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Frati A, Armocida D, Tartara F, Cofano F, Corvino S, Paolini S, Santoro A, Garbossa D. Can Post-Operative Posterior Reversible Encephalopathy Syndrome (PRES) Be Considered an Insidious Rare Surgical Complication? Brain Sci 2023; 13:brainsci13050706. [PMID: 37239179 DOI: 10.3390/brainsci13050706] [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: 03/21/2023] [Revised: 04/11/2023] [Accepted: 04/20/2023] [Indexed: 05/28/2023] Open
Abstract
Introduction: Posterior reversible encephalopathy syndrome (PRES) is a neurological disorder characterized by neurological symptoms and distinctive neuroimaging findings. There are a few cases reported in the literature in which PRES can occur after surgery, and there is no clear direct relationship between a procedure and its debut. Methods: We performed a review of the literature by analyzing all reported cases of PRES syndrome which debuted after a surgical procedure with the aim of identifying the clinical features, the timing of the symptoms' onset and the therapy of patients suffering from this unusual surgical complication. Results: The total number of patients collected was 47, with a mean age of 40.9 years. Postoperative PRES can occur in either pediatric or adult patients (ages 4-82 years). The most frequent form of comorbidity reported was cardiovascular disease (fourteen patients, 29.78%). Sixteen patients (36%) had no relevant risk factors or comorbidities at the time of the surgical procedure. The types of surgery most correlated were cranial neuro and maxillofacial surgery (twenty-one patients, 44.68%) followed by transplant surgery (eight patients, 17%). The time of onset of PRES after surgery occurred within the first 3 weeks (mean time of onset 4.7 days), and when rapidly treated with antihypertensive and antiepileptic drugs appeared to have a reversible and benign course. Conclusion: PRES syndrome can be considered a rare complication of procedures and can occur following a wide range of surgeries, especially cranial and transplant surgery. Being able to recognize it in time and treat it ensures a full reversibility of symptoms in most cases.
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Affiliation(s)
- Alessandro Frati
- Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S), Neuromed, Via Atinense 18, 86077 Pozzilli, Italy
| | - Daniele Armocida
- Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S), Neuromed, Via Atinense 18, 86077 Pozzilli, Italy
- Human Neurosciences Department, Neurosurgery Division "Sapienza" University, AOU Policlinico Umberto I, 00161 Rome, Italy
| | - Fulvio Tartara
- Headache Science and Neurorehabilitation Center, IRCCS Mondino Foundation, Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy
| | - Fabio Cofano
- Neurosurgery, Department of Neuroscience, A.O.U. Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy
| | - Sergio Corvino
- Department of Neuroscience, Reproductive and Odontostomatological Sciences, Division of Neurosurgery Università degli Studi di Napoli Federico II, 80131 Naples, Italy
| | - Sergio Paolini
- Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S), Neuromed, Via Atinense 18, 86077 Pozzilli, Italy
| | - Antonio Santoro
- Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S), Neuromed, Via Atinense 18, 86077 Pozzilli, Italy
| | - Diego Garbossa
- Neurosurgery, Department of Neuroscience, A.O.U. Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy
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Oxford BG, Khattar NK, Adams SW, Schaber AS, Williams BJ. Posterior reversible encephalopathy syndrome with lumbar drainage and surgery: coincidence or correlation? A case report. BMC Neurol 2019; 19:214. [PMID: 31470816 PMCID: PMC6716908 DOI: 10.1186/s12883-019-1438-8] [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: 06/18/2019] [Accepted: 08/21/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a rare neurological disorder usually associated with specific medical conditions that cause a disturbance of the CNS homeostasis. It has seldom been reported to be a consequence of an iatrogenic intervention causing intracranial hypotension. CASE PRESENTATION We report the case of an individual 69-year-old male presenting with headache and blurred vision following cerebrospinal fluid (CSF) leak from resection of a sellar mass. The patient developed the condition following removal of the lumbar drain post-operatively. Magnetic Resonance Imaging showed bilateral occipital, parieto-occipital, and cerebellar T2 FLAIR hyper-intensities, suggesting a radiological diagnosis of posterior reversible encephalopathy syndrome (PRES). The patient's symptoms started to improve shortly afterwards and had completely resolved at 3 months follow-up. CONCLUSIONS The absence of severe hypertension and presence of an intraoperative CSF leak requiring placement of the lumbar drain suggests that decreased CSF volume and associated reactive hyperemia could have a role in the pathophysiology of the disease.
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Affiliation(s)
- Brent G Oxford
- Department of Neurological Surgery, University of Louisville School of Medicine, 220 Abraham Flexner Way, 15th Floor, Louisville, KY, 40202, USA
| | - Nicolas K Khattar
- Department of Neurological Surgery, University of Louisville School of Medicine, 220 Abraham Flexner Way, 15th Floor, Louisville, KY, 40202, USA
| | - Shawn W Adams
- Department of Neurological Surgery, University of Louisville School of Medicine, 220 Abraham Flexner Way, 15th Floor, Louisville, KY, 40202, USA
| | - Alexandra S Schaber
- Department of Neurological Surgery, University of Louisville School of Medicine, 220 Abraham Flexner Way, 15th Floor, Louisville, KY, 40202, USA
| | - Brian J Williams
- Department of Neurological Surgery, University of Louisville School of Medicine, 220 Abraham Flexner Way, 15th Floor, Louisville, KY, 40202, USA.
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Unusual Delayed Presentation of Posterior Reversible Encephalopathy Syndrome Following Vestibular Schwannoma Surgery: A Rare Neurologic Emergency. World Neurosurg 2018; 120:532-536. [PMID: 30261399 DOI: 10.1016/j.wneu.2018.09.084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/07/2018] [Accepted: 09/11/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a rare neurologic condition that manifests with heterogeneous clinical findings, including altered mental status, seizure, vision loss, and vomiting. It characteristically leads to diffuse subcortical vasogenic edema, most commonly in the parieto-occipital regions. Although frequently reported with conditions such as hypertension, eclampsia, sepsis, electrolyte imbalances, autoimmune diseases, and immunosuppressive therapy, PRES may rarely occur after surgery for posterior fossa tumors. In the postsurgical setting, clinical features of PRES usually develop intraoperatively or in the immediate postoperative period. Delayed presentation months after the surgery has not been reported earlier. CASE DESCRIPTION A 23-year-old woman who underwent surgery for vestibular schwannoma 8 months earlier presented with altered sensorium, generalized seizures, and high blood pressure. Common possibilities were ruled out by clinical history, diagnostic imaging, and appropriate blood tests. Radiologic imaging revealed rapid recurrence of tumor with diffuse subcortical edema involving both hemispheres. The patient showed complete neurologic recovery with antihypertensive and antiepileptic drugs. CONCLUSIONS PRES is a rare but important cause of acute neurologic deterioration following posterior fossa tumor surgery. Prompt diagnosis and aggressive treatment often lead to complete neurologic recovery.
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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: 5] [Impact Index Per Article: 0.8] [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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Niwa R, Oya S, Nakamura T, Hana T, Matsui T. Rapid intracranial pressure drop as a cause for posterior reversible encephalopathy syndrome: Two case reports. Surg Neurol Int 2017; 8:103. [PMID: 28695050 PMCID: PMC5473084 DOI: 10.4103/sni.sni_55_17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Accepted: 02/23/2017] [Indexed: 01/12/2023] Open
Abstract
Background: Posterior reversible encephalopathy syndrome (PRES) is characterized by reversible edematous lesions on radiological examinations as well as symptoms of altered consciousness and seizures. To date, the underlying mechanism remains largely unknown. Case Descriptions: Case 1 is a 72-year-old man with a history of hypertension presented with a subarachnoid hemorrhage. Fourteen days after the successful clipping of a ruptured aneurysm; he experienced inadvertent overdrainage via the intraventricular drain. Nine hours later, he started to have seizures followed by disturbances in consciousness. An emergency magnetic resonance imaging showed multiple high-intensity lesions in the frontal, temporal, parietal, and occipital lobes, basal ganglia, brainstem, and cerebellar hemispheres bilaterally, which are compatible with typical magnetic resonance findings in PRES patients. He was treated conservatively and recovered well. Case 2 is a 68-year-old woman with a mild history of hypertension and a ventriculo-peritoneal shunt for obstructive hydrocephalus, who underwent a cysto-peritoneal shunt placement because of an enlarging symptomatic arachnoid cyst. Immediately following surgery, she experienced disturbances in consciousness and developed status epilepticus. Radiological examinations revealed remarkable shrinkage of the arachnoid cyst and multiple edematous lesions, which led us to strongly suspect PRES. With conservative treatment, her symptoms and the radiological abnormalities disappeared. Conclusion: Based on the previous literature and our cases, we believe that the association between rapid reduction of intracranial pressure (ICP) and the development of PRES should be recognized because most neurosurgical procedures such as craniotomy or cerebrospinal fluid diversion present a potential risk of rapid reduction of ICP.
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Affiliation(s)
- Ryoko Niwa
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Soichi Oya
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Takumi Nakamura
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Taijun Hana
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Toru Matsui
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
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Wakasaki T, Gotoh S, Tomonobe E, Mihara T, Fukushima J. Posterior Reversible Encephalopathy Syndrome During Combined Modality Therapy for Head and Neck Squamous Cell Carcinoma. Ann Otol Rhinol Laryngol 2016; 125:844-9. [PMID: 27317313 DOI: 10.1177/0003489416654710] [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] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Posterior reversible encephalopathy syndrome (PRES) is a rare and acute disease with central nervous system symptoms. Without appropriate therapy, patients may exhibit a poor prognosis. PRES should be recognized as a possible problem during therapy for head and neck squamous cell carcinoma (HNSCC). METHODS A 56-year-old female developed PRES during combined modality therapy for HNSCC. On the fourth day after surgery and following chemoradiotherapy, PRES developed with a sudden visual disorder, followed by headache located at the back of the head and convulsions accompanied by impaired consciousness. We diagnosed PRES based on the clinical manifestations and magnetic resonance imaging data. RESULTS The patient recovered from PRES by appropriate treatment. CONCLUSION This is the first case report of PRES developed during treatment for HNSCC. Masked by other cerebrovascular disorders, more cases of PRES could exist than usually expected; therefore, we should consider PRES as a differential diagnosis for central nervous system disorders developing during high-intensity therapy.
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Affiliation(s)
- Takahiro Wakasaki
- Department of Otorhinolaryngology, Japanese Red Cross Fukuoka Hospital, Fukuoka, Japan
| | - Seiji Gotoh
- Department of Cerebrovascular Medicine, Japanese Red Cross Fukuoka Hospital, Fukuoka, Japan
| | - Eri Tomonobe
- Department of Otorhinolaryngology, Japanese Red Cross Fukuoka Hospital, Fukuoka, Japan
| | - Takenao Mihara
- Department of Otorhinolaryngology, Japanese Red Cross Fukuoka Hospital, Fukuoka, Japan
| | - Junichi Fukushima
- Department of Otorhinolaryngology, Japanese Red Cross Fukuoka Hospital, Fukuoka, Japan
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González Quarante LH, Mena-Bernal JH, Martín BP, Ramírez Carrasco M, Muñoz Casado MJ, Martínez de Aragón A, de las Heras RS. Posterior reversible encephalopathy syndrome (PRES): a rare condition after resection of posterior fossa tumors: two new cases and review of the literature. Childs Nerv Syst 2016; 32:857-63. [PMID: 26584552 DOI: 10.1007/s00381-015-2954-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 11/05/2015] [Indexed: 11/25/2022]
Abstract
INTRODUCTION In 1996, Hinchey and colleagues coined the term "Posterior reversible encephalopathy syndrome" (PRES) to describe a condition seen in patients with acute neurological symptoms and reversible subcortical vasogenic edema predominantly involving parieto-occipital areas demonstrated in brain MRI. The occurrence of this phenomenon after surgical resection of CNS tumors is typically linked to pediatric cases. MATERIAL AND METHODS Two new cases of PRES after posterior fossa surgery are reported. A thorough review of the literature is carried out with the purpose of updating and summarizing the main features regarding PRES in similar cases. Seven cases of PRES after resection of a posterior fossa tumor have been hitherto reported (4 patients were <20 years old). There is another pediatric case described after a ventriculoperitoneal shunting procedure in a patient with fourth ventricle ependymoma. Two resected tumors were ependymomas, 2 hemangiopericytomas in one patient, 1 pilocyticastrocytoma, 1 vestibular schwannoma, and 1 of the reported cases did not describe the final pathology diagnosis. CASE REPORTS We present 2 new cases of PRES after surgical resection of a posterior fossa tumor (medulloblastoma in case 1 and ependymoma in case 2) in pediatric patients. Case 1 developed delayed seizures and altered mental status(10 days after surgical resection) after receiving treatment with bromocriptine for cerebellar mutism. Case 2 presented with generalized seizures and altered mental status within the first 48 postoperative hours followed by right hemiparesis. Both patients fully recovered and returned to neurological baseline status. A thorough review of the literature was carried out with the purpose of updating and summarizing the main features regarding PRES in similar cases. CONCLUSIONS We report 2 new pediatric cases of posterior reversible encephalopathy syndrome (PRES) that developed after surgical resection of a posterior fossa tumor. Appropriate management includes supportive measures, antihypertensive agents, and antiepileptic drugs, if needed. Full recovery is the most likely outcome in line with previous articles.
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Affiliation(s)
- Lain Hermes González Quarante
- Department of Pediatric Neurosurgery, Hospital General 12 de Octubre, Madrid, Spain.
- Department of Neurosurgery, HGU Gregorio Marañón, Calle Doctor Esquerdo número 46, C.P, 28007, Madrid, Spain.
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