Reversible posterior leukoencephalopathy syndrome in a patient with Takayasu arteritis

Corticosteroids in posterior reversible encephalopathy syndrome: Friend or foe? A systematic review

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) is a complex neurological disorder characterized by symptoms such as headaches, seizures, confusion, and visual disturbances. The pathophysiology of PRES involves endothelial dysfunction, disrupted cerebral autoregulation, and resulting vasogenic edema. Hypertension and other factors that alter cerebral autoregulation are critical in its development. Corticosteroids, widely used for their anti-inflammatory and immunosuppressive properties, play a controversial role in PRES.

AIM

To elucidate the dual role of corticosteroids in the context of PRES by critically evaluating the existing literature. Specifically, it seeks to assess the results of PRES induced by corticosteroid therapy and the efficacy and safety of corticosteroids in the treatment of PRES. By synthesizing case reports and series, this review aims to provide a comprehensive understanding of the mechanisms, clinical presentations, and management strategies associated with corticosteroid-related PRES.

METHODS

The review was carried out according to the PRISMA guidelines. The databases searched included Science Direct, PubMed, and Hinari. The search strategy encompassed terms related to corticosteroids and PRES. Studies were included if they were peer-reviewed articles examining corticosteroids in PRES, excluding non-English publications, reviews, and editorials. Data on patient demographics, clinical characteristics, imaging findings, corticosteroid regimens, and outcomes were extracted. The risk of bias was evaluated using the Joanna Briggs Institute tool for case reports.

RESULTS

A total of 56 cases of PRES (66.1% women, 33.9% men) potentially induced by corticosteroids and 14 cases in which corticosteroids were used to treat PRES were identified. Cases of PRES reportedly caused by corticosteroids showed a mean age of approximately 25.2 years, with seizures, headaches, hypertension, and visual disturbances being common clinical sequelae. Magnetic resonance findings typically revealed vasogenic edema in the bilateral parieto-occipital lobes. High-dose or prolonged corticosteroid therapy was a significant risk factor. On the contrary, in the treatment cases, corticosteroids were associated with positive outcomes, including resolution of vasogenic edema and stabilization of symptoms, particularly in patients with underlying inflammatory or autoimmune diseases.

CONCLUSION

Corticosteroids have a dual role in PRES, capable of both inducing and treating the condition. The current body of literature suggests that corticosteroids may play a greater role as a precipitating agent of PRES rather than treating. Corticosteroids may induce PRES through hypertension and subsequent increased cerebral blood flow and loss of autoregulation. Corticosteroids may aid in the management of PRES: (1) Enhancing endothelial stability; (2) Anti-inflammatory properties; and (3) Improving blood-brain barrier integrity. Mechanisms which may reduce or mitigate vasogenic edema formation.

Relapsing Polychondritis with a Cobble-stone Appearance of the Tracheal Mucosa, Preceded by Posterior Reversible Encephalopathy Syndrome

A 25-year-old woman had convulsions and disturbance of consciousness. Head magnetic resonance imaging (MRI) showed punctate areas in the occipital lobes with increased signals on T2-weighted imaging. The MRI abnormalities responded well to steroid pulse therapy, so we made a diagnosis of posterior reversible encephalopathy syndrome (PRES). Three months later, she developed a fever and dyspnea. Chest computed tomography revealed marked thickness of the tracheal and bronchial wall, and bronchoscopy showed a cobble-stone appearance of the tracheal mucosa, indicative of relapsing polychondritis (RPC). We consider that PRES had developed due to autoimmune vasculitis in the brain with RPC.

Corticosteroid therapy and severity of vasogenic edema in posterior reversible encephalopathy syndrome

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) is a variable cerebrovascular syndrome associated with hypertension and autoregulatory failure. Steroids have been reported to both precipitate and treat PRES. We sought to determine the prevalence of steroid therapy at the time of PRES and to assess the relationship between steroid therapy and extent of vasogenic edema.

METHODS

We performed a retrospective review of radiology reports between 2008 and 2014 from two academic medical centers to identify cases of PRES. Clinical and radiographic data were collected. Descriptive statistics were used to determine the prevalence of corticosteroid therapy at the time of PRES onset and the latency from steroid initiation to PRES onset. The association between steroid therapy and extent of vasogenic edema was assessed in multiple regression models.

RESULTS

We identified 99 cases of PRES in 96 patients. The median age was 55years (IQR 30-65) and 74% were women. Steroid therapy at time of PRES onset was identified in 44 of 99 cases. Excluding patients on chronic therapy, the median duration of steroid exposure before PRES onset was 6 (IQR, 3-10) days. Steroid therapy was not associated with extent of vasogenic edema in unadjusted or linear and logistic regression models adjusted for age, sex, and maximum systolic blood pressure on day of onset.

CONCLUSION

Corticosteroid therapy, often of brief duration, frequently preceded the onset of PRES and was not associated with severity of vasogenic edema.

Cerebral vasculitis

The noninfectious, inflammatory vasculitides include giant cell arteritis, Takayasu disease, Churg-Strauss angiitis, Wegener disease, polyarteritis nodosa, microscopic polyangiitis, Buerger disease, amyloid-β-related angiitis, and isolated vasculitis of the central nervous system. While these disorders are relatively uncommon, they produce a variety of neurologic diseases including muscle disease, mononeuropathy multiplex, polyneuropathy, cranial nerve palsies, visual loss, seizures, an encephalopathy, venous thrombosis, ischemic stroke, and intracranial hemorrhage. The multisystem vasculitides often have stereotypical clinical findings that reflect disease of the kidney, sinuses, lungs, skin, joints, or cardiovascular system. These disorders also usually have abnormalities found on serologic testing. Isolated vasculitis of the central nervous system is more difficult to diagnose because the clinical and brain imaging findings are relatively nonspecific. Examination of the cerebrospinal fluid will demonstrate changes consistent with an inflammatory process. Arteriography often shows areas of segmental narrowing affecting multiple intracranial vessels and brain/meningeal biopsy may be required to establish the diagnosis. Management of patients with a multisystem vasculitis or isolated vasculitis of the central nervous system is centered on the administration of immunosuppressive agents. In many cases, corticosteroids remain the mainstay of medical treatment.

Takayasu's arteritis and posterior reversible encephalopathy syndrome: a case-based review

Autoimmune vasculitides can have diverse neurological manifestations, including posterior reversible encephalopathy syndrome (PRES). Takayasu's arteritis (TA) is an uncommon vasculitis rarely associated with PRES. Common clinical features of TA include hypertension, audible arterial bruits, absence of peripheral pulses, claudication of the extremities, reduced blood pressure in one or both arms, and angiographic abnormalities. PRES has been mostly associated with severe hypertension, endothelial injury, and conditions such as renal disease, immunosuppressive medication use, and rheumatologic diseases. Headaches, seizures, and altered mental status are the main clinical features as well as characteristic findings in magnetic resonance imaging. TA frequently presents with hypertension and is associated with endothelial injury, making this entity an ideal setting for the development of PRES. We report the case of a 17-year-old female who presented to the emergency department with severe hypertension, headache, and seizures. Magnetic resonance imaging findings were suggestive of PRES. She had absent pulses in the right upper extremity, abdominal bruits, and angiographic findings included subclavian and renal artery stenoses. The diagnosis of TA was made, and she responded well to treatment. We found ten additional cases of TA and PRES in the literature. All patients were females under the age of 40, had renovascular hypertension, and presented with headaches and seizures. Current literature relevant to this rare association is presented and discussed.

Neurological manifestations of Takayasu arteritis

OBJECTIVE

To investigate the clinical neurological manifestations of Takayasu arteritis (TA).

METHODS

A retrospective study was conducted with 63 consecutive TA cases admitted to Peking Union Medical College Hospital from January 2009 to May 2010. All the patients fulfilled the diagnostic criteria of TA by the American College of Rheumatology. Among the 63 TA patients, 27 with neurological manifestations were included in the present study. All the patients were evaluated using standardized neurological examination, sonography, computed tomography (CT) angiography, and cerebral CT or magnetic resonance imaging.

RESULTS

Dizziness and visual disturbance were the most common symptoms, which occurred in 20 (74.1%) and 16 (59.3%) patients respectively. Another common symptom was headache, observed in 15 (55.6%) patients. Six (22.2%) patients had suffered from ischemic stroke; 7 (25.9%) patients had epileptic seizures. Two (7.4%) patients were diagnosed as reversible posterior encephalopathy syndrome (RPES) based on typical clinical and imaging manifestations.

CONCLUSIONS

Neurological manifestations are common symptoms in TA patients in the chronic phase, including dizziness, visual disturbance, headache, ischemic stroke, seizures, and some unusual ones such as RPES. We suggested RPES be included into the differential diagnosis of acute neurological changes in TA.

Hypertensive crisis in young woman with Takayasu arteritis

A young woman who was experiencing repeated convulsions was admitted. The patient's brain magnetic resonance image revealed reversible posterior leukoencephalopathy. Blood pressure fluctuated at times to more than 200 mmHg, and the measurement of the right and left upper arms differed by approximately 70 mmHg. Enhanced computed tomography revealed stenotic lesions of some arteries including the left renal artery. Such findings led to an initial diagnosis of Takayasu arteritis and hypertensive encephalopathy caused by renovascular hypertension. A percutaneous transluminal renal angioplasty was successfully performed. The patient's blood pressure returned to normal value without the use of antihypertensive drugs.

Reversible cerebral vasoconstriction syndrome in a patient with Takayasu's arteritis

We herein present the first reported case of reversible cerebral vasoconstriction syndrome (RCVS) in Takayasu's arteritis (TA), in a patient with severe thunderclap headache and generalized tonic-clonic seizure. Magnetic resonance imaging and angiography revealed posterior reversible encephalopathy syndrome, followed by severe vasoconstriction in multiple arteries. RCVS should be included in the differential diagnosis of thunderclap headache attacks with radiologic intracranial vascular abnormalities in connective tissue diseases, including TA.