Posterior reversible encephalopathy syndrome in the emergency department: A single center retrospective study

Posterior reversible encephalopathy syndrome due to nonadherence to antihypertensive treatment: A case report from Nepal

Key Clinical Message

Posterior reversible encephalopathy syndrome may occur secondary to abrupt cessation of antihypertensive therapy. A gradual reduction in blood pressure and counseling regarding medication adherence are crucial to prevent adverse consequences.

Abstract

Posterior reversible encephalopathy syndrome (PRES) is a reversible clinical radiographic syndrome with headache, hypertensive encephalopathy, seizures, and visual disturbances as common modes of presentation. PRES can be attributed to several risk factors. We reported the case of a 66-year-old Asian female with PRES following nonadherence to antihypertensive treatment. Initially, her computed tomography scan of the head was normal. After 48 h, we again ordered a head CT scan, which showed lesions suggestive of hypertensive encephalopathy. We immediately reduced 20%-25% of mean arterial pressure, followed by a gradual blood pressure lowering to avoid adverse consequences. We did a follow-up CT scan of the head at 2 weeks, showing the resolution of early lesions. Hence, we made a diagnosis of PRES. In these patients, it is crucial to ensure medication adherence to avoid complications.

Misdiagnosis of Posterior Reversible Encephalopathy Syndrome and Reversible Cerebral Vasoconstriction Syndrome in the Emergency Department

Background Cerebrovascular dysregulation syndromes, posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS), are challenging to diagnose because they are rare and require advanced neuroimaging for confirmation. We sought to estimate PRES/RCVS misdiagnosis in the emergency department and its associated factors. Methods and Results We conducted a retrospective cohort study of PRES/RCVS patients using administrative claims data from 11 states (2016-2018). We defined patients with a probable PRES/RCVS misdiagnosis as those with an emergency department visit for a neurological symptom resulting in discharge to home that occurred ≤14 days before PRES/RCVS hospitalization. Proportions of patients with probable misdiagnosis were calculated, characteristics of patients with and without probable misdiagnosis were compared, and regression analyses adjusted for demographics and comorbidities were performed to identify factors affecting probable misdiagnosis. We identified 4633 patients with PRES/RCVS. A total of 210 patients (4.53% [95% CI, 3.97-5.17]) had a probable preceding emergency department misdiagnosis; these patients were younger (mean age, 48 versus 54 years; P<0.001) and more often female (80.4% versus 69.3%; P<0.001). Misdiagnosed patients had fewer vascular risk factors except prior stroke (36.3% versus 24.2%; P<0.001) and more often had comorbid headache (84% versus 21.4%; P<0.001) and substance use disorder (48.8% versus 37.9%; P<0.001). Facility-level factors associated with probable misdiagnosis included smaller facility, lacking a residency program (62.2% versus 73.7%; P<0.001), and not having on-site neurological services (75.7% versus 84.3%; P<0.001). Probable misdiagnosis was not associated with higher likelihood of stroke or subarachnoid hemorrhage during PRES/RCVS hospitalization. Conclusions Probable emergency department misdiagnosis occurred in ≈1 of every 20 patients with PRES/RCVS in a large, multistate cohort.

Posterior reversible encephalopathy syndrome triggered by FLOT (5-fluorouracil, oxaliplatin, docetaxel, and calcium levofolinate) chemotherapy and thrombocytopenia (docetaxel and cisplatin) chemotherapy

INTRODUCTION

Posterior reversible encephalopathy syndrome is a clinical and imaging syndrome characterized by endothelial dysfunction, blood-brain barrier disruption, and vasogenic edema. The common clinical symptoms of posterior reversible encephalopathy syndrome include headache, altered consciousness, visual disturbances, and seizures, among which headache and seizures are the most common. The classic imaging patterns usually reveal vasogenic edema.

CASE REPORT

We describe the case of a middle-aged woman with gastric cancer. She was under treatment by fluorouracil, leucovorin, oxaliplatin, and docetaxel regimen and thrombocytopenia regimen after tumor progression, but developed unconsciousness, irritability, and headache shortly after initiation of treatment. Her magnetic resonance imaging in our hospital shows abnormal signals in bilateral frontal parietal occipital lobes with hyperintensities on T2-weighted magnetic resonance imaging and fluid-attenuated inversion recovery imaging, accompanied by the increased value of apparent diffusion coefficient. And T1-weighted images illustrate hypointense foci, with increased diffusion-weighted imaging signals.

MANAGEMENT AND OUTCOME

After admission, she was treated to control blood pressure, reduce brain edema, expand blood vessels, improve consciousness, and symptomatic support treatment. 3 days after the onset of the disease, her headache symptoms and state of consciousness gradually improved, and her blood pressure can be controlled at about 130/80 mmHg.

DISCUSSION

This is the first report that posterior reversible encephalopathy syndrome is caused by a thrombocytopenia regimen, and our case highlights the pathogenic role of a thrombocytopenia regimen in posterior reversible encephalopathy syndrome. However, the association between the thrombocytopenia regimen and previous fluorouracil, leucovorin, oxaliplatin, and docetaxel regimens needs further study.

Posterior reversible encephalopathy syndrome in a child after burns: A case report and literature review

Posterior reversible encephalopathy syndrome is a clinical-neuroradiological syndrome with typical neuroimaging features of posterior cerebral white matter changes that are usually reversible. However, there are only few reports of burns with posterior reversible encephalopathy syndrome in the literature. Hence, it is a clinical entity that many burn medicine physicians may be unfamiliar with. We report a case of severe burns complicated by posterior reversible encephalopathy syndrome in a 14-month-old male patient. On the eighth day of hospitalization, the child had persistent fever, occasional convulsions, eyes staring to the right, and high-pitched cry. Magnetic resonance imaging on day 10 showed the diagnosis is posterior reversible encephalopathy syndrome. We used hormone therapy to reduce cerebral oedema, oxcarbazepine to control convulsions, and multiple other drugs and physical measures to treat fever. The symptoms, signs, and imaging abnormalities of his posterior reversible encephalopathy syndrome were rapidly reversed in a short period of time. At the 1-year follow-up, the patient had recovered completely with no residual neurological signs and symptoms. To our knowledge, the patient may be the youngest recorded patient with both burns and posterior reversible encephalopathy syndrome. Careful observation, computed tomography, and magnetic resonance imaging can achieve early detection, early diagnosis, and early treatment of posterior reversible encephalopathy syndrome, which facilitates the achievement of desired therapeutic results. Further investigation is required to determine whether burns can serve as an independent posterior reversible encephalopathy syndrome causative factor and clarify the underlying pathogenesis mechanism.

Exertional Rhabdomyolysis Combined with Acute Kidney Injury and Complicated by Posterior Reversible Encephalopathy Syndrome

Posterior reversible encephalopathy syndrome is an uncommon syndrome in exertional rhabdomyolysis. We herein report a case of rhabdomyolysis and acute kidney injury after intense exercise. The patient also had generalized hypertension, headache, and painless complete loss of vision in both eyes, which was consistent with the symptoms of posterior reversible encephalopathy syndrome detected by magnetic resonance imaging of the brain. The patient fully recovered through active fluid replacement, diuresis, blood pressure control, alkalization of urine and blood purification, and supportive measures. This case report describes an infrequent neurological complication of exertional rhabdomyolysis. Understanding the range of complications is critical for improving patient outcomes.

Extensive Brainstem Posterior Reversible Encephalopathy Syndrome in a Hemodialysis Non-Adherent Patient

Posterior reversible encephalopathy syndrome (PRES) refers to a disorder of reversible vasogenic edema caused by rapid hyperperfusion of the brain that classically involves areas supplied by the posterior circulation such as the parieto-occipital region. It may present with atypical features such as brainstem and spinal cord involvement. Common causes include renal failure, pre-eclampsia/eclampsia among pregnant women, rapid changes in systemic blood pressure, and autoimmune diseases. The most prevalent presenting signs and symptoms are encephalopathy, seizures and headache. A 64-year-old female presented to a dialysis unit after missing several sessions with twitching in her extremities and elevated blood pressure. Additionally, she recently terminated clonidine use and was likely experiencing rebound hypertension. The continuous electroencephalogram (EEG) demonstrated generalized, non-convulsive seizures. MRI findings were notable for hyperintensities in the pons, middle cerebellar peduncles, cerebellar hemispheres, and periventricular and subcortical matter with medulla and proximal spinal cord involvement. A notable clinical sequela of PRES in this patient was coma. Aggressive blood pressure control led to significant improvement and return to her neurologic baseline. PRES can present with extensive brainstem involvement with a clinical sequela of coma. Multiple underlying causes such as dialysis non-adherence and rebound hypertension following clonidine discontinuation contributed to the development of this condition in this patient.