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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: 6.8] [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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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: 0.8] [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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Posterior Reversible Encephalopathy Syndrome and Maternal Death in an Obstetric Patient: Case Report. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791602300508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Cerebral events occur more often in the postpartum period and are associated with hypertensive diseases of pregnancy. Superimposed with pre-eclampsia, these cause severe complications. Posterior reversible encephalopathy syndrome occurs because of acute elevation of blood pressure above the upper limit of cerebral blood flow auto-regulation. We present a case of posterior reversible encephalopathy syndrome that developed with superimposed pre-eclampsia resulting in intraparenchymal haemorrhage and maternal death.
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Bo QY, Zhao XH, Yang X, Wang SJ. Reversible posterior encephalopathy syndrome associated with late onset postpartum eclampsia: A case report. Exp Ther Med 2016; 12:1885-1888. [PMID: 27602098 DOI: 10.3892/etm.2016.3533] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 06/23/2016] [Indexed: 11/05/2022] Open
Abstract
Late onset postpartum eclampsia (LPE) is defined by its onset at >48 h after delivery. Reversible posterior encephalopathy syndrome (RPES) associated with LPE is uncommon, with the majority of RPES cases having a late postpartum onset within 4 weeks after childbirth. The present study reported the case of a 15-year old female presenting with convulsions that began 5 weeks after delivery. A magnetic resonance imaging scan of the brain revealed multiple lesions in the cortex, subcortical region and deep white matter of the bilateral cerebellum, and occipital, frontal and parietal lobes. The clinical manifestations and radiological abnormalities were readily resolved subsequent to antihypertension and anticonvulsion treatment. In conclusion, the present rare case indicates that LPE should be considered as a potential diagnosis even at 4 weeks after delivery. Furthermore, clinicians should familiarize with the reversible radioimaging features of RPES, since early recognition and adequate treatment are important to the outcome of patients.
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Affiliation(s)
- Qi-Yu Bo
- Department of Operating Room, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Xiu-He Zhao
- Department of Neurology, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Xue Yang
- Department of Neurology, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Sheng-Jun Wang
- Department of Neurology, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
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Therapy and differential diagnosis of posterior reversible encephalopathy syndrome (PRES) during pregnancy and postpartum. Arch Gynecol Obstet 2015; 292:1217-23. [PMID: 26122264 DOI: 10.1007/s00404-015-3800-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 06/17/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Posterior reversible encephalopathy syndrome (PRES) is an usually reversible neuro-radiological clinical entity characterized by headache, confusion, visual disturbances or blindness and seizures. It rarely occurs without seizures. METHODS We conducted a literature review in MEDLINE about PRES during post partum and pregnancy, focusing on differential diagnosis and therapy. We reviewed 28 articles (case reports, original articles and reviews) describing PRES as well as a case of a severe, immediate postpartum HELLP syndrome (haemolysis, elevated liver enzyme levels, low platelet count) with PRES without generalized seizure. RESULTS The development of PRES after delivery is unusual. Magnetic resonance imaging represents the gold standard for the diagnosis of this condition. White matter oedema in the posterior cerebral hemispheres is typical on neuroimaging. PRES is reversible when early diagnosis is established and appropriate treatment is started without delay. The pathogenesis of PRES is discussed and the importance of a prompt diagnosis is emphasized, as the crucial role of rapid blood press reduction. CONCLUSION MRI is the diagnostic gold standard and it may be useful in the differential diagnosis. The goal of the therapy is to control elevated blood pressure and to prevent seizures or promptly manage it.
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Poma S, Delmonte MP, Gigliuto C, Imberti R, Delmonte M, Arossa A, Iotti GA. Management of posterior reversible syndrome in preeclamptic women. Case Rep Obstet Gynecol 2014; 2014:928079. [PMID: 25506009 PMCID: PMC4254080 DOI: 10.1155/2014/928079] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Revised: 10/30/2014] [Accepted: 11/01/2014] [Indexed: 11/17/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a neurological syndrome associated with a number of conditions including preeclampsia. It is characterized by seizures, alteration of consciousness, visual disturbances, and symmetric white matter abnormalities, typically in the posterior parietooccipital regions of the cerebral hemispheres, at computed tomography (CT) and magnetic resonance (MRI). We report three new cases of PRES in preeclamptic patients and describe the management of these patients. We present a brief review of other cases in the literature, with particular attention to the anesthetic management.
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Affiliation(s)
- S. Poma
- Unit of Obstetric Anesthesia, Department of Anesthesia and Intensive Care, Fondazione Policlinico San Matteo Hospital, Viale Golgi 19, 27100 Pavia, Italy
| | - M. P. Delmonte
- Unit of Obstetric Anesthesia, Department of Anesthesia and Intensive Care, Fondazione Policlinico San Matteo Hospital, Viale Golgi 19, 27100 Pavia, Italy
| | - C. Gigliuto
- Department of Anesthesia and Intensive Care, Fondazione Policlinico San Matteo Hospital, Viale Golgi 19, 27100 Pavia, Italy
| | - R. Imberti
- Direzione Scientifica, Fondazione Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
| | - M. Delmonte
- Dipartimento di Medicina Diagnostica e Servizi, Servizio di Radiodiagnostica, Fondazione Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
| | - A. Arossa
- Department of Obstetrics and Gynecology, Fondazione Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
| | - G. A. Iotti
- Department of Anesthesia and Intensive Care, Fondazione Policlinico San Matteo Hospital, Viale Golgi 19, 27100 Pavia, Italy
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Zeng K, Li Y, Liang M, Gao Y, Cai H, Lin C. The influence of goal-directed fluid therapy on the prognosis of elderly patients with hypertension and gastric cancer surgery. DRUG DESIGN DEVELOPMENT AND THERAPY 2014; 8:2113-9. [PMID: 25378913 PMCID: PMC4218889 DOI: 10.2147/dddt.s66724] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Purpose We aimed to investigate the influence of perioperative goal-directed fluid therapy (GDFT) on the prognosis of elderly patients with gastric cancer and hypertension. Methods Sixty elderly patients (>60 years old) with primary hypertension who received gastric cancer radical surgery and who were American Society of Anesthesiologists (ASA) class II or III were enrolled in the current study. Selected patients were divided randomly into two arms, comprising a conventional intraoperative fluid management arm (arm C, n=30) and a GDFT arm (arm G, n=30). Patients in arm C were infused with crystalloids or colloids according to the methods of Miller’s Anesthesia (6th edition), while those in arm G were infused with 200 mL hydroxyethyl starch over 15 minutes under the FloTrac/Vigileo monitoring system, with stroke volume variation between 8% and 13%. Hemodynamics and tissue perfusion laboratory indicators in patients were recorded continuously from 30 minutes before the operation to 24 hours after the operation. Results Compared with arm C, the average intraoperative intravenous infusion quantity in arm G was significantly reduced (2,732±488 mL versus 3,135±346 mL, P<0.05), whereas average colloid fluid volume was significantly increased (1,235±360 mL versus 760±280 mL, P<0.05). In addition, there were more patients exhibiting intraoperatively and postoperatively stable hemodynamics and less patients with low blood pressure in arm G. Postoperative complications were less frequent, and the time of postoperative hospital stay shorter, in arm G. No significant differences were observed in mortality between the two arms. Conclusion Our research showed that GDFT stabilized perioperative hemodynamics and reduced the occurrence of postoperative complications in elderly patients who underwent gastric cancer surgery.
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Affiliation(s)
- Kai Zeng
- Department of Anesthesia, The First Affiliated Hospital, Fujian Medical University, Fuzhou, People's Republic of China
| | - Yanzhen Li
- Department of Anesthesia, The First Affiliated Hospital, Fujian Medical University, Fuzhou, People's Republic of China
| | - Min Liang
- Department of Anesthesia, The First Affiliated Hospital, Fujian Medical University, Fuzhou, People's Republic of China
| | - Youguang Gao
- Department of Anesthesia, The First Affiliated Hospital, Fujian Medical University, Fuzhou, People's Republic of China
| | - Hongda Cai
- Department of Anesthesia, The First Affiliated Hospital, Fujian Medical University, Fuzhou, People's Republic of China
| | - Caizhu Lin
- Department of Anesthesia, The First Affiliated Hospital, Fujian Medical University, Fuzhou, People's Republic of China
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Stroescu I, Salinas CM, Nahab FB, Stringer AY. Long-term Neurocognitive and Neuroimaging Outcomes in Posterior Reversible Encephalopathy Syndrome: Two Case Reports and Implications. Clin Neuropsychol 2011; 25:1386-402. [DOI: 10.1080/13854046.2011.628339] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Andrus SS, Wolfson AB. Postpartum Preeclampsia Occurring After Resolution of Antepartum Preeclampsia. J Emerg Med 2010; 38:168-70. [DOI: 10.1016/j.jemermed.2008.04.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2006] [Revised: 10/04/2007] [Accepted: 11/07/2007] [Indexed: 11/17/2022]
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Andrés MAA, Ortiz-Gómez JR, Mansob AMM, Martí IP, García SH, Ortigosa FS. [Eclampsia and total bilateral amaurosis in a woman subsequently diagnosed with reversible posterior leukoencephalopathy syndrome]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2008; 55:304-307. [PMID: 18661690 DOI: 10.1016/s0034-9356(08)70574-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Eclampsia is a complication of preeclampsia and is characterized by the appearance of grand mal seizures and/or coma, in the absence of any other neurological abnormalities. Neither focal neurological deficit nor prolonged coma tends to develop following a crisis. Eclampsia should therefore lead us to consider other clinical entities that may require special treatment. We report the case of a pregnant woman who presented total bilateral loss of vision following a grand mal seizure. The patient was subsequently diagnosed with reversible posterior leukoencephalopathy syndrome, which has clinical and radiologic manifestations linked to several causes, such as hypertensive encephalopathy, eclampsia, kidney failure, and immunosuppressant therapy. The syndrome involves headache, altered states of consciousness, changes in vision (including blindness), and seizures; these symptoms generally coincide with a rapid increase in blood pressure. Diagnosis requires neuroimaging, and the typical finding is edema in the posterior zones of the brain hemispheres. The most widely accepted hypothesis concerning the pathophysiologic mechanism underlying this syndrome is failure of cerebral autoregulation with development of vasogenic edema. The prognosis is good and the alterations usually resolve completely with appropriate treatment, which is the same as for the management of eclampsia, with strict monitoring of blood pressure.
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Affiliation(s)
- M A Arteche Andrés
- Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital García Orcoyen, Estella, Navarra.
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Abstract
Current hypotheses regarding the origins of preeclampsia have focused on the “Two stage model”. This model suggests that the primary steps in the pathophysiologic sequence of preeclampsia are initiated by abnormal placentation including the classic finding of abnormal trophoblast invasion of maternal decidual spiral arteries. The second stage of the sequence includes the elaboration of a single or multiple substances from these disordered placentas which contribute to the generalized maternal systemic illness, eventually manifesting as endothelial injury, hypertension and proteinuria. Recent studies have focused on the role of pro and anti-angiogenic peptides as potential placentally derived aetiologic agents in this pathophysiologic sequence, although other placental products have been highlighted in recent research. Despite the fact that this modeling of preeclampsia has widespread support significant limitations to this hypothesis can be identified.
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Affiliation(s)
- Marilyn J Cipolla
- Department of Neurology, University of Vermont College of Medicine, Burlington, VT 05405, USA.
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Hong JY, Jee YS, Lee IH, Shin JS, Choi HJ. Posterior Reversible Encephalopathy Syndrome after Cesarean Section under Spinal Anesthesia -A case report-. Korean J Anesthesiol 2007. [DOI: 10.4097/kjae.2007.52.6.s86] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Jeong-Yeon Hong
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital, Yonsei University College of Medicine, Korea
| | - Young Suck Jee
- Department of Anesthesiology and Pain Medicine, Cheil General Hospital & Women's Healthcare Center, Kwandong University College of Medicine, Korea
| | - In Ho Lee
- Department of Anesthesiology and Pain Medicine, Cheil General Hospital & Women's Healthcare Center, Kwandong University College of Medicine, Korea
| | - Joong Sik Shin
- Department of Obstetric and Gynecology, CHA General Hospital, College of Medicine, Pochon CHA University, Korea
| | - Hyuk Joong Choi
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Korea
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