR 2.25 (95%CI 1.02-4.95), p = 0.04), and mechanical ventilation (OR 2.54 (95%CI 1.22-5.25), p = 0.01) were not affected. The overall ICU mortality was 58.4% (104/178).

CONCLUSION

The hyperlactatemia patients who underwent CRRT were at increased ICU mortality. Gender, AST, PT, SOFA score, history of hypertension, and mechanical ventilation were independent predictors for ICU mortality. Future studies with prospectively design, large sample size, and subgroup analyses are warranted to validate these findings.

Uremic encephalopathy: A definite diagnosis by magnetic resonance imaging?

The aim of this study was to investigate the magnetic resonance imaging (MRI) findings for the diagnose uremic encephalopathy and describe the usefulness of MRI findings in the ultimate diagnosis of uremic encephalopathy (UE). A total of 20 patients with uremic encephalopathy admitted to the hospital were evaluated in this prospective study. The clinical manifestations, laboratory and MRI imaging findings, demographic information, and clinical outcome were analyzed for each patient. We observed that the 20 prospectively reviewed patients with UE had no involvement of the basal ganglia or the lentiform fork sign (LFS). However, two-thirds of the patients had white matter involvement, and 80% of the subjects had cerebral or cortical atrophy. The arterial blood gas (ABG) analysis revealed that 50% of the patients suffered from metabolic acidosis (n=10). The results of the present study demonstrated that although the observation of Lentiform Fork Sign and Basal Ganglia involvement in MRI of UE patients is a specific finding the absence of which does not rule out UE. Thus, simultaneous examination of clinical manifestation and laboratory test analyses, along with imaging findings, should also be taken into account.

Posterior Reversible Encephalopathy Syndrome Onset Within 24 Hours Following Moderna mRNA Booster COVID-19 Vaccination: Vaccine Adverse Event Vs. Hypertension?

We present a case of a female who presented with the acute onset of neurological changes within 24 hours of receiving her third, or booster, dose of the mRNA Moderna (Cambridge, Massachusetts) coronavirus disease 2019 (COVID-19) vaccination. Her clinicoradiological findings were most consistent with posterior reversible encephalopathy syndrome (PRES). Although PRES has been reported with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, this raised suspicion of a possible vaccine-induced PRES with her only confounder being hypertension managed with a beta-blocker. Extensive workup for other entities associated with PRES, including infection, autoimmune, paraneoplastic syndrome, and alcohol were unrevealing. Thus far, there have not been any reports of PRES post mRNA vaccination. We encourage providers to report similar cases with neurological manifestations post mRNA vaccination to the vaccine adverse event reporting system (VAERS). Timely diagnosis and treatment of PRES may help minimize any irreversible neurological sequelae.

Etiology and clinical characteristics of pediatric non-neoplastic posterior reversible encephalopathy: systematic review

Although more commonly seen in adult population, posterior reversible encephalopathy syndrome (PRES) can also be observed in pediatric patients. The etiopathogenesis of pediatric PRES is poorly understood, and the available evidence comes mostly from childhood cancer. Analysis of the sociodemographic and clinical characteristics of the different noncancer-related types can improve the understanding of pediatric PRES.

Atypical Posterior Reversible Encephalopathy Syndrome in Intraorbital Lymphoma after Tumor Biopsy: An Illustrative Case

Introduction  A 63-year-old male presented with visual loss and left eye proptosis. Magnetic resonance imaging revealed a left orbital tumor, measuring 1.4 cm × 0.9 cm. The patient underwent left frontotemporal craniotomy to perform a biopsy of the tumor. During the postoperative period, the patient developed the first episode of a generalized tonic-clonic seizure. Case Summary  Computed tomography of the brain showed hypodensity of the bilateral basal ganglia and thalami with associated edematous white matter hypodensity of bilateral temporo-occipital lobes compatible with atypical posterior reversible encephalopathy syndrome (PRES). The patient received antiepileptic medication and was observed for clinical seizure. One week later, computed tomography of the brain showed the reversible process of PRES. The pathology report revealed diffuse large B cell lymphoma. Following pathological diagnosis, the patient received treatment with whole-brain radiotherapy. Conclusion  This is the first reported case of atypical PRES associated with orbital lymphoma following craniotomy for the purpose of tumor biopsy. Early detection as well as seizure and blood pressure control, is essential for the proper treatment of PRES.

Posterior reversible encephalopathy syndrome due to unilateral renal artery stenosis: A case report

A tricenarian female with a past medical history of status epilepticus secondary to posterior reversible encephalopathy syndrome (PRES) of unknown etiology presented with a 2-week history of double vision, dizziness, elevated blood pressure, and altered mental status. On hospital day 2, she experienced status epilepticus, during which her blood pressure rose to 240/160 from her baseline of around 140/90. The patient was subsequently intubated for airway protection and transferred to the intensive care unit, where she was started on a nicardipine drip. Due to her history of thrombotic microangiopathy, empiric treatment with plasma exchange and prednisone was started but discontinued when ADAMTS13 came back negative. Urine metanephrines also were found to be negative. Computed tomography angiography of the abdomen showed left renal artery stenosis and stent was placed. Remarkably, over the coming days, her blood pressure normalized, and her neurologic symptoms significantly improved. As a result, antihypertensive medications were titrated down, and the patient was finally provided with a cause of her repetitive, life-threatening episodes of PRES.

Atypical posterior reversible encephalopathy syndrome associated with Lenvatinib therapy in a patient with metastatic thyroid cancer-A case report

Posterior reversible encephalopathy syndrome (PRES) is a disorder of reversible subcortical vasogenic brain oedema in patients with acute neurological symptoms. Drug‐induced PRES has been described with the usage of drugs that target receptors regulating vascular permeability or altering immune response. Lenvatinib is a receptor tyrosine kinase inhibitor that inhibits the kinase activities of vascular endothelial growth factor receptors implicated in cancer progression in addition to their normal cellular functions. The oedema associated with PRES is a consequence of disruption of cerebral blood flow autoregulation. Herein, we present a case of a 77‐year‐old lady who was on treatment with Lenvatinib for metastatic thyroid cancer who subsequently developed PRES. Her clinical and radiological findings improved after discontinuing Lenvatinib and the patient was switched to a different drug and remains asymptomatic on the same. This is the first such report of atypical findings of PRES in a patient on Lenvatinib therapy. Recognition of this entity is crucial for timely withdrawal of the drug and prevent further morbidity and mortality.

Blood-brain barrier dysfunction in L-ornithine induced acute pancreatitis in rats and the direct effect of L-ornithine on cultured brain endothelial cells

Background

In severe acute pancreatitis (AP) the CNS is affected manifesting in neurological symptoms. Earlier research from our laboratory showed blood–brain barrier (BBB) permeability elevation in a taurocholate-induced AP model. Here we aimed to further explore BBB changes in AP using a different, non-invasive in vivo model induced by l-ornithine. Our goal was also to identify whether l-ornithine, a cationic amino acid, has a direct effect on brain endothelial cells in vitro contributing to the observed BBB changes.

Methods

AP was induced in rats by the intraperitoneal administration of l-ornithine-HCl. Vessel permeability and the gene expression of the primary transporter of l-ornithine, cationic amino acid transporter-1 (Cat-1) in the brain cortex, pancreas, liver and lung were determined. Ultrastructural changes were followed by transmission electron microscopy. The direct effect of l-ornithine was tested on primary rat brain endothelial cells and a triple co-culture model of the BBB. Viability and barrier integrity, including permeability and TEER, nitrogen monoxide (NO) and reactive oxygen species (ROS) production and NF-κB translocation were measured. Fluorescent staining for claudin-5, occludin, ZO-1, β-catenin, cell adhesion molecules Icam-1 and Vcam-1 and mitochondria was performed. Cell surface charge was measured by laser Doppler velocimetry.

Results

In the l-ornithine-induced AP model vessel permeability for fluorescein and Cat-1 expression levels were elevated in the brain cortex and pancreas. On the ultrastructural level surface glycocalyx and mitochondrial damage, tight junction and basal membrane alterations, and glial edema were observed. l-ornithine decreased cell impedance and elevated the BBB model permeability in vitro. Discontinuity in the surface glycocalyx labeling and immunostaining of junctional proteins, cytoplasmic redistribution of ZO-1 and β-catenin, and elevation of Vcam-1 expression were measured. ROS production was increased and mitochondrial network was damaged without NF-κB, NO production or mitochondrial membrane potential alterations. Similar ultrastructural changes were seen in l-ornithine treated brain endothelial cells as in vivo. The basal negative zeta potential of brain endothelial cells became more positive after l-ornithine treatment.

Conclusion

We demonstrated BBB damage in the l-ornithine-induced rat AP model suggesting a general, AP model independent effect. l-ornithine induced oxidative stress, decreased barrier integrity and altered BBB morphology in a culture BBB model. These data suggest a direct effect of the cationic l-ornithine on brain endothelium. Endothelial surface glycocalyx injury was revealed both in vivo and in vitro, as an additional novel component of the BBB-related pathological changes in AP.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12987-022-00308-0.

Initial Normotensive Presentation of a Primigravida With Posterior Reversible Encephalopathy Syndrome: A Case Report

Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiological entity characterized by variable neurological manifestations, primarily caused by pathophysiological changes related to cerebral autoregulation that result in radiologically evident vasogenic edema. It is usually associated with hypertensive states, but it is not exclusively related to those. 

A healthy 18-year-old primigravid woman with no proteinuria or hypertension on admission presented with normotensive PRES. She had an intense diffuse headache that preceded a generalized tonic-clonic seizure. Her neurological status deteriorated, and hypertension was detected afterward. Brain imaging revealed bilateral vasogenic edema in the occipital region. Magnesium sulfate and antihypertensive medications were administered. A cesarean section was performed, and her neurological symptoms subsequently improved, leading to discharge with no complications. 

This case highlights the importance of suspecting PRES in pregnant patients even in the absence of preeclampsia.

The association of posterior reversible encephalopathy syndrome with COVID-19: A systematic review

The rise in Coronavirus disease 2019 (COVID-19) cases is revealing its unique neurological manifestations. In light of the emerging evidence, a possible association with Posterior Reversible Encephalopathy Syndrome (PRES) is being consistently reported. We conducted a systematic literature search on four databases namely Pubmed/MEDLINE, Cochrane, Google Scholar, and Science Direct. After rigorous screening as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a total of 34 articles describing 56 cases were selected as a part of this review. The mean age of the patients was 56.6 ± 15.3 years. The most common clinical presentation of PRES was altered mental status (58.9%) followed by seizures (46.4%) and visual disturbances (23.2%) while hypertension and diabetes mellitus were the most commonly reported comorbidities. 91.1% of the cases reported Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) findings suggestive of PRES in the brain. Symptomatic management was employed in most of the cases to control seizures and blood pressure, and 44 patients (78.5%) fully or partially recovered. The most likely underlying mechanism involves COVID-19 mediated cytokine storm syndrome that leads to endothelial damage and increased permeability of the cerebral vessels, thus causing the characteristic edema of PRES. High neuronal and glial cell expression of Angiotensin Converting Enzyme-2 (ACE-2) receptors also suggests the possibility of direct viral damage. Since timely diagnosis and treatment reports a good prognosis, it is vital for physicians and neurologists to be well-versed with this association.

Acute posterior reversible encephalopathy syndrome (PRES) in setting of interferon-beta use: case presentation with reduction of edema in 72 h after cessation of interferon-beta therapy with sub-clinical inflammation

Background

Posterior reversible encephalopathy syndrome (PRES) represents a transient change in mental status with associated vasogenic edema of cortical and subcortical brain structures. It is often attributed to multifactorial etiology including hypertension and altered hemodynamics and disruption of vessel integrity. Patients with autoimmune disease and certain immune modulator therapies are at greater risk.

Case presentation

A 54-year-old female with past medical history of well-controlled multiple sclerosis on interferon-beta since 2013, presented with witnessed tonic colonic seizure. She also was noted to demonstrate left gaze deviation and left-sided hemiparesis. MRI fluid-attenuated inversion recovery sequence showed hyperintensity of the subcortical U fibers, concentrated in the occipital, parietal lobes and frontal lobes. Systolic blood pressure was 160 mmHg on arrival. The patient was started on seizure prophylxis and Interferon beta was discontinued. The patient’s mentation, seizures and hemiapresis significantly improved in next 72 h with tight blood pressure control, and had notble improvement on MRI imaging and inflammatory markers. Lumbar puncture CSF results were devoid of infectious and autoimmune pathology.

Conclusions

A middle-aged female with multiple sclerosis who was on chronic IFN-beta presented to the emergency room with a witnessed tonic-clonic seizure, with MRI T2 FLAIR imaging consistent with PRES. She had notable clinical improvement with decreased edema on imaging and improved inflammatory markers 72 h after cessation of IFN-beta therapy.

When Brain Biopsy Solves the Dilemma of Diagnosing Atypical Cerebral Amyoild Angiopathy: A Case Report

Patient: Female, 67-year-old

Final Diagnosis: Cerebral amyloid angiopathy related inflammation

Symptoms: Headache, Behavioral Changes • Seizures

Medication: —

Clinical Procedure: —

Specialty: Neurology • Neurosurgery

Eclampsia and posterior reversible encephalopathy syndrome (PRES): A retrospective review of risk factors and outcomes

Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiological entity initially described in 1996. PRES frequently develops in patients with preeclampsia and eclampsia. There is not much literature on risk factors causing PRES in pregnant patients with eclampsia. This study aimed to determine the incidence of PRES in eclampsia, its association with pregnancy, risk factors, and maternal and perinatal outcomes.

Patients and methods: All patients who were admitted with eclampsia and developed PRES in an intensive care unit of a tertiary medical facility between 1997 and 2017 were included in the study. Patients’ demographics, pregnancy and gestational data, treatment mode, and outcomes were retrospectively obtained from their medical charts/files. Data were entered using SPSS program version 23. Chi-square test was used to compare the variables, and a p value of < 0.05 was considered statistically significant.

Results: A total of 151 patients were admitted during the study period, and 25 developed PRES. The diagnosis was common in patients older than 25 years. Eclampsia patients who developed PRES were without any pregnancy-associated comorbidities (p < 0.08). At the time of diagnosis, their gestational age was more than 36 weeks, which was significant (p < 0.04). Incidence was significantly higher in patients presenting with eclampsia and had recurrent seizures (p < 0.01 and 0.002, respectively). Its incidence was significantly higher in postpartum eclampsia patients (p < 0.01). It was also significantly higher in patients who had cesarean section and hypertension treated with labetalol (p < 0.001 and 0.02, respectively). Overall, the maternal mortality rate of eclampsia patients complicated with PRES was 4% in our population.

Conclusion: Of eclampsia patients, 16% developed PRES, which is on the lower side than the reviewed literature (10%–90%). Eclampsia on presentation, recurrent seizures, postpartum eclampsia, cesarean delivery, and labetalol use were associated with increased risk of PRES development.

Posterior Reversible Encephalopathy Syndrome Associated With Coarctation of the Aorta

Posterior reversible encephalopathy syndrome (PRES) is a neurological syndrome characterized by acute encephalopathy due to different medical conditions. This syndrome may present with a wide spectrum of neurological symptoms including headache, disorders of consciousness, visual changes, seizures, and focal neurological deficits, in addition to nonspecific symptoms such as nausea and vomiting. Neuroimaging findings of bilateral cortical and subcortical brain edema involving the parieto-occipital regions are a hallmark of the disease. We present a case report of an eight-year-old boy who complained of headache and vomiting for 20 days until the discovery of severely high blood pressure (BP). He developed altered mental status, hemiplegia, loss of visual field, and seizure, requiring transfer to the intensive care unit. Magnetic resonance imaging of the brain showed hyperintense signals in the bilateral cortical and subcortical parieto-occipital areas. The BP measure of the extremities recognized a hypertensive upper extremity and normotensive lower extremity, and an MRI angiography was consistent with coarctation of the aorta (CoA). The fundoscopic exam showed no abnormalities. The diagnosis was kept as PRES secondary to a hypertensive emergency. Later, stenting of the aorta was performed, improving overall symptoms leaving a sequel loss of peripheral vision.

Unusual Presentation of a Posterior Reversible Encephalopathy Syndrome With Brainstem Involvement and Subarachnoid Haemorrhage

Posterior reversible encephalopathy syndrome is an increasingly recognized disorder characterized by a headache, visual disturbances, and seizures. It is a reversible neurotoxic state, with multiple risk factors in which endothelial injury and compromised brain perfusion are the common characteristics. Diagnosis is usually made by cerebral magnetic resonance imaging that typically shows early-stage bilateral symmetrical parieto-occipital hyperintensities on T2 and fluid-attenuated inversion recovery (FLAIR) sequences. However, other locations have been described where the disease may appear less frequently. We describe the case of a 62-year-old man, with a medical history of hypertension, who presented with anisocoria with mydriatic non-reactive pupil and ptosis of the left eye. CT head showed a slightly hypodense brainstem, in relation to vasogenic edema. This was confirmed with magnetic resonance imaging. The angiography did not identify cerebral artery aneurysms. The symptoms and radiological findings were almost completely reversible after improving the patient's blood pressure. This case highlights a rare single presentation of posterior reversible encephalopathy syndrome associated with subarachnoid hemorrhage. A high index of suspicion, careful examination, and exploration with imaging techniques were essential to reach this diagnosis.

Rapid clinical recovery of posterior reversible encephalopathy syndrome in two cases of IgA nephropathy disease and nephrotic syndrome type 9 post-renal transplant

Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiological syndrome often associated with immunosuppressant drug use, renal disease, and eclampsia and characterized by parieto-occipital vasogenic edema that usually resolves within days. Globally and in the settings of renal transplant, literature concerning PRES is very scattered. In this report, we provide two cases, one diagnosed with IgA nephropathy and another with nephrotic syndrome type 9 that developed episodes of tonic-clonic seizure immediately after renal transplant in case 1 and four days post-transplant in case 2. The two patients had a history of hypertension, renal disease, corticosteroid and immunosuppressant drug use. Neuro-imaging showed typical vasogenic edema involving the parieto-occipital areas. Therefore, the clinical-radiological presentation confirmed the diagnosis of PRES in both cases. Also, rapid neurologic recovery was witnessed upon administration of anti-epileptic and anti-hypertensive medications. Non-discontinuation of immunosuppressants, steroids, early symptomatic management, and blood pressure control are favorable factors that might explain the rapid recovery of these two patients.

Reversible contrast-induced encephalopathy after coil embolization of epistaxis

A 37-year-old woman (35 weeks pregnant) was admitted to a local hospital due to severe epistaxis resulting in shock and the need for emergency cesarean section. After failure to tamponade the bleeding, angiographic treatment was provided. After the procedure, she was admitted to the neurocritical intensive care unit and was confused and agitated, requiring sedation and endotracheal intubation. In the intensive care unit, diagnostic investigations included brain magnetic resonance imaging, lumbar puncture with viral panel, electroencephalogram, tests for autoimmunity, and hydroelectrolytic and metabolic evaluations. Magnetic resonance imaging showed a puntiform restricted diffusion area on the left corona radiata on diffusion weighted imaging and mild cortical posterior edema (without restricted diffusion), and an electroencephalogram showed moderate diffuse slow activity and fronto-temporal slow activity of the left hemisphere with associated scarce paroxysmal components. The other exams did not show any relevant alterations. Due to the temporal relationship, the clinical history and the magnetic resonance imaging results, a diagnosis of contrast-induced encephalopathy was made. After 2 days in the intensive care unit, sedation was withdrawn, the patient was extubated, and total neurological recovery was verified within the next 24 hours.

Tocilizumab-associated posterior reversible encephalopathy syndrome in giant-cell arteritis - case report

Backround

We describe one of the first cases of a Posterior reversible encephalopathy syndrome (PRES) under tocilizumab as treatment of Giant cell arteritis (GCA).

Case presentation

A 65-year-old female with known GCA and treatment with Tocilizumab (TCZ) developed a convulsive epileptic seizure for the first time. MRI was suggestive of PRES and an associated left sided occipital hemorrhage. Extensive high blood pressure values were not detected. The patient recovered within a week and no further seizures occurred under anticonvulsive medication.

Conclusion

PRES during the treatment with Tocilizumab hasn’t been described in GCA so far. There are single reports of an association between TCZ and PRES in other entities. Thus, a link between interleukin-6 and the integrity of the vasculature could be considered. The clinical consequence should be a stringent blood pressure monitoring in the ambulant setting of patients receiving TCZ.

Safety, Tolerability, and Pharmacokinetics of FAAH Inhibitor BIA 10-2474: A Double-Blind, Randomized, Placebo-Controlled Study in Healthy Volunteers

This study evaluated the safety, tolerability, pharmacokinetics, and pharmacodynamics of BIA 10‐2474, a fatty acid amide hydrolase (FAAH) inhibitor, after first administration to healthy male and female participants. Participants (n = 116) were recruited into this phase I, double‐blind, randomized, placebo‐controlled, single ascending dose and multiple ascending dose (10‐day) study. The primary outcome was the safety and tolerability of BIA 10‐2474. Secondary outcomes were pharmacokinetics of BIA 10‐2474 and pharmacodynamics, considering plasma concentrations of anandamide and three other fatty acid amides (FAAs) and leukocyte FAAH activity. Single oral doses of 0.25–100 mg and repeated oral doses of 2.5–50 mg were evaluated. BIA 10‐2474 was well tolerated up to 100 mg as a single dose and up to 20 mg once daily for 10 days. In the cohort receiving repeated administrations of 50 mg, there were central nervous system adverse events in five of six participants, one with fatal outcome, which led to early termination of the study. BIA 10‐2474 showed a linear relationship between dose and area under plasma concentration‐time curve (AUC) across the entire dose range and reached steady state within 5–6 days of administration, with an accumulation ratio, based on AUC_0–24h, of <2 on Day 10. BIA 10‐2474 was rapidly absorbed with a mean terminal elimination half‐life of 8–10 hours (Day 10). BIA 10‐2474 caused reversible, dose‐related increases in plasma FAAs. In conclusion, we propose that these data, as well as the additional data generated since the clinical trial was stopped, do not provide a complete mechanistic explanation for the tragic fatality.

Intensive Care and Treatment of Severe Guillain-Barré Syndrome

Guillain–Barré syndrome (GBS) is an acute polyneuropathy mostly characterized by acute flaccid paralysis with or without sensory/autonomous nerve dysfunction. Current immuno therapies including intravenous immunoglobulin (IVIg), plasma exchange (PE), and newly developed biological drugs benefit patients by alleviating hyperreactive immune responses. Up to 30% of patients develop respiratory failure during hospitalization and require mechanical ventilation and intensive care. Immunotherapies, mechanical ventilation, supportive care, and complication management during the intensive care unit (ICU) stay are equally emphasized. The most important aspect of intensive care and treatment of severe GBS, that is, mechanical ventilation, has been extensively reviewed elsewhere. In contrast to immunotherapies, care and treatment of GBS in the ICU setting are largely empirical. In this review, we intend to stress the importance of intensive care and treatment, other than mechanical ventilation in patients with severe GBS. We summarize the up-to-date knowledge of pharmacological therapies and ICU management of patients with severe GBS. We aim to answer some key clinical questions related to the management of severe GBS patients including but not limited to: Is IVIg better than PE or vice versa? Whether combinations of immune therapies benefit more? How about the emerging therapies promising for GBS? When to perform tracheal intubation or tracheostomy? How to provide multidisciplinary supportive care for severe cases? How to avert life-threatening complications in severe cases?

Posterior reversible encephalopathy syndrome associated with focal segmental glomerulosclerosis in a child

Posterior reversible encephalopathy syndrome (PRES) is a rare neurological entity, typically manifested by reversible oedema in the parieto-occipital lobes. It is usually associated with primary hypertension, autoimmune diseases and immunosuppressants. Renal disease is an uncommon cause of PRES. We report a case of an 11-year-old boy with STimulator of INterferon Genes-associated vasculopathy with onset in infancy complicated by focal segmental glomerulosclerosis leading to hypertension and PRES. The patient presented with headache, acute bilateral visual loss and hypertension. Brain MRI showed atypical features revealed by parieto-occipital haemorrhage. The child improved few days after antihypertensive therapy. Follow-up MRI showed complete resolution of haemorrhage. It is important to keep high index of suspicion for the uncommon association of PRES with underlying kidney disease with or without immunosuppressive agents. This combination is the first to our knowledge to be described in paediatric population. Atypical MRI features such as haemorrhage should be kept in mind. Symptoms are reversible within days to weeks with early diagnosis and treatment.

Rapid development of seizures and PRES in a COVID-19 patient

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Posterior reversible encephalopathy syndrome (PRES) with seizures should be suspected in patients with both COVID-19 and sickle cell disease.

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PRES with seizures might be one reason that patients with sickle cell disease have more severe COVID-19 infections.

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COVID-19, either directly or indirectly, may increase the risk of seizures in susceptible patients.

Neurological dysfunction has been noted in up to 36% of patients hospitalized with COVID-19, and a variety of mechanisms of neurological injury are possible. Here we report the rapid development of PRES and acute seizures in a patient with COVID-19 infection and sickle cell disease. The combination of COVID and sickle cell disease may raise the risk of PRES and could contribute to the higher mortality rate of COVID in patients with sickle cell disease.