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Vennapusa JR, Godavarthy PK, Garikipaty S, Kulkarni M, Chippa S. A (PRES)sing Matter: Two Cases of Posterior Reversible Encephalopathy Syndrome (PRES) in Pregnancy and Postpartum. Cureus 2025; 17:e79255. [PMID: 39974296 PMCID: PMC11835615 DOI: 10.7759/cureus.79255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2025] [Indexed: 02/21/2025] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a rare but serious neurological condition characterized by headaches, seizures, vision disturbances, and altered mental status. While it is commonly associated with hypertensive disorders, including preeclampsia and eclampsia, its exact pathophysiology remains unclear. We discuss the cases of two obstetric patients diagnosed with PRES: one in antepartum and the other during postpartum. Both exhibited severe hypertension and neurological symptoms, confirmed with neuroimaging, requiring urgent intervention with blood pressure control and seizure prophylaxis. Despite the reversible nature of PRES, a delay in diagnosis can lead to significant morbidity. These cases highlight the diverse clinical presentations of PRES and underscore the importance of early diagnosis and aggressive management to prevent complications. Through a discussion of potential underlying mechanisms, imaging findings, and treatment strategies, this report contributes to the growing understanding of PRES in pregnancy and postpartum, emphasizing the need for continued research and awareness.
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Affiliation(s)
- Jithin Reddy Vennapusa
- Department of Obstetrics and Gynaecology, Mamata Academy of Medical Sciences, Hyderabad, IND
| | | | - Shreya Garikipaty
- Department of Obstetrics and Gynaecology, Mamata Academy of Medical Sciences, Hyderabad, IND
| | - Maitri Kulkarni
- Department of Obstetrics and Gynaecology, Mamata Academy of Medical Sciences, Hyderabad, IND
| | - Sangeeta Chippa
- Department of Obstetrics and Gynaecology, Mamata Academy of Medical Sciences, Hyderabad, IND
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2
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Stadsholt S, Strauss A, Kintzel J, Schob S, Elolf E, Rutenkröger M, Strauss C, Scheller C, Leisz S, Prell J, Scheer M. Posterior reversible enzephalopathie syndrome (PRES) following vestibular schwannoma surgery - Case report and review of the current theories on pathophysiology of PRES. BRAIN & SPINE 2024; 5:104167. [PMID: 39898006 PMCID: PMC11786757 DOI: 10.1016/j.bas.2024.104167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Revised: 12/10/2024] [Accepted: 12/23/2024] [Indexed: 02/04/2025]
Abstract
Introduction Posterior reversible encephalopathy syndrome (PRES) is an acute form of encephalopathy. Main characteristic of this syndrome is the development of subcortical/cortical edema in the occipital lobes. The most common causes are diseases such as pre-eclampsia, autoimmune diseases, allogeneic stem cell transplantation and after treatment with immunosuppressants or cytostatics. However, PRES is also occasionally observed in connection with neurosurgical procedures, particularly in the posterior fossa in pediatric patients. Research question PRES in adults is extremely rare. After cranial surgery, the impaired consciousness caused by this syndrome may be misdiagnosed. Material and methods We present a rare case of PRES associated with vestibular schwannoma (VS) surgery and metronidazole use and have conducted a literature review. Results We found only two cases of PRES after surgery of a VS in the literature and three cases in connection with the administration of metronidazole. All cases involved women but the onset of symptoms was highly variable. The constellation of surgery and administration of metronidazole has not yet been described. Discussion and conclusion The purpose of this review is to raise awareness of a very rare complication such as PRES in this setting. Antibiotics should be chosen carefully after such an operation, as this syndrome can be triggered by certain substances.
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Affiliation(s)
- Solveig Stadsholt
- Department of Neurosurgery, University Hospital Halle, Ernst-Grube-Straße 40, 06120, Halle, Germany
| | - Aivars Strauss
- Department of Neurosurgery, University Hospital Halle, Ernst-Grube-Straße 40, 06120, Halle, Germany
| | - Jenny Kintzel
- Department of Neurosurgery, University Hospital Halle, Ernst-Grube-Straße 40, 06120, Halle, Germany
| | - Stefan Schob
- Department of Radiology, University Hospital Halle, Ernst-Grube-Straße 40, 06120, Halle, Germany
| | - Erck Elolf
- Department of Radiology, University Hospital Halle, Ernst-Grube-Straße 40, 06120, Halle, Germany
| | - Mareike Rutenkröger
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Christian Strauss
- Department of Neurosurgery, University Hospital Halle, Ernst-Grube-Straße 40, 06120, Halle, Germany
| | - Christian Scheller
- Department of Neurosurgery, University Hospital Halle, Ernst-Grube-Straße 40, 06120, Halle, Germany
| | - Sandra Leisz
- Department of Neurosurgery, University Hospital Halle, Ernst-Grube-Straße 40, 06120, Halle, Germany
| | - Julian Prell
- Department of Neurosurgery, University Hospital Halle, Ernst-Grube-Straße 40, 06120, Halle, Germany
| | - Maximilian Scheer
- Department of Neurosurgery, University Hospital Halle, Ernst-Grube-Straße 40, 06120, Halle, Germany
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Katwal S, Ghimire A, Bhusal A, Bajracharya A. Posterior reversible encephalopathy syndrome in postpartum patients with gestational hypertension: A case report emphasizing early recognition and management. Radiol Case Rep 2023; 18:4564-4568. [PMID: 37886729 PMCID: PMC10597782 DOI: 10.1016/j.radcr.2023.09.068] [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] [Received: 09/08/2023] [Revised: 09/20/2023] [Accepted: 09/22/2023] [Indexed: 10/28/2023] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a rare neuroradiological condition causing headaches, altered mental status, seizures, visual disturbances, and focal deficits. It is often associated with preeclampsia and eclampsia in pregnancy, but can also occur in patients with other medical conditions, such as hypertension, autoimmune diseases, renal dysfunction etc. This case report highlights the importance of recognizing PRES in postpartum patients with hypertension and the need for prompt diagnosis and management to prevent potential complications. A 30-year-old woman with gestational hypertension underwent scheduled induction of labor. After a successful delivery, she experienced a sudden headache but no other neurological symptoms. Imaging showed bilateral frontoparietal white matter edema, consistent with PRES. She was closely monitored, treated with analgesics, and improved within a week. The case highlights the rarity of PRES in postpartum patients without preeclampsia or eclampsia. It underscores the importance of considering PRES as a possible diagnosis in postpartum patients with hypertension, even in the absence of typical risk factors. Prompt control of blood pressure and careful monitoring are essential to ensure a positive outcome, as PRES can lead to life-threatening complications if not managed appropriately. The study highlights the importance of heightened awareness of PRES in postpartum patients with gestational hypertension. Early detection and timely management can improve prognosis, even in atypical cases. Healthcare professionals should be vigilant in assessing hypertension patients to diagnose and manage PRES, preventing neurological sequelae. Further research is needed to better understand PRES pathophysiology and risk factors in postpartum patients.
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Affiliation(s)
- Shailendra Katwal
- Department of Radiology, Dadeldhura Subregional Hospital, Dadeldhura, Nepal
| | - Aastha Ghimire
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Amrit Bhusal
- BP Koirala Institute of Health Sciences, Dharan, Koshi Province, Nepal
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Lin TC, Wang YC, Yu KJ, Hsieh PC. Is decompressive craniectomy necessary in malignant posterior reversible encephalopathy syndrome with brain edema caused uncal herniation? A case report of reversible coma without surgical decompression. Br J Neurosurg 2023; 37:1336-1338. [PMID: 33464131 DOI: 10.1080/02688697.2021.1873247] [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] [Received: 03/21/2019] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is considered a benign entity and is usually reversible with only medical management, but persistent neurologic deficits and disability or death can occur without adequate treatment. Favorable outcomes have been associated with surgical decompression in malignant-type PRES in which hemorrhagic transformation or brain stem compression has developed. CASE DESCRIPTION Here we report a case of malignant PRES in a 61-year-old female of Asian descent in which the disease rapidly progressed to coma and a near-fatal condition with uncal herniation caused by severe brain edema; however, this patient achieved a dramatic recovery without surgical decompression. CONCLUSION After reviewing previous reports regarding malignant PRES, we propose that hemorrhagic transformation is a crucial indicator for surgical decompression and an important prognostic factor in malignant PRES.
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Affiliation(s)
- Tzu-Chin Lin
- Department of Neurosurgery, Chang Gung Memorial Hospital, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Yu-Chi Wang
- Department of Neurosurgery, Chang Gung Memorial Hospital, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Kai-Jie Yu
- Department of Urology, Chang Gung Memorial Hospital, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Po-Chuan Hsieh
- Department of Neurosurgery, Chang Gung Memorial Hospital, Chang Gung Medical College and University, Taoyuan, Taiwan
- Department of Neurosurgery, New Taipei Municipal Tucheng Hospital (Built and Operated by Chang Gung Medical Foundation), Tucheng, Taiwan
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Odoma VA, Zahedi I, Haq H, Lopez Pantoja SC, Onyejide EC, Rahman F. Malignant Hypercalcemia: A Rare Etiology of Posterior Reversible Encephalopathy Syndrome. Cureus 2023; 15:e41229. [PMID: 37529521 PMCID: PMC10387446 DOI: 10.7759/cureus.41229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2023] [Indexed: 08/03/2023] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a rare and severe neurotoxic encephalopathic state characterized by variable neurologic manifestations ranging from headache and confusion to seizures, coma, and reversible subcortical vasogenic edema on imaging. PRES is commonly induced by chronic renal failure, hypertension, chemotherapeutic drugs, and eclampsia. PRES induced by hypercalcemia is uncommon and not widely underlined in the literature. We underline a case of a 61-year-old female diagnosed with advanced breast carcinoma presented with altered sensorium and generalized limb weakness. She was found to have malignant hypercalcemia, and brain imaging demonstrated subcortical vasogenic edema in the occipital and frontal lobe, suggestive of PRES. Her condition gradually improved after the treatment of hypercalcemia.
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Affiliation(s)
- Victor A Odoma
- Cardiology/Oncology, Indiana University (IU) Health, Bloomington, USA
| | - Iman Zahedi
- Internal Medicine, Arrowhead Regional Medical Center, Los Angeles, USA
| | - Hassan Haq
- Medicine, Jinnah Sindh Medical University, Karachi, PAK
| | | | - Ezrah C Onyejide
- Family Medicine, Metropolitan University College of Medicine, St. John's, ATG
| | - Farzana Rahman
- Internal Medicine, Jalalabad Ragib Rabeya Medical College and Hospital, Sylhet, BGD
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Savaliya M, Surati D, Surati R, Padmani S, Boussios S. Posterior Reversible Encephalopathy Syndrome after Pazopanib Therapy. Diseases 2023; 11:76. [PMID: 37366864 DOI: 10.3390/diseases11020076] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/15/2023] [Accepted: 05/19/2023] [Indexed: 06/28/2023] Open
Abstract
The term posterior reversible encephalopathy syndrome (PRES) refers to an acute syndrome characterised by a range of neurological symptoms and posterior transient changes on neuroimaging. Common clinical presentation includes headache, confusion, visual disturbances, seizures, and focal neurological deficit. With the advancement and increasing availability of neuroimaging, this syndrome is increasingly recognised. There are several underlying causes for PRES, including certain medications. Tyrosine kinase inhibitors (TKIs) such as pazopanib can increase the risk of developing PRES by markedly elevating the blood pressure due to its effect of inhibition of vascular endothelial growth factor receptors (VEGFRs). We are reporting a case of a 55-year-old male patient with the clear cell type of renal cell carcinoma (RCC) who developed PRES within a short period after starting pazopanib therapy. With the effective control of his blood pressure and discontinuation of pazopanib, his typical magnetic resonance imaging (MRI) lesion of PRES resolved in the follow-up scan after four weeks.
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Affiliation(s)
- Madhavkumar Savaliya
- Department of Medical Oncology, Medway NHS Foundation Trust, Windmill Road, Gillingham ME7 5NY, UK
- Metas Adventist Hospital, Surat 395001, India
| | - Drishty Surati
- Department of Medical Oncology, Medway NHS Foundation Trust, Windmill Road, Gillingham ME7 5NY, UK
- Metas Adventist Hospital, Surat 395001, India
| | | | | | - Stergios Boussios
- Department of Medical Oncology, Medway NHS Foundation Trust, Windmill Road, Gillingham ME7 5NY, UK
- School of Cancer & Pharmaceutical Sciences, Faculty of Life Sciences & Medicine, King's College London, London SE1 9RT, UK
- Kent Medway Medical School, University of Kent, Canterbury CT2 7LX, UK
- AELIA Organization, 9th Km Thessaloniki-Thermi, 57001 Thessaloniki, Greece
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Yavuz G, Heck S, Sienel W, Irlbeck M, Kneidinger N, Michel S, Forbrig R, Walter J, Zimmermann J, Kovács J, Glück OM, Pan M, Schneider C, Fertmann JM, Hatz RA, Kauke T. Posterior reversible encephalopathy syndrome after lung transplantation: Risk factors and management. Clin Transplant 2023; 37:e14850. [PMID: 36398875 DOI: 10.1111/ctr.14850] [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: 07/30/2022] [Revised: 11/02/2022] [Accepted: 11/04/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Posterior reversible encephalopathy syndrome is a rare neurologic complication that can occur under immunosuppressive therapy with CNI after organ transplantation. METHODS We retrospectively reviewed medical records of 545 patients who underwent lung transplantation between 2012 and 2019. Within this group, we identified 30 patients with neurological symptoms typical of PRES and compared the characteristics of patients who were diagnosed with PRES (n = 11) to those who were not (n = 19). RESULTS The incidence of PRES after lung transplantation was 2%. Notably, 73% of the patients with PRES were female and the mean age was 39.2. Seizure (82% vs. 21%, p = .002) was the most common neurological presentation. The risk of developing PRES was significantly associated with age (OR = .92, p < .0001) and having cystic fibrosis (CF) (OP = 10.1, p < .0001). Creatinine level (1.9 vs. 1.1 mg/dl, p = .047) and tacrolimus trough level (19.4 vs. 16.5 ng/ml, p = .048) within 1 week prior to neurological symptoms were significantly higher in patients with PRES. CONCLUSION Renal insufficiency and high tacrolimus levels are associated with PRES. A change of immunosuppressive drug should be done after confirmed PRES diagnosis or immediately in case of severe neurological dysfunction to improve neurological outcomes and minimize the risk of early allograft rejection.
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Affiliation(s)
- Gökce Yavuz
- Department of Thoracic Surgery, University Hospital of Munich, LMU, Munich, Germany
| | - Suzette Heck
- Department of Neurology, University Hospital of Munich, LMU, Munich, Germany
| | - Wulf Sienel
- Department of Thoracic Surgery, University Hospital of Munich, LMU, Munich, Germany
| | - Michael Irlbeck
- Department of Anesthesiology, University Hospital of Munich, LMU, Munich, Germany
| | - Nikolaus Kneidinger
- Department of Internal Medicine V, University Hospital of Munich, LMU, Munich, Germany
| | - Sebastian Michel
- Department of Cardiac Surgery, University Hospital of Munich, LMU, Munich, Germany.,Comprehensive Pneumology Center Munich, German Center for Lung Research (DZL), Munich, Germany
| | - Robert Forbrig
- Department of Neuroradiology, University Hospital of Munich, LMU, Munich, Germany
| | - Julia Walter
- Department of Internal Medicine V, University Hospital of Munich, LMU, Munich, Germany
| | - Julia Zimmermann
- Department of Thoracic Surgery, University Hospital of Munich, LMU, Munich, Germany
| | - Julia Kovács
- Department of Thoracic Surgery, University Hospital of Munich, LMU, Munich, Germany
| | - Olaf M Glück
- Department of Thoracic Surgery, University Hospital of Munich, LMU, Munich, Germany
| | - Ming Pan
- Department of Thoracic Surgery, University Hospital of Munich, LMU, Munich, Germany
| | - Christian Schneider
- Department of Thoracic Surgery, University Hospital of Munich, LMU, Munich, Germany
| | - Jan M Fertmann
- Department of Thoracic Surgery, University Hospital of Munich, LMU, Munich, Germany
| | - Rudolf A Hatz
- Department of Thoracic Surgery, University Hospital of Munich, LMU, Munich, Germany
| | - Teresa Kauke
- Department of Thoracic Surgery, University Hospital of Munich, LMU, Munich, Germany.,Transplant Center, University Hospital of Munich, LMU, Munich, Germany
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Wang Y, Zhang Q. Postpartum posterior reversible encephalopathy syndrome secondary to preeclampsia and cerebrospinal fluid leakage: A case report and literature review. World J Clin Cases 2022; 10:10332-10338. [PMID: 36246802 PMCID: PMC9561592 DOI: 10.12998/wjcc.v10.i28.10332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/28/2022] [Accepted: 08/25/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Postpartum posterior reversible encephalopathy syndrome (PRES) is not uncommon. Its mechanisms and risk factors are not clear.
CASE SUMMARY A 28-year-old woman underwent cesarean section but had inadvertent dural puncture during epidural anesthesia. To manage the symptoms of intracranial hypotension, crystalloid fluid was infused. However, the patient developed postpartum preeclampsia and PRES. The patient was treated with diazepam and dehydration therapy. The signs of cerebral lesions on magnetic resonance imaging disappeared on postpartum day 7.
CONCLUSION Postpartum preeclampsia and PRES can develop concomitantly. Treating postdural puncture headaches with infusion of crystalloid fluid may precipitate the development of PRES.
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Affiliation(s)
- Yu Wang
- Department of Anesthesiology, Zhabei Central Hospital, Shanghai 200071, China
| | - Qing Zhang
- Department of Anesthesiology, Zhabei Central Hospital, Shanghai 200071, China
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Oza CM, Mehta S, Khadilkar V, Khadilkar A. Primary pigmented nodular adrenal disease presenting as hypertensive crisis. BMJ Case Rep 2022; 15:e250023. [PMID: 35649622 PMCID: PMC9161052 DOI: 10.1136/bcr-2022-250023] [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] [Accepted: 05/11/2022] [Indexed: 11/03/2022] Open
Abstract
We present a case of a young girl who presented with hypertensive crisis and recent onset weight gain with hirsutism. On evaluation for Cushing syndrome (CS), her cortisol concentration was high, showed a paradoxical cortisol rise on dexamethasone suppression and the adrenocorticotropic hormone (ACTH) was low. Adrenal imaging showed normal adrenal morphology. Genetic diagnosis of primary pigmented nodular adrenal disease (PPNAD) was made. She was operated for bilateral adrenalectomy and histopathology confirmed the diagnosis of PPNAD. Our case highlights the rare aetiology of PPNAD as a cause of CS resulting in a hypertensive crisis. To the best of our knowledge, this is the youngest case of ACTH independent CS presenting as hypertensive encephalopathy.
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Affiliation(s)
- Chirantap Markand Oza
- Growth and Endocrine Unit, Hirabai Cowasji Jehangir Medical Research Institute, Pune, Maharashtra, India
| | - Sajili Mehta
- Pediatric Endocrinology, Surya Mother and Child Care Super Speciality Hospital, Pune, Maharashtra, India
- Pediatric Endocrinology, MIMER, Pune, Maharashtra, India
| | - Vaman Khadilkar
- Growth and Endocrine Unit, Hirabai Cowasji Jehangir Medical Research Institute, Pune, Maharashtra, India
- Interdisciplinary School of Health Sciences, Savitribai Phule Pune University, Pune, Maharashtra, India
| | - Anuradha Khadilkar
- Growth and Endocrine Unit, Hirabai Cowasji Jehangir Medical Research Institute, Pune, Maharashtra, India
- Interdisciplinary School of Health Sciences, Savitribai Phule Pune University, Pune, Maharashtra, India
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Babici D, Hindi F, Hanafy KA. Posterior reversible encephalopathy syndrome due to unilateral renal artery stenosis: A case report. Brain Circ 2022; 8:108-111. [PMID: 35909707 PMCID: PMC9336591 DOI: 10.4103/bc.bc_14_22] [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] [Received: 04/02/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Denis Babici
- Department of Neurology, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| | - Fawzi Hindi
- Department of Neurology, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| | - Khalid A Hanafy
- Department of Neurocritical Care, Marcus Neuroscience Institute, Boca Raton, Florida, USA
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Zerbib Y, Gibert L, Bennis Y, Masmoudi K, Maizel J, Brault C. Posterior Reversible Encephalopathy Syndrome After Self-Medication With an Oral Decongestant: A Case Report. Front Med (Lausanne) 2022; 9:837324. [PMID: 35321464 PMCID: PMC8935013 DOI: 10.3389/fmed.2022.837324] [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: 12/16/2021] [Accepted: 02/09/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Posterior reversible encephalopathy syndrome (PRES) is a rare neurological disorder caused by the dysregulation of cerebral perfusion. Case Presentation We report on a 18-year-old female patient with a history of end-stage renal disease and thrice weekly hemodialysis. She was admitted to the emergency department with mental confusion, blurred vision, headaches, and vomiting, following self-medication with an oral decongestant containing pseudoephedrine. We observed hypointense lesions with T1-weighted MRI and hyperintense areas with T2-weighted and fluid-attenuated inversion recovery MRI sequences. The lack of diffusion restriction was consistent with a diagnosis of PRES. A concomitant Enterobacter cloacae hemodialysis catheter-bloodstream infection was also diagnosed. We hypothesize that both sepsis and inappropriate self-medication with oral pseudoephedrine contributed to hypertension, endothelial dysfunction, and vasogenic edema. The patient received intensive care and made a full recovery. Discussion PRES is a life-threatening condition that requires intensive care. Identification of the etiology is the keystone of medical care. Inappropriate self-medication with an oral decongestant might trigger PRES - highlighting the importance of patient education.
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Affiliation(s)
- Yoann Zerbib
- Intensive Care Unit, Amiens University Medical Center, Amiens, France
| | - Louis Gibert
- Intensive Care Unit, Amiens University Medical Center, Amiens, France
| | - Youssef Bennis
- Department of Clinical Pharmacology, Amiens University Medical Center, Amiens, France
- MP3CV Laboratory, UR UPJV 7517, Amiens, France
| | - Kamel Masmoudi
- Department of Clinical Pharmacology, Amiens University Medical Center, Amiens, France
| | - Julien Maizel
- Intensive Care Unit, Amiens University Medical Center, Amiens, France
- MP3CV Laboratory, UR UPJV 7517, Amiens, France
| | - Clément Brault
- Intensive Care Unit, Amiens University Medical Center, Amiens, France
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12
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Triplett JD, Kutlubaev MA, Kermode AG, Hardy T. Posterior reversible encephalopathy syndrome (PRES): diagnosis and management. Pract Neurol 2022; 22:183-189. [PMID: 35046115 DOI: 10.1136/practneurol-2021-003194] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2021] [Indexed: 01/31/2023]
Abstract
Posterior reversible encephalopathy syndrome (PRES) may present with diverse clinical symptoms including visual disturbance, headache, seizures and impaired consciousness. MRI shows oedema, usually involving the posterior subcortical regions. Triggering factors include hypertension, pre-eclampsia/eclampsia, renal failure, cytotoxic agents and autoimmune conditions. The mechanism underlying PRES is not certain, but endothelial dysfunction is implicated. Treatment is supportive and involves correcting the underlying cause and managing associated complications, such as seizures. Although most patients recover, PRES is not always reversible and may be associated with considerable morbidity and even mortality.
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Affiliation(s)
- James D Triplett
- Neurology, Concord Hospital, Concord, New South Wales, Australia
| | | | - Allan G Kermode
- Perron Institute, University of Western Australia, Perth, Western Australia, Australia.,CMMIT, Murdoch University, Murdoch, Western Australia, Australia
| | - Todd Hardy
- Neurology, Concord Hospital, Concord, New South Wales, Australia.,Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
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13
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An Unusual Presentation of Posterior Reversible Encephalopathy Syndrome Following Liver Transplantation. Transplant Direct 2022; 8:e1269. [PMID: 35018303 PMCID: PMC8735783 DOI: 10.1097/txd.0000000000001269] [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: 06/22/2021] [Revised: 10/18/2021] [Accepted: 10/30/2021] [Indexed: 12/07/2022] Open
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Huang H, Zhang Y, Yang M, Lian B, Guo R, Cao L. Case Report: Early-Onset Charcot-Marie-Tooth 2N With Reversible White Matter Lesions Repeatedly Mimicked Stroke or Encephalitis. Front Pediatr 2022; 10:935721. [PMID: 35911843 PMCID: PMC9326065 DOI: 10.3389/fped.2022.935721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/14/2022] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Charcot-Marie-Tooth (CMT) disease is a rare group of peripheral neuropathies with high clinical and genetic heterogeneity. CMT type 2N (CMT 2N) is a rare subtype of CMT with few clinical reports. The clinical presentation mimics that of other diseases, frequently leading to misdiagnoses. We present a case of CMT 2N with reversible white matter lesions (WMLs), which repeatedly mimicked stroke or encephalitis. We include a literature review to the improve management of this disease. CASE DESCRIPTION An 8-year-old boy was admitted to the hospital with slurred speech and limb weakness that had persisted for 1 day. Physical examination revealed lethargy, dysarthria, and a positive bilateral Babinski sign. Cerebrospinal fluid (CSF) analysis showed no abnormalities. Brain magnetic resonance imaging (MRI) revealed symmetrical abnormal signal areas in the paraventricular white matter and corpus callosum. The patient was suspected of having viral encephalitis and recovered rapidly after treatment.He was hospitalized 3 years later for limb weakness, barylalia, and facial paralysis persisting for 1 day. MRI showed an abnormal signal in the bilateral corona radiata. He was suspected of having a stroke or encephalitis. He was completely recovered after treatment.After a second 3-year span, he was admitted for another stroke-like episode. Physical examination revealed facial-lingual hemiparesis, mild atrophy of the left thenar muscle, decreased muscle strength in the extremities, and disappearance of the tendon reflex. MRI revealed more pronounced abnormal signals in the bilateral centrum semiovale and corpus callosum. Antibodies against autoimmune encephalitis were negative. A nerve conduction velocity (NCV) study showed motor and sensory four-limb nerve demyelination with axonal damage, most notably at the distal end. His symptoms were resolved after active treatment. A follow-up MRI showed the complete disappearance of the abnormal white matter signal. Whole exon sequencing showed a heterozygous mutation [c.2093C > T(p.Ser698Phe)] in the alanyl-tRNA synthetase 1 gene (AARS1). His mutation, clinical features, and electrophysiological testing led to a diagnosis of CMT 2N. DISCUSSION Early-Onset CMT 2N with reversible WMLs can often mimic stroke or encephalopathy. Affected individuals may show an atypical posterior reversible encephalopathy syndrome (PRES) on MRI. Careful family history assessment, physical examination, nerve conduction studies, MRIs, and genetic testing are essential for early diagnosis. Further studies are required to confirm these findings.
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Affiliation(s)
- Huasheng Huang
- Department of Neurology, Liuzhou People’s Hospital, Liuzhou, China
| | - Yu Zhang
- Nursing Department, Zhejiang Hospital, Hangzhou, China
- Teaching Office, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Mingxiu Yang
- Department of Neurology, Liuzhou People’s Hospital, Liuzhou, China
| | - Baorong Lian
- Shantou University Medical College, Shantou University, Shantou, China
| | - Rui Guo
- Radiology Department, Liuzhou People’s Hospital, Liuzhou, China
| | - Liming Cao
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
- *Correspondence: Liming Cao,
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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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Wang Y, Zheng Y, Wen J, Ren J, Yuan X, Yang T, Hu J. Cyclosporine A-related neurotoxicity after haploidentical hematopoietic stem cell transplantation in children with hematopathy. Ital J Pediatr 2021; 47:83. [PMID: 33794964 PMCID: PMC8017700 DOI: 10.1186/s13052-021-01037-0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/23/2021] [Indexed: 12/02/2022] Open
Abstract
Background To evaluate cyclosporine A (CSA)-related neurotoxicity after haploidentical hematopoietic stem cell transplantation (HID-HSCT) in children with hematopathy. Methods This retrospective case series study included children with hematopathy who underwent HID-HSCT at Fujian Medical University Union Hospital between February 2013 and January 2017. Results Fifty-one children (39 males) were included in the study with a median age of 8 (range, 1.1–18) years. Seven patients (13.7%) developed CSA-related neurotoxicity after a median 38 (range, − 3 to 161) days from HID-HSCT. Hypertension (5/7, 71%) was the most common prodrome. Brain magnetic resonance imaging showed posterior reversible encephalopathy syndrome in six patients and atypical abnormalities in one patient. One patient died from grade IV graft-versus-host disease (GvHD) on day + 160, and six patients were alive at the last follow-up. Four patients (71.4%) achieved complete remission, while two patients developed secondary epilepsy and exhibited persistent MRI and electroencephalogram abnormalities at the 5-year follow-up. Hypertension after CSA was more common in patients with CSA-related neurotoxicity than in those without (71% vs. 11%, P = 0.002). Five-year overall survival did not differ significantly between patients with CSA-related neurotoxicity (85.7 ± 13.2%) and those without (65.8 ± 7.2%). Conclusions The incidence of CSA-related neurotoxicity in children with hematopathy undergoing HID-HSCT is relatively high.
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Affiliation(s)
- Yong Wang
- Department of Pediatric, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Gulou District, Fuzhou City, Fujian Province, China
| | - Yongzhi Zheng
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Gulou District, Fuzhou City, Fujian Province, China
| | - Jingjing Wen
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Gulou District, Fuzhou City, Fujian Province, China
| | - Jinhua Ren
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Gulou District, Fuzhou City, Fujian Province, China
| | - Xiaohong Yuan
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Gulou District, Fuzhou City, Fujian Province, China
| | - Ting Yang
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Gulou District, Fuzhou City, Fujian Province, China.
| | - Jianda Hu
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Gulou District, Fuzhou City, Fujian Province, China.
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Chen X, Zhu W, Jiang S. A case report of reversible posterior encephalopathy syndrome with intracranial hemorrhage in a child. Medicine (Baltimore) 2021; 100:e25266. [PMID: 33761727 PMCID: PMC9281917 DOI: 10.1097/md.0000000000025266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 03/04/2021] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION The objective is to analyze the clinical diagnosis and treatment of children with rescindable posterior encephalopathy syndrome (PRES) and intracranial hemorrhage (ICH) to improve the pediatrician's understanding of PRES combined with ICH in children. PATIENT CONCERNS AND DIAGNOSIS After liver transplantation, the patient developed symptoms of epilepsy and coma. Meanwhile, massive necrosis of acute cerebral infarction and small hemorrhage was observed in the left cerebellar hemisphere and left occipital lobe, respectively. The above symptoms were initially diagnosed as PRES. INTERVENTIONS AND OUTCOMES After adjusting the anti-rejection drug regimen, it was found that the child's neurological symptoms were relieved, and the limb motor function gradually recovered during follow-up. Imaging examination showed significant improvement on abnormal signals in brain. CONCLUSION In general, children with PRES may further develop ICH and contribute to a poor prognosis. Early diagnosis, detection of risk factors and timely adjustment of medication regimen are the keys to prevent irreversible brain damage.
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Affiliation(s)
- Xiaoqian Chen
- Department of Pediatrics, First People's Hospital of Foshan, Foshan, Guangdong, PR China
| | - Weixue Zhu
- Department of Pediatrics, First People's Hospital of Foshan, Foshan, Guangdong, PR China
| | - Suhua Jiang
- Department of Pediatrics, First People's Hospital of Foshan, Foshan, Guangdong, PR China
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18
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Gewirtz AN, Gao V, Parauda SC, Robbins MS. Posterior Reversible Encephalopathy Syndrome. Curr Pain Headache Rep 2021; 25:19. [PMID: 33630183 PMCID: PMC7905767 DOI: 10.1007/s11916-020-00932-1] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2020] [Indexed: 12/11/2022]
Abstract
Purpose of Review This review provides an updated discussion on the clinical presentation, diagnosis and radiographic features, mechanisms, associations and epidemiology, treatment, and prognosis of posterior reversible encephalopathy syndrome (PRES). Headache is common in PRES, though headache associated with PRES was not identified as a separate entity in the 2018 International Classification of Headache Disorders. Here, we review the relevant literature and suggest criteria for consideration of its inclusion. Recent Findings COVID-19 has been identified as a potential risk factor for PRES, with a prevalence of 1–4% in patients with SARS-CoV-2 infection undergoing neuroimaging, thus making a discussion of its identification and treatment particularly timely given the ongoing global pandemic at the time of this writing. Summary PRES is a neuro-clinical syndrome with specific imaging findings. The clinical manifestations of PRES include headache, seizures, encephalopathy, visual disturbances, and focal neurologic deficits. Associations with PRES include renal failure, preeclampsia and eclampsia, autoimmune conditions, and immunosuppression. PRES is theorized to be a syndrome of disordered autoregulation and endothelial dysfunction resulting in preferential hyperperfusion of the posterior circulation. Treatment typically focuses on treating the underlying cause and removal of the offending agents.
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Affiliation(s)
- Alexandra N Gewirtz
- Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10065, USA.
| | - Virginia Gao
- Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10065, USA
| | - Sarah C Parauda
- Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10065, USA
| | - Matthew S Robbins
- Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10065, USA
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19
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Recurrent Posterior Reversible Encephalopathy Syndrome in an Adolescent Boy with End-Stage Renal Disease. Case Rep Pediatr 2021; 2021:6675454. [PMID: 33643673 PMCID: PMC7902131 DOI: 10.1155/2021/6675454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/20/2021] [Accepted: 01/25/2021] [Indexed: 12/20/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES), also known as reversible posterior leukoencephalopathy syndrome, is a neurological entity characterized by acute change in consciousness, visual impairment, headache, and seizures. It is associated with autoimmune disease, immunosuppressive agents, organ transplantation, acute glomerulonephritis, and sepsis. Typically, vasogenic edema is seen in the white matter of parieto-occipital lobes but can also involve atypical locations such as frontal lobes, thalamus, basal ganglia, and gray matter. While occurring extensively in adults, few cases, especially recurrent episodes, have been described in children. We report a case of recurrent PRES in a 17-year-old boy with end-stage renal disease on a peritoneal dialysis program who initially presented with hypertension and seizures. He emergently received intravenous antihypertensive medication with immediate and sustained improvement in his mental status. Information about recurrent PRES in children is limited because it is not commonly seen. We examine the clinical features of PRES and highlight important points for the diagnosis and management of this rare syndrome. This report demonstrates the importance of pediatricians to consider PRES in the differential diagnosis in children presenting with acute altered mental status. Blood pressure measurements, which are often overlooked in pediatric care, may assist in correctly diagnosing patients.
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Cantone M, Lanza G, Puglisi V, Vinciguerra L, Mandelli J, Fisicaro F, Pennisi M, Bella R, Ciurleo R, Bramanti A. Hypertensive Crisis in Acute Cerebrovascular Diseases Presenting at the Emergency Department: A Narrative Review. Brain Sci 2021; 11:70. [PMID: 33430236 PMCID: PMC7825668 DOI: 10.3390/brainsci11010070] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/02/2021] [Accepted: 01/04/2021] [Indexed: 02/07/2023] Open
Abstract
Hypertensive crisis, defined as an increase in systolic blood pressure >179 mmHg or diastolic blood pressure >109 mmHg, typically causes end-organ damage; the brain is an elective and early target, among others. The strong relationship between arterial hypertension and cerebrovascular diseases is supported by extensive evidence, with hypertension being the main modifiable risk factor for both ischemic and hemorrhagic stroke, especially when it is uncontrolled or rapidly increasing. However, despite the large amount of data on the preventive strategies and therapeutic measures that can be adopted, the management of high BP in patients with acute cerebrovascular diseases presenting at the emergency department is still an area of debate. Overall, the outcome of stroke patients with high blood pressure values basically depends on the occurrence of hypertensive emergency or hypertensive urgency, the treatment regimen adopted, the drug dosages and their timing, and certain stroke features. In this narrative review, we provide a timely update on the current treatment, debated issues, and future directions related to hypertensive crisis in patients referred to the emergency department because of an acute cerebrovascular event. This will also focus greater attention on the management of certain stroke-related, time-dependent interventions, such as intravenous thrombolysis and mechanic thrombectomy.
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Affiliation(s)
- Mariagiovanna Cantone
- Department of Neurology, Sant’Elia Hospital, ASP Caltanissetta, Via Luigi Russo, 6, 93100 Caltanissetta, Italy;
| | - Giuseppe Lanza
- Department of Surgery and Medical-Surgical Specialties, University of Catania, Via Santa Sofia, 78, 95123 Catania, Italy
- Department of Neurology IC, Oasi Research Institute—IRCCS, Via Conte Ruggero, 73, 94018 Troina, Italy
| | - Valentina Puglisi
- Department of Neurology and Stroke Unit, ASST Cremona, Viale Concordia, 1, 26100 Cremona, Italy; (V.P.); (L.V.)
| | - Luisa Vinciguerra
- Department of Neurology and Stroke Unit, ASST Cremona, Viale Concordia, 1, 26100 Cremona, Italy; (V.P.); (L.V.)
| | - Jaime Mandelli
- Department of Neurosurgery, Sant’Elia Hospital, ASP Caltanissetta, Via Luigi Russo, 6, 93100 Caltanissetta, Italy;
| | - Francesco Fisicaro
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia, 89, 95123 Catania, Italy; (F.F.); (M.P.)
| | - Manuela Pennisi
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia, 89, 95123 Catania, Italy; (F.F.); (M.P.)
| | - Rita Bella
- Department of Medical and Surgical Sciences and Advanced Technologies, University of Catania, Via Santa Sofia, 78, 95123 Catania, Italy;
| | - Rosella Ciurleo
- IRCCS Centro Neurolesi Bonino-Pulejo, S.S. 113, Via Palermo C/da Casazza, 98123 Messina, Italy; (R.C.); (A.B.)
| | - Alessia Bramanti
- IRCCS Centro Neurolesi Bonino-Pulejo, S.S. 113, Via Palermo C/da Casazza, 98123 Messina, Italy; (R.C.); (A.B.)
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21
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Hypertensive Crisis in Acute Cerebrovascular Diseases Presenting at the Emergency Department: A Narrative Review. Brain Sci 2021. [PMID: 33430236 DOI: 10.3390/brainsci11010070.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Hypertensive crisis, defined as an increase in systolic blood pressure >179 mmHg or diastolic blood pressure >109 mmHg, typically causes end-organ damage; the brain is an elective and early target, among others. The strong relationship between arterial hypertension and cerebrovascular diseases is supported by extensive evidence, with hypertension being the main modifiable risk factor for both ischemic and hemorrhagic stroke, especially when it is uncontrolled or rapidly increasing. However, despite the large amount of data on the preventive strategies and therapeutic measures that can be adopted, the management of high BP in patients with acute cerebrovascular diseases presenting at the emergency department is still an area of debate. Overall, the outcome of stroke patients with high blood pressure values basically depends on the occurrence of hypertensive emergency or hypertensive urgency, the treatment regimen adopted, the drug dosages and their timing, and certain stroke features. In this narrative review, we provide a timely update on the current treatment, debated issues, and future directions related to hypertensive crisis in patients referred to the emergency department because of an acute cerebrovascular event. This will also focus greater attention on the management of certain stroke-related, time-dependent interventions, such as intravenous thrombolysis and mechanic thrombectomy.
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22
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Hun M, Xie M, She Z, Abdirahman AS, Li C, Wu F, Luo S, Han P, Phorn R, Wu P, Luo H, Chen K, Tian J, Wan W, Wen C. Management and Clinical Outcome of Posterior Reversible Encephalopathy Syndrome in Pediatric Oncologic/Hematologic Diseases: A PRES Subgroup Analysis With a Large Sample Size. Front Pediatr 2021; 9:678890. [PMID: 34277519 PMCID: PMC8280768 DOI: 10.3389/fped.2021.678890] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 06/02/2021] [Indexed: 12/13/2022] Open
Abstract
This study investigated the management and clinical outcomes along with associated factors of posterior reversible encephalopathy syndrome (PRES) in childhood hematologic/oncologic diseases. We present data from children with hematologic/oncologic diseases who developed PRES after treatment of the primary disease with chemotherapy and hematopoietic stem cell transplantation (HSCT) at 3 medical centers in Changsha, China from 2015 to 2020, and review all previously reported cases with the aim of determining whether this neurologic manifestation affects the disease prognosis. In the clinical cohort of 58 PRES patients, hypertension [pooled odds ratio (OR) = 4.941, 95% confidence interval (CI): 1.390, 17.570; P = 0.001] and blood transfusion (OR = 14.259, 95% CI: 3.273, 62.131; P = 0.001) were significantly associated with PRES. Elevated platelet (OR = 0.988, 95% CI: 0.982, 0.995; P < 0.001), hemoglobin (OR = 0.924, 95% CI: 0.890, 0.995; P < 0.001), and blood sodium (OR = 0.905, 95% CI: 0.860, 0.953; P < 0.001), potassium (OR = 0.599, 95% CI: 0.360, 0.995; P = 0.048), and magnesium (OR = 0.093, 95% CI: 0.016, 0.539; P = 0.008) were protective factors against PRES. Data for 440 pediatric PRES patients with hematologic/oncologic diseases in 21 articles retrieved from PubMed, Web of Science, and Embase databases and the 20 PRES patients from our study were analyzed. The median age at presentation was 7.9 years. The most common primary diagnosis was leukemia (62.3%), followed by solid tumor (7.7%) and lymphoma (7.5%). Most patients (65.0%) received chemotherapy, including non-induction (55.2%) and induction (44.8%) regimens; and 86.5% used corticosteroids before the onset of PRES. Although 21.0% of patients died during follow-up, in most cases (93.2%) this was not attributable to PRES but to severe infection (27.3%), underlying disease (26.1%), graft-vs.-host disease (14.8%), multiple organ dysfunction syndrome (8.0%), and respiratory failure (3.4%). PRES was more common with HSCT compared to chemotherapy and had a nearly 2 times higher mortality rate in patients with oncologic/hematologic diseases than in those with other types of disease. Monitoring neurologic signs and symptoms in the former group is therefore critical for ensuring good clinical outcomes following treatment of the primary malignancy.
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Affiliation(s)
- Marady Hun
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Min Xie
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Zhou She
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Amin S Abdirahman
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Cuifang Li
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Feifeng Wu
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Senlin Luo
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Phanna Han
- Department of Ophthalmology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Rithea Phorn
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Pan Wu
- Department of Hematology, Hunan Children's Hospital, University of South China, Changsha, China
| | - Haiyan Luo
- Department of Hematology, Hunan Children's Hospital, University of South China, Changsha, China
| | - Keke Chen
- Department of Hematology, Children's Medical Center, Hunan Provincial People's Hospital, Hunan Normal University, Changsha, China
| | - Jidong Tian
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Wuqing Wan
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Chuan Wen
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
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Gabriel M, Hoeben BAW, Uhlving HH, Zajac-Spychala O, Lawitschka A, Bresters D, Ifversen M. A Review of Acute and Long-Term Neurological Complications Following Haematopoietic Stem Cell Transplant for Paediatric Acute Lymphoblastic Leukaemia. Front Pediatr 2021; 9:774853. [PMID: 35004543 PMCID: PMC8734594 DOI: 10.3389/fped.2021.774853] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/02/2021] [Indexed: 12/02/2022] Open
Abstract
Despite advances in haematopoietic stem cell transplant (HSCT) techniques, the risk of serious side effects and complications still exists. Neurological complications, both acute and long term, are common following HSCT and contribute to significant morbidity and mortality. The aetiology of neurotoxicity includes infections and a wide variety of non-infectious causes such as drug toxicities, metabolic abnormalities, irradiation, vascular and immunologic events and the leukaemia itself. The majority of the literature on this subject is focussed on adults. The impact of the combination of neurotoxic drugs given before and during HSCT, radiotherapy and neurological complications on the developing and vulnerable paediatric and adolescent brain remains unclear. Moreover, the age-related sensitivity of the nervous system to toxic insults is still being investigated. In this article, we review current evidence regarding neurotoxicity following HSCT for acute lymphoblastic leukaemia in childhood. We focus on acute and long-term impacts. Understanding the aetiology and long-term sequelae of neurological complications in children is particularly important in the current era of immunotherapy for acute lymphoblastic leukaemia (such as chimeric antigen receptor T cells and bi-specific T-cell engager antibodies), which have well-known and common neurological side effects and may represent a future treatment modality for at least a fraction of HSCT-recipients.
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Affiliation(s)
- Melissa Gabriel
- Cancer Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Bianca A W Hoeben
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Hilde Hylland Uhlving
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Olga Zajac-Spychala
- Department of Pediatric Oncology, Hematology and Transplantology, Poznan University of Medical Sciences, Poznań, Poland
| | - Anita Lawitschka
- Haematopoietic Stem Cell Transplant Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria
| | - Dorine Bresters
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Marianne Ifversen
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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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: 0.8] [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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Miller J, McNaughton C, Joyce K, Binz S, Levy P. Hypertension Management in Emergency Departments. Am J Hypertens 2020; 33:927-934. [PMID: 32307541 PMCID: PMC7577644 DOI: 10.1093/ajh/hpaa068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 02/25/2020] [Accepted: 04/15/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Elevated blood pressure (BP) is pervasive among patients that visit emergency departments (EDs) for their care. METHODS In this review article, we outline the current approach to the management of these individuals and highlight the crucial role emergency medicine clinicians play in reducing the morbidity associated with elevated BP. RESULTS We highlight the critical importance of immediate treatment when elevated BP contributes to new or worsening end-organ injury but emphasize that such hypertensive emergencies are rare. For the vast majority of patients with elevated BP in the ED who do not have new or worsening end-organ injury from elevated BP, immediate BP reduction within the ED is not recommended or safe. Nonetheless, within weeks after an ED visit, there is a pressing need to improve the care of patients with elevated or previously undiagnosed hypertension. For many, it may be their only regular point of engagement with the healthcare system. To address this, we present novel perspectives that envision a new role for emergency medicine in chronic hypertension management-one that acknowledges the significant population-level gaps in BP control that contribute to disparities in cardiovascular disease and sets the stage for future changes in systems-based practice. CONCLUSIONS Emergency medicine plays a key and evolving role in reducing morbidity associated with elevated BP.
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Affiliation(s)
- Joseph Miller
- Henry Ford Hospital, Detroit, Michigan, USA
- Wayne State University, Detroit, Michigan, USA
| | - Candace McNaughton
- Vanderbilt University Medical Center and Tennessee Valley Healthcare System VA, Nashville, Tennessee, USA
| | - Katherine Joyce
- Henry Ford Hospital, Detroit, Michigan, USA
- Wayne State University, Detroit, Michigan, USA
| | - Sophia Binz
- Henry Ford Hospital, Detroit, Michigan, USA
- Wayne State University, Detroit, Michigan, USA
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Hun M, Tian J, Xie M, She Z, Abdirahman AS, Han P, Wan W, Wen C. Analysis of Risk Factors Associated With Poor Outcome in Posterior Reversible Encephalopathy Syndrome After Treatment in Children: Systematic Review and Meta-Analysis. Front Neurol 2020; 11:938. [PMID: 32982945 PMCID: PMC7479335 DOI: 10.3389/fneur.2020.00938] [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] [Received: 06/02/2020] [Accepted: 07/20/2020] [Indexed: 12/15/2022] Open
Abstract
Objective: Chemotherapy and hematopoietic stem cell transplantation (HSCT) play important roles in clinical etiology, symptoms, signs, imaging findings, and biochemical parameters for inducing posterior reversible encephalopathy syndrome (PRES) in pediatric oncologic diseases. We aimed to evaluate various risk factors of pediatric oncologic diseases after conducting chemotherapy and HSCT to induce PRES for predicting the clinical prognosis frequency. Methods: The literature was performed on PubMed, Web of Science, and Embase databases to recognize the qualified studies. The odds ratios (ORs) of related risk factors and their corresponding 95% confidence intervals (CIs) were used to compute the pooled assessments of the outcomes. Results: Six studies were included in the meta-analysis, involving 828 records. The risk of female children has a significantly higher incidence than male children in oncologic age groups of PRES. Children over the age of 10 years old in oncologic age groups develop a significantly increased risk of PRES. Acute graft-versus-host disease (GVHD) has a significant promotion effect on the occurrence of PRES. Hypertension can promote the occurrence of PRES in children. The risk of PRES in immunodeficient children increases significantly. Children with sickle cell disease (SCD) have a significantly increased risk of PRES. The risk of PRES in children with T-cell leukemia rises considerably. The central nervous system (CNS) leukemia/involvement has a significant role in promoting the occurrence of PRES in children. The pooled OR for the factors male, ≥ 10 years old of age, acute GVHD, hypertension, immunodeficiency, SCD, T-cell leukemia, CNS leukemia/involvement was 0.66 (95% CI: 0.58, 0.76; P < 0.00001), 2.06 (95% CI: 1.23, 3.43; P < 0.006), 1.32 (95% CI: 1.14, 1.53; P < 0.0003), 8.84 (95% CI: 7.57, 10.32; P < 0.00001), 2.72 (95% CI: 1.81, 4.08; P < 0.00001), 2.87 (95% CI: 2.15, 3.83; P < 0.00001), 2.84 (95% CI: 1.65, 4.88; P < 0.0002), and 3.13 (95% CI: 1.43, 6.84; P < 0.004), respectively. Conclusions: The result of this meta-analysis suggests that female children, age over 10 years old, acute GVHD, hypertension, immunodeficiency, SCD, T-cell leukemia, and CNS leukemia/involvement are likely to have the poor outcome in pediatric oncologic/hematologic diseases in PRES.
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Affiliation(s)
- Marady Hun
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Jidong Tian
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Min Xie
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Zhou She
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Amin Sheikh Abdirahman
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Phanna Han
- Department of Ophthalmology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Wuqing Wan
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Chuan Wen
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
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YILDIRIM-ÇETİN G. Posterior Reversibl Ensefalopati Sendromu: Sistemik Lupus Eritematozuslu hastalarda görülen nadir ve acil klinik bir antite. KAHRAMANMARAŞ SÜTÇÜ İMAM ÜNIVERSITESI TIP FAKÜLTESI DERGISI 2020. [DOI: 10.17517/ksutfd.626090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Parasher A, Jhamb R. Posterior reversible encephalopathy syndrome (PRES): presentation, diagnosis and treatment. Postgrad Med J 2020; 96:623-628. [PMID: 32467104 DOI: 10.1136/postgradmedj-2020-137706] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/09/2020] [Accepted: 05/10/2020] [Indexed: 11/03/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a neurological disorder which is characterised by variable symptoms, which include visual disturbances, headache, vomiting, seizures and altered consciousness. The exact pathophysiology of PRES has not been completely explained, but hypertension and endothelial injury seem to be almost always present. Vasoconstriction resulting in vasogenic and cytotoxic edema is suspected to be responsible for the clinical symptoms as well as the neuro-radiological presentation. On imaging studies, Symmetrical white matter abnormalities suggestive of edema are seen in the computer tomography (CT) and magnetic resonance imaging (MRI) scans, commonly but not exclusively in the posterior parieto-occipital regions of the cerebral hemispheres. The management is chiefly concerned with stabilization of the patient, adequate and prompt control of blood pressure, prevention of seizures and timely caesarean section in obstetric cases with pre-eclampsia/eclampsia. In conclusion, persistently elevated blood pressures remain the chief culprit for the clinical symptoms as well as the neurological deficits. Early diagnosis by diffusion weighted MRI scans, and differentiation from other causes of altered sensorium i.e. seizures, meningitis and psychosis, is extremely important to initiate treatment and prevent further complications. Although most cases resolve successfully and carry a favorable prognosis, patients with inadequate therapeutic support or delay in treatment may not project a positive outcome.
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Affiliation(s)
- Anant Parasher
- Medicine, Guru Teg Bahadur Hospital, New Delhi, India .,Medicine, Guru Teg Bahadur Hospital, New Delhi, India
| | - Rajat Jhamb
- Medicine, Guru Teg Bahadur Hospital, New Delhi, India
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29
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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: 106] [Impact Index Per Article: 21.2] [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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30
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Gandini J, Manto M, Charette N. Delayed Posterior Reversible Leukoencephalopathy Syndrome Triggered by FLOT Chemotherapy. Front Neurol 2020; 10:1405. [PMID: 32082236 PMCID: PMC7002563 DOI: 10.3389/fneur.2019.01405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 12/23/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jordi Gandini
- Department of Neurology, CHU-Charleroi, Charleroi, Belgium
| | - Mario Manto
- Department of Neurology, CHU-Charleroi, Charleroi, Belgium
- Service des Neurosciences, University of Mons, Mons, Belgium
- *Correspondence: Mario Manto
| | - Nicolas Charette
- Department of Gastroenterology, CHU-Charleroi, Charleroi, Belgium
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31
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Ronnie T, Beyerlein L, Murati M, Louie JP. A PRESing case of visual changes and confusion. Am J Emerg Med 2019; 38:411.e1-411.e3. [PMID: 31784391 DOI: 10.1016/j.ajem.2019.09.006] [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: 09/05/2019] [Accepted: 09/24/2019] [Indexed: 11/15/2022] Open
Abstract
Visual disturbances are an uncommon pediatric chief complaint. Usually, after a complete ocular exam including visual acuity, most causes are benign and not life-threatening. Children with abnormal visual complaints who have underlying medical conditions, such as SLE or other autoimmune conditions, a recipient of a transplant, renal disease, and even eclampsia require closer scrutiny. We report a 10-year-old female with a history of systemic lupus erythematosus complicated by hypertension and cardiomyopathy secondary to lupus who presented to the emergency department with a history of vision loss and headache. Head computer tomography demonstrated findings of posterior reversible encephalopathy syndrome (PRES). PRES is a clinical disease associated with cranial radiological findings of heterogenous etiologies that is often reversible. Prompt recognition and treatment are important in preventing permanent damage, long term morbidity and even death.
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Affiliation(s)
- Tanisha Ronnie
- University of Minnesota School of Medicine, 420 Delaware Street SE, Minneapolis, MN 55455, United States.
| | - Larrisa Beyerlein
- University of Minnesota, Department of Pediatrics, 2450 Riverside Avenue, Minneapolis, MN 55454, United States.
| | - Michael Murati
- University of Minnesota, Department of Radiology, 420 Delaware Street SE, Minneapolis, MN 55455, United States.
| | - Jeffrey P Louie
- University of Minnesota, Department of Pediatrics, 2450 Riverside Avenue, Minneapolis, MN 55454, United States.
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32
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Postpartum Posterior Reversible Encephalopathy Syndrome (PRES): Three Case Reports and Literature Review. Case Rep Obstet Gynecol 2019; 2019:9527632. [PMID: 30809401 PMCID: PMC6369475 DOI: 10.1155/2019/9527632] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 12/23/2018] [Accepted: 12/26/2018] [Indexed: 11/17/2022] Open
Abstract
Posterior reversible encephalopathy syndrome is a rare complication generally associated with headache and acute changes in blood pressure. Delay in the diagnosis and treatment may result in death or in irreversible neurological sequelae. We present three cases of PRES occurring in young women during puerperium. We report a literature review ranged from January 1990 to June 2015 describing clinical features, diagnostic and medical approach, and maternal outcome.
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Katsevman GA, Turner RC, Cheyuo C, Rosen CL, Smith MS. Post-partum posterior reversible encephalopathy syndrome requiring decompressive craniectomy: case report and review of the literature. Acta Neurochir (Wien) 2019; 161:217-224. [PMID: 30659351 DOI: 10.1007/s00701-019-03798-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 01/04/2019] [Indexed: 10/27/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is an uncommon but potentially devastating syndrome if not recognized and treated appropriately. As the name implies, recognition of the condition and proper management may reverse the clinical and radiological findings. However, diagnosis is not always straightforward. We present the case of a 24-year-old female who was 4 days post-partum and presented with headache, neck pain, and new-onset seizures. She had undergone epidural anesthesia during labor, and initial imaging was suggestive of intracranial hypotension versus pachymeningitis. Despite initial conservative therapy including anti-epileptic drugs, magnesium therapy, empiric antibiotics, and Trendelenburg positioning, the patient continued to deteriorate. Follow-up imaging was suggestive of PRES with signs of intracranial hypertension. The patient underwent a decompressive suboccipital craniectomy for refractory and severe PRES and later fully recovered. This case highlights the sometimes difficult diagnosis of PRES, possible association with pregnancy, eclampsia/preeclampsia and/or cerebrospinal fluid drainage, and the rare but life-saving need for decompression in severe cases.
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34
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Comellini V, Pacilli AMG, Nava S. Benefits of non-invasive ventilation in acute hypercapnic respiratory failure. Respirology 2019; 24:308-317. [PMID: 30636373 DOI: 10.1111/resp.13469] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/18/2018] [Accepted: 12/09/2018] [Indexed: 02/02/2023]
Abstract
Non-invasive ventilation (NIV) with bilevel positive airway pressure is a non-invasive technique, which refers to the provision of ventilatory support through the patient's upper airway using a mask or similar device. This technique is successful in correcting hypoventilation. It has become widely accepted as the standard treatment for patients with hypercapnic respiratory failure (HRF). Since the 1980s, NIV has been used in intensive care units and, after initial anecdotal reports and larger series, a number of randomized trials have been conducted. Data from these trials have shown that NIV is a valuable treatment for HRF. This review aims to explore the principal areas in which NIV can be useful, focusing particularly on patients with acute HRF (AHRF). We will update the evidence base with the goal of supporting clinical practice. We provide a practical description of the main indications for NIV in AHRF and identify the group of patients with hypercapnic failure who will benefit most from the application of NIV.
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Affiliation(s)
- Vittoria Comellini
- Respiratory and Critical Care Unit, University Hospital St Orsola-Malpighi, Bologna, Italy
| | - Angela Maria Grazia Pacilli
- Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Stefano Nava
- Respiratory and Critical Care Unit, University Hospital St Orsola-Malpighi, Bologna, Italy.,Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
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35
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Gama S, Sebitloane M, de Vasconcellos K. Outcomes of patients admitted to the intensive care unit for complications of hypertensive disorders of pregnancy at a South African tertiary hospital - a 4-year retrospective review. SOUTHERN AFRICAN JOURNAL OF CRITICAL CARE 2019; 35:10.7196/SAJCC.2019.v35i2.001. [PMID: 36960076 PMCID: PMC10029745 DOI: 10.7196/sajcc.2019.v35i2.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2019] [Indexed: 11/08/2022] Open
Abstract
Background Hypertensive disorders of pregnancy (HDP) are a major cause of maternal mortality and adverse outcomes. A previous study in the intensive care unit (ICU) at King Edward VIII Hospital, Durban, South Africa, in 2000 found 10.5% mortality among eclampsia patients. Objectives To describe the mortality and adverse neurological outcomes associated with HDP in a tertiary ICU, compare these with results from 2000 and describe factors associated therewith. Methods The data of 85 patients admitted with HDP to ICU at King Edward VIII Hospital from 2010 to 2013 were retrospectively reviewed. Mortality and adverse neurological outcome (Glasgow Coma Scale (GCS) ≤14 on discharge from ICU) were assessed. Two sets of analyses were conducted. The first compared those alive on discharge from ICU with those who died in ICU. The second compared good neurological outcome with poor outcome (adverse neurological outcome, or death). Results The mortality was 11.6%, and overall, 9% had adverse neurological outcomes. There was no significant difference in mortality between patients with eclampsia in 2010 - 2013 (11.0%) and those in 2000 (10.5%) (p=0.9). Factors associated with mortality were: intra- or postpartum onset of seizures; twins; failure to perform operative delivery when indicated; lowest GCS score <10; failure to use magnesium sulphate when indicated; respiratory failure; and lower respiratory tract infections. Factors associated with poor outcomes (adverse neurological outcome, or death) were: parity (better outcomes in primiparous patients); time of antenatal onset of hypertension (worse if earlier onset); HIV infection; failure to perform operative delivery when indicated; lowest GCS score <10; failure to use magnesium sulphate when indicated; use of anticonvulsants other than magnesium sulphate or benzodiazepines in eclampsia. Conclusion The lack of improvement in ICU eclampsia mortality demonstrates a need to develop and implement a protocol for HDP management. Contributions of the study The study provides a comparison of present mortality among eclamptic patients with hyperensive disorders of pregnancy (HDP) with the mortality of eclamptic patients described in an article from the year 2000. It further looks at adverse maternal outcomes, specifically adverse neurological outcomes.In addition, it analyses other factors that may affect outcomes in HDP patients. This information is useful in making recommendations in an attempt to improve the outcomes.
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Affiliation(s)
- S Gama
- Department of Anesthesiology and Critical Care, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - M Sebitloane
- Department of Obstetrics and Gynaecology, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - K de Vasconcellos
- Department of Anesthesiology and Critical Care, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
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36
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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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Delgado-López PD, Garcés-Pérez G, García-Carrasco J, Alonso-García E, Gómez-Menéndez AI, Martín-Alonso J. Posterior Reversible Encephalopathy Syndrome with Status Epilepticus Following Surgery for Lumbar Stenosis and Spondylolisthesis. World Neurosurg 2018; 116:309-315. [PMID: 29864559 DOI: 10.1016/j.wneu.2018.05.174] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 05/23/2018] [Accepted: 05/24/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiologic condition encountered in many different clinical settings; it generally occurs in the context of hypertensive crisis, immunosuppressive therapy, or autoimmune diseases. It is characterized by headache, stupor, seizures, and visual alterations. Magnetic resonance imaging findings include white matter changes preferentially in the parieto-occipital regions. Although pathogenesis is not fully elucidated, vasoconstriction and brain hypoperfusion seem to be the cause of brain ischemia and vasogenic edema. Cerebrospinal fluid hypotension is also a reported plausible pathogenic mechanism. CASE DESCRIPTION We present a case of PRES following laminectomy and fixation for L4-5 lumbar stenosis and spondylolisthesis. The patient presented with status epilepticus immediately after surgery that lasted 5 days. Brain magnetic resonance imaging showed fluid attenuated inversion recovery and T2 hyperintensities in the bilateral parietal and occipital lobes and external capsules. On the basis of postoperative lumbar images, we hypothesized that an unnoticed cerebrospinal fluid leak might have contributed to development of PRES. The patient developed multiple postoperative complications but ultimately recovered after treatment for severe hypertension and seizures. CONCLUSIONS Prompt recognition and treatment of this potentially life-threatening syndrome is necessary to increase the likelihood of favorable outcome. Spinal surgeons need to be aware of the possibility of neurologic deterioration after spinal surgery and be alert about the occurrence of a dural leak, either recognized or unnoticed, as the plausible mechanism triggering PRES.
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Affiliation(s)
| | - Gloria Garcés-Pérez
- Department of Anesthesiology, Hospital Universitario de Burgos, Burgos, Spain
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38
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Acar H, Acar K. Posterior reversible encephalopathy syndrome in a pregnant patient without eclampsia or preeclampsia. Am J Emerg Med 2018; 36:1721.e3-1721.e4. [PMID: 29880411 DOI: 10.1016/j.ajem.2018.05.074] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 05/29/2018] [Indexed: 11/25/2022] Open
Abstract
Posterior Reversible Encephalopathy syndrome (PRES) is a rare neurologic disorder characterised by vasogenic edema in occipital and parietal lobes on MR. Patients usually complain about headache, visual disturbance, seizure and altered mental status. We repot a case of PRES seen in a pregnant patient. Although pre-eclampsia and eclampsia are among the common causes of this syndrome in this case patient was normotensive and no proteinuria was present. To our knowledge this is the first PRES case presented of a pregnant patient without eclampsia or pre-eclampsia.
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Affiliation(s)
- Hüseyin Acar
- Atatürk Eğitim ve Araştırma Hastanesi Basın Sitesi, Izmir 35360, Emergency Department, Turkey.
| | - Kadriye Acar
- Sakarya Üniversitesi, Sağlık bilimleri enstitüsü, Kemalpaşa Mahallesi Üniversite Caddesi, 54050 Serdivan, Sakarya, Turkey
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39
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Syndrome d'encéphalopathie postérieure réversible ou Posterior Reversible Encephalopathy Syndrome (PRES) secondaire au bevacizumab. ANNALES FRANCAISES DE MEDECINE D URGENCE 2018. [DOI: 10.1007/s13341-017-0788-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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40
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Hayman EG, Wessell A, Gerzanich V, Sheth KN, Simard JM. Mechanisms of Global Cerebral Edema Formation in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2017; 26:301-310. [PMID: 27995510 DOI: 10.1007/s12028-016-0354-7] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
A growing body of clinical literature emphasizes the impact of cerebral edema in early brain injury following aneurysmal subarachnoid hemorrhage (aSAH). Aneurysm rupture itself initiates global cerebral edema in up to two thirds of cases. Although cerebral edema is not a universal feature of aSAH, it portends a poor clinical course, with quantitative analysis revealing a direct correlation between cerebral edema and poor outcome, including mortality and cognitive deficits. Mechanistically, global cerebral edema has been linked to global ischemia at the time of aneurysm rupture, dysfunction of autoregulation, blood breakdown products, neuroinflammation, and hyponatremia/endocrine abnormalities. At a molecular level, several culprits have been identified, including aquaporin-4, matrix metalloproteinase-9, SUR1-TRPM4 cation channels, vascular endothelial growth factor, bradykinin, and others. Here, we review these cellular and molecular mechanisms of global cerebral edema formation in aSAH. Given the importance of edema to the outcome of patients with aSAH and its status as a highly modifiable pathological process, a better understanding of cerebral edema in aSAH promises to hasten the development of medical therapies to improve outcomes in this frequently devastating disease.
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Affiliation(s)
- Erik G Hayman
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA
| | - Aaron Wessell
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA
| | - Volodymyr Gerzanich
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA
| | - Kevin N Sheth
- Department of Neurology, Yale New Haven Hospital, New Haven, CT, USA.,Department of Neurosurgery, Yale New Haven Hospital, New Haven, CT, USA
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA. .,Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA. .,Department of Physiology, University of Maryland School of Medicine, Baltimore, MD, USA.
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41
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Chaudhary RK, Dhakal P, Aryal A, Bhatt VR. Central nervous system complications after allogeneic hematopoietic stem cell transplantation. Future Oncol 2017; 13:2297-2312. [PMID: 28984145 DOI: 10.2217/fon-2017-0274] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Allogenic hematopoietic stem cell transplant (alloSCT) is a potentially curative modality of treatment for patients with hematological malignancies. However, CNS complications following transplant pose a risk to survival of the patients. Early recognition and management of these complications are crucial to reduce morbidity and mortality of patients following transplant. Early CNS complications associated with alloSCT are infection, cerebrovascular events, chemotherapy and radiation-induced toxicities while late complications include post-transplant lymphoproliferative disorder, CNS relapse of underlying malignancy and viral and fungal infections. Development of graft-versus-host disease can further increase the risk of CNS complications and outcomes after alloSCT. Strategies aimed to reduce the risk of CNS complications and early management may ameliorate the morbidity and mortality in transplant recipients.
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Affiliation(s)
- Ranjit Kumar Chaudhary
- Department of Radiodiagnosis & Imaging, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Prajwal Dhakal
- Department of Medicine, Michigan State University, East Lansing, MI 48824, USA
| | - Aashrayata Aryal
- Department of Neurology, University of Nebraska Medical Center; Omaha, NE 68198, USA
| | - Vijaya Raj Bhatt
- Department of Internal Medicine, Division of Hematology & Oncology, University of Nebraska Medical Center; Omaha, NE 68198, USA
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42
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Posterior reversible encephalopathy syndrome in children with kidney disease. Int Urol Nephrol 2017; 49:1793-1800. [DOI: 10.1007/s11255-017-1684-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 08/17/2017] [Indexed: 01/13/2023]
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Nakamura K, Saiki H, Muramatsu H, Morinaga S, Kobayashi I, Kajikawa K, Nishikawa G, Kato Y, Watanabe M, Kanao K, Sumitomo M. Axitinib-induced reversible posterior leukoencephalopathy syndrome in a patient with metastatic renal cell carcinoma. Int Cancer Conf J 2017; 6:197-199. [PMID: 31149502 DOI: 10.1007/s13691-017-0306-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 07/25/2017] [Indexed: 10/19/2022] Open
Abstract
A 61-year-old woman with metastatic renal carcinoma was treated with axitinib as a second-line tyrosine kinase inhibitor. Thirteen days after the treatment, the patient developed reversible posterior leukoencephalopathy syndrome (RPLS). Her symptoms and imaging findings resolved after withdrawal of axitinib, blood pressure control, and administration of glycerin and levetiracetam. RPLS should be kept in mind as a possible rare adverse event after axitinib administration.
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Affiliation(s)
- Kogenta Nakamura
- Department of Urology, Aichi Medical University School of Medicine, 1-1 Karimata, Yazako, Nagakute, Aichi 480-1195 Japan
| | - Hiroshi Saiki
- Department of Urology, Aichi Medical University School of Medicine, 1-1 Karimata, Yazako, Nagakute, Aichi 480-1195 Japan
| | - Hiroyuki Muramatsu
- Department of Urology, Aichi Medical University School of Medicine, 1-1 Karimata, Yazako, Nagakute, Aichi 480-1195 Japan
| | - Shingo Morinaga
- Department of Urology, Aichi Medical University School of Medicine, 1-1 Karimata, Yazako, Nagakute, Aichi 480-1195 Japan
| | - Ikuo Kobayashi
- Department of Urology, Aichi Medical University School of Medicine, 1-1 Karimata, Yazako, Nagakute, Aichi 480-1195 Japan
| | - Keishi Kajikawa
- Department of Urology, Aichi Medical University School of Medicine, 1-1 Karimata, Yazako, Nagakute, Aichi 480-1195 Japan
| | - Genya Nishikawa
- Department of Urology, Aichi Medical University School of Medicine, 1-1 Karimata, Yazako, Nagakute, Aichi 480-1195 Japan
| | - Yoshiharu Kato
- Department of Urology, Aichi Medical University School of Medicine, 1-1 Karimata, Yazako, Nagakute, Aichi 480-1195 Japan
| | - Masahito Watanabe
- Department of Urology, Aichi Medical University School of Medicine, 1-1 Karimata, Yazako, Nagakute, Aichi 480-1195 Japan
| | - Kent Kanao
- Department of Urology, Aichi Medical University School of Medicine, 1-1 Karimata, Yazako, Nagakute, Aichi 480-1195 Japan
| | - Makoto Sumitomo
- Department of Urology, Aichi Medical University School of Medicine, 1-1 Karimata, Yazako, Nagakute, Aichi 480-1195 Japan
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Torres MU, Delgado LV, Giraldo N, Urueña P, Franco S, Hernández OH. [Posterior reversible encephalopathy syndrome: Report of a fatal case and analysis of predictive factors of a poor prognosis]. BIOMEDICA : REVISTA DEL INSTITUTO NACIONAL DE SALUD 2017; 37:13-19. [PMID: 28527261 DOI: 10.7705/biomedica.v37i2.3299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 06/28/2016] [Indexed: 06/07/2023]
Abstract
Posterior reversible encephalopathy syndrome is an illness with multiple causes and distinctive clinicalradiological characteristics that should be known by intensivists and emergency room physicians for a timely diagnosis and treatment. A fatal case of posterior reversible encephalopathy syndrome is presented, and the risk factors related to the outcome are identified.A 60-year-old man without a relevant medical history arrived at the emergency room presenting with depressed consciousness, seizures, and high blood pressure. Tomographic images revealed a posterior cerebellar hematoma. Resonance images showed ischemic zones, vasogenic edema from the thalamus to the brain stem, middle cerebellar peduncles, deep white matter of the cerebral hemispheres, and zones of hemorrhagic transformation. Despite medical-surgical management, the patient died. The risk factors described as the cause of the fatal outcome were identified. This case demonstrates that posterior reversible encephalopathy syndrome can occur without triggering risk factors and highlights the need for early recognition to establish an appropriate intervention to avoid injury or a fatal outcome. Cases of posterior reversible encephalopathy syndrome provide opportunities to investigate the susceptibility for the development of this condition and to establish appropriate preventive measures.
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Affiliation(s)
- Moisés Ulises Torres
- Especialización en Medicina Crítica y Cuidados Intensivos, Facultad de Medicina, Universidad CES, Medellín, Colombia.
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45
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Neurologic complications in critically ill pregnant patients. HANDBOOK OF CLINICAL NEUROLOGY 2017. [PMID: 28190440 DOI: 10.1016/b978-0-444-63599-0.00035-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Neurologic complications in a critically ill pregnant woman are uncommon but some of the complications (such as eclampsia) are unique to pregnancy and the puerperal period. Other neurologic complications (such as seizures in the setting of epilepsy) may worsen during pregnancy. Clinical signs and symptoms such as seizure, headache, weakness, focal neurologic deficits, and decreased level of consciousness require careful consideration of potential causes to ensure prompt treatment measures are instituted to prevent ongoing neurologic injury. Clinicians should be familiar with syndromes such as pre-eclampsia, eclampsia, stroke, posterior reversible encephalopathy syndrome, and reversible cerebral vasoconstriction syndrome. Necessary imaging studies can usually be performed safely in pregnancy. Scoring systems for predicting maternal mortality are inadequate, as are recommendations for neurorehabilitation. Tensions can arise when there is conflict between the interests of the mother and the interests of the fetus, but in general maternal health is prioritized. The complexity of care requires a multidisciplinary and multiprofessional approach to achieve best outcome in an often unexpected situation.
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46
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John ES, Sedhom R, Dalal I, Sharma R. Posterior reversible encephalopathy syndrome in alcoholic hepatitis: Hepatic encephalopathy a common theme. World J Gastroenterol 2017; 23:373-376. [PMID: 28127211 PMCID: PMC5236517 DOI: 10.3748/wjg.v23.i2.373] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 09/06/2016] [Accepted: 10/10/2016] [Indexed: 02/06/2023] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a neuro-radiologic diagnosis that has become more widely recognized and reported over the past few decades. As such, there are a number of known risk factors that contribute to the development of this syndrome, including volatile blood pressures, renal failure, cytotoxic drugs, autoimmune disorders, pre-eclampsia, and eclampsia. This report documents the first reported case of PRES in a patient with severe alcoholic hepatitis with hepatic encephalopathy and delves into a molecular pathophysiology of the syndrome.
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Chen CY, Hung SY, Lee YJ, Lin YC, Pai CC. Delayed onset of posterior reversible encephalopathy syndrome in a case of scleroderma renal crisis with maintenance hemodialysis: Case report and literature review. Medicine (Baltimore) 2016; 95:e5725. [PMID: 28033278 PMCID: PMC5207574 DOI: 10.1097/md.0000000000005725] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [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
INTRODUCTION In some cases, scleroderma renal crisis (SRC) is not easily distinguishable from other thrombotic microangiopathies such as thrombotic thrombocytopenic purpura, especially when the presentation includes neurological or extra-renal manifestations. Here, we present a case of SRC who developed a rare neurotoxic complication, posterior reversible encephalopathy syndrome (PRES).A 36-year-old man with a history of diffuse cutaneous systemic sclerosis developed SRC and acute-on-chronic renal failure and ultimately required maintenance hemodialysis. Three weeks after starting hemodialysis, the patient presented with confusion and a new-onset seizure disorder. Laboratory examinations revealed thrombocytopenia, a low haptoglobin level, and schizocytes on a blood smear. SRC-related PRES was considered first after PRES was confirmed by brain magnetic resonance imaging. Antihypertensive therapy comprising captopril and amlodipine was administered, and the patient experienced a complete neurological recovery 3 days later without plasma exchange. In all previously reported cases of SRC-associated PRES, PRES developed before hemodialysis. Our report is, therefore, the first to describe a case of onset of SRC-related PRES 3 weeks after the initiation of maintenance hemodialysis. CONCLUSION This case demonstrates that microangiopathy and extra-renal manifestations can develop even in SRC patients with end-stage renal disease and that these manifestations can be successfully managed with angiotensin-converting enzyme inhibitors (ACEIs) and aggressive blood pressure control. We recommend continuing ACEI therapy if elevated blood pressure persists after maintenance hemodialysis.
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Affiliation(s)
- Ching-Yang Chen
- Division of Nephrology, Department of Internal Medicine, E-DA Hospital, No. 1, Yida Road, Jiaosu Village, Yanchao District, Kaohsiung City 82445, Taiwan, R.O.C
| | - Shin-Yuan Hung
- Division of Nephrology, Department of Internal Medicine, E-DA Hospital, No. 1, Yida Road, Jiaosu Village, Yanchao District, Kaohsiung City 82445, Taiwan, R.O.C
- School of Medicine for International Students, I-Shou University, No. 8, Yida Rd., Jiaosu Village Yanchao District, Kaohsiung City 82445, Taiwan, R.O.C
| | - Yi-Jer Lee
- Division of Nephrology, Department of Internal Medicine, E-DA Hospital, No. 1, Yida Road, Jiaosu Village, Yanchao District, Kaohsiung City 82445, Taiwan, R.O.C
| | - Yi-Chan Lin
- Division of Nephrology, Department of Internal Medicine, E-DA Cancer Hospital, No. 21, Yida Road, Jiaosu Village, Yanchao District, Kaohsiung City 82445, Taiwan, R.O.C
| | - Chu-Cheng Pai
- Division of Nephrology, Department of Internal Medicine, E-DA Cancer Hospital, No. 21, Yida Road, Jiaosu Village, Yanchao District, Kaohsiung City 82445, Taiwan, R.O.C
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48
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Alves DR, Cruz C, Antunes C, Gonçalves N, Aquino E, Franco S, Carvalho C, Pais Martins A. Posterior Reversible Encephalopathy Syndrome in a pregnant patient: a PRESsing matter. Acta Anaesthesiol Scand 2016; 60:1473-1476. [PMID: 27666320 DOI: 10.1111/aas.12812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 07/12/2016] [Accepted: 08/31/2016] [Indexed: 11/30/2022]
Affiliation(s)
- D. R. Alves
- Centro Hospitalar de Lisboa Ocidental; Lisbon Portugal
| | - C. Cruz
- Centro Hospitalar de Lisboa Central; Lisbon Portugal
| | - C. Antunes
- Centro Hospitalar de Lisboa Ocidental; Lisbon Portugal
| | - N. Gonçalves
- Centro Hospitalar de Lisboa Ocidental; Lisbon Portugal
| | - E. Aquino
- Centro Hospitalar de Lisboa Ocidental; Lisbon Portugal
| | - S. Franco
- Centro Hospitalar de Lisboa Ocidental; Lisbon Portugal
| | - C. Carvalho
- Centro Hospitalar de Lisboa Ocidental; Lisbon Portugal
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Dhakal LP, Harriott AM, Capobianco DJ, Freeman WD. Headache and Its Approach in Today's NeuroIntensive Care Unit. Neurocrit Care 2016; 25:320-34. [PMID: 27000642 DOI: 10.1007/s12028-016-0260-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Headache is a very common symptom in the neurointensive care unit (neuroICU). While headache in the neuroICU can be caused by worsening of a pre-existing primary headache disorder, most are secondary to another condition. Additionally, headache can be the presenting symptom of a number of conditions requiring prompt recognition and treatment including subarachnoid hemorrhage, ischemic and hemorrhagic stroke, central nervous system infection, pituitary apoplexy, and cerebral vasoconstriction. The neuroICU also has a unique postoperative population in which postcraniectomy and postcraniotomy headache, postintravascular intervention headache, hyperperfusion syndrome, ventriculitis, medication overuse or withdrawal headache, and hypercapnia may be encountered. Management varies dramatically depending on the etiology of the headache. Overreliance on opiate analgesics may produce significant adverse effects and lengthen ICU stays. However, nonnarcotic medications are increasingly being recognized as helpful in reducing the pain among various postsurgical and headache patients. Taken together, a multimodal approach targeting the underlying pathology and choosing appropriate systemic and local analgesic medications may be the best way to manage headache in critically ill patients.
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Affiliation(s)
- Laxmi P Dhakal
- Departments of Neurology and Critical Care, Mayo Clinic, Jacksonville, FL, 32224, USA
| | | | | | - William D Freeman
- Departments of Neurology, Neurosurgery, and Critical Care, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
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50
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Solh Z, Taccone MS, Marin S, Athale U, Breakey VR. Neurological PRESentations in Sickle Cell Patients Are Not Always Stroke: A Review of Posterior Reversible Encephalopathy Syndrome in Sickle Cell Disease. Pediatr Blood Cancer 2016; 63:983-9. [PMID: 26871763 DOI: 10.1002/pbc.25932] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 12/24/2015] [Accepted: 01/12/2016] [Indexed: 01/05/2023]
Abstract
Acute neurological changes in sickle cell disease (SCD) patients often raise the suspicion for stroke. Posterior reversible encephalopathy syndrome (PRES) can mimic stroke in its clinical presentation. We aimed to (i) review the PRES literature in SCD patients including clinical presentation, risk factors, pathophysiology, and management and (ii) elucidate the distinction between PRES and stroke in SCD. The exact pathophysiology of PRES in SCD remains elusive but is likely multifactorial and related to sickling, ischemia, and chronic anemia predisposing to vasogenic edema. PRES and stroke in SCD are distinguishable conditions. Our review may help elucidate a clinical approach to this distinction.
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Affiliation(s)
- Ziad Solh
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Michael S Taccone
- Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Samantha Marin
- Division of Pediatric Neurology, Department of Pediatrics, Health Sciences Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Uma Athale
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Vicky R Breakey
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
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