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Cheng X, Li J, Lan Y, Liu J, Chen S, Lu G. Cerebrovascular Disease in the Setting of Posterior Reversible Encephalopathy Syndrome. Front Neurol 2021; 12:765333. [PMID: 34867751 PMCID: PMC8635685 DOI: 10.3389/fneur.2021.765333] [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: 08/26/2021] [Accepted: 10/25/2021] [Indexed: 12/03/2022] Open
Abstract
Overlap between the pathogenesis of posterior reversible encephalopathy syndrome and that of cerebrovascular disease can confound their clinical and radiological presentations, posing a diagnostic challenge. This article presents a literature review and discussion of the clinical manifestations, pathological mechanisms, and imaging manifestations of subarachnoid hemorrhage and vasculitis leading to posterior reversible encephalopathy syndrome, coexistence of posterior reversible encephalopathy syndrome with reversible cerebral vasoconstriction syndrome, and hemorrhage and infarction secondary to posterior reversible encephalopathy syndrome. The findings show that posterior reversible encephalopathy syndrome shares some overlapping pathophysiological mechanisms with cerebrovascular disease. Importantly, neuroimaging plays an important role in identifying this entity in a timely manner and differentiating it from other diseases.
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Affiliation(s)
- XiaoQing Cheng
- Department of Medical Imaging, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - JianRui Li
- Department of Medical Imaging, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Ying Lan
- Special Medical Service, Lushan Rehabilitation and Recuperation Center of People's Liberation Army (PLA), Jiujiang, China
| | - Jia Liu
- Department of Medical Imaging, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Sui Chen
- Department of Medical Imaging, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - GuangMing Lu
- Department of Medical Imaging, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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Abstract
New onset or exacerbation of preexisting neurologic symptoms during pregnancy often necessitates brain or spinal cord imaging. Magnetic resonance techniques are preferred imaging modalities during pregnancy and the postpartum period. Ionizing radiation with computed tomography and intravenous contrast material with magnetic resonance or computed tomography should be avoided during pregnancy. New onset of headaches in the last trimester or in the postpartum period may indicate cerebrovascular disease or a mass lesion, for which brain imaging is necessary. The continuum of cerebrovascular complications of pregnancy and enlarging lesions may produce neurologic symptoms later in pregnancy and after delivery, necessitating imaging.
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Affiliation(s)
- Dara G Jamieson
- Department of Neurology, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10065, USA.
| | - Jennifer W McVige
- Dent Neurologic Institute, 3980 Sheridan Drive, Amherst, NY 14226, USA
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Khan IR, Pai V, Mundada P, Sitoh YY, Purohit B. Detecting the Uncommon Imaging Manifestations of Posterior Reversible Encephalopathy Syndrome (PRES) in Adults: a Comprehensive Illustrated Guide for the Trainee Radiologist. Curr Probl Diagn Radiol 2020; 51:98-111. [PMID: 33257096 DOI: 10.1067/j.cpradiol.2020.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/28/2020] [Accepted: 11/09/2020] [Indexed: 12/11/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) has traditionally been described as a reversible leukoencephalopathy with a distinct pattern of posteriorly distributed vasogenic oedema involving the subcortical regions of parietal and occipital lobes. PRES commonly occurs in the setting of hypertensive emergencies, pre-eclampsia/eclampsia, impaired renal function, and immunosuppressive therapy. The various clinical presentations of PRES include encephalopathy, seizures, headache, visual, and focal neurological deficits. As knowledge of this entity grows, the range of clinical, and radiological features is seen to be much broader than originally described. The brain oedema may not always be posteriorly distributed and the syndrome may not be uniformly reversible. Of special note are some uncommon imaging features (unilateral cerebral involvement, and isolated posterior fossa involvement) and also some uncommon complications (haemorrhage, cytotoxic oedema, and vasoconstriction). These red herrings may lead to potential diagnostic challenges and pitfalls especially for trainee radiologists, who often read these scans in an emergency setting. Early and accurate diagnosis is crucial for prompt optimum management, thereby avoiding residual morbidity. This review article focusses on the atypical radiological features of PRES in adults with extensive case-based imaging examples. A brief description of the pathophysiology, clinical, and classic radiological features of PRES has also been included. A tabulated summary of potential mimics with diagnostic pearls is provided to highlight pertinent take home points and to serve as an easy guide for day-to-day clinical practice.
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Affiliation(s)
- Iram R Khan
- Department of Neuroradiology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore
| | - Vivek Pai
- Department of Neuroradiology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore
| | - Pravin Mundada
- Department of Diagnostic and Interventional Radiology, Raffles Hospital, 585 North Bridge Rd, Singapore
| | - Yih Yian Sitoh
- Department of Neuroradiology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore
| | - Bela Purohit
- Department of Neuroradiology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore.
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Posterior Reversible Encephalopathy Syndrome and Cerebral Sinus Thrombosis in a Case of Pediatric B-Cell ALL. J Pediatr Hematol Oncol 2017; 39:e71-e73. [PMID: 28060109 DOI: 10.1097/mph.0000000000000728] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) and cerebral sinus thrombosis are 2 known complications of acute lymphoblastic leukemia and its treatment. We describe a patient with acute lymphoblastic leukemia whose course was complicated by both of these conditions. This case is novel both for the fact that PRES developed before the initiation of therapy and that PRES was followed shortly by the development of cerebral sinus thrombosis. Our patient's story raises questions about our current understanding of the pathophysiology of PRES, and it suggests that PRES may actually be a predisposing risk factor for cerebral sinus thrombosis.
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Abstract
Pregnant women are most likely to have primary headaches, such as migraine and tension-type headaches, which can be diagnosed and treated without brain imaging. Primary headaches may even start de novo during pregnancy, especially in the first few months. However, when the headache occurs late in pregnancy or in the peripartum period, secondary causes of headaches need to be considered and evaluated by brain and/or vascular imaging, generally using magnetic resonance techniques. There is considerable overlap between the cerebrovascular complications of pregnancy, including preeclampsia/eclampsia, posterior reversible encephalopathy syndrome (PRES), reversible cerebral vasoconstriction syndrome (RCVS), and both hemorrhagic and ischemic strokes; although, their imaging may be distinctive. Imaging is necessary to distinguish between arterial and venous pathology causing headache in the peripartum patient, as there can be similar presenting symptoms. Mass lesions, both neoplastic and inflammatory, can enlarge and produce headaches and neurological symptoms late in pregnancy.
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Affiliation(s)
- Maryna Skliut
- Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, 10 Union Square E, Suite 5 D, New York, NY, 10003, USA
| | - Dara G Jamieson
- Weill Cornell Medicine, New York Presbyterian Hospital, 428 East 72nd Street, Suite 400, New York, NY, 10021, USA.
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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: 0.9] [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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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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Eryılmaz MK, Mutlu H, Salim DK, Musri FY, Coşkun HŞ. Fatal posterior revesible leukoencephalopathy syndrome associated coma induced by bevacizumab in metastatic colorectal cancer and review of literature. J Oncol Pharm Pract 2015; 22:806-810. [PMID: 26467267 DOI: 10.1177/1078155215611048] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Posterior reversible leukoencephalopathy syndrome (PRES) is a syndrome characterized by headache, hypertension, confusion, visual disturbance, and seizures accompanied by subcortical vasogenic edema, predominantly involving the parietal and occipital lobes. The syndrome is usually described in malignant hypertension, eclampsia, renal failure, immunosuppressive, and cytotoxic chemotherapies. Bevacizumab, a monoclonal antibody that binds to the vascular endothelial growth factor (VEGF) has been linked to PRES. We carried out review of reports documenting the occurrence of PRES in patients receiving bevacizumab. This literature review was conducted by utilizing PubMed Database. If early diagnosed, PRES is reversible. We present a case of fatal PRES-associated coma induced by bevacizumab in metastatic colorectal cancer.
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Affiliation(s)
| | - Hasan Mutlu
- Department of Medical Oncology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Derya Kıvrak Salim
- Department of Medical Oncology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Fatma Yalçın Musri
- Department of Medical Oncology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Hasan Şenol Coşkun
- Department of Medical Oncology, Akdeniz University School of Medicine, Antalya, Turkey
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Wang W, Zhao LR, Lin XQ, Feng F. Reversible posterior leukoencephalopathy syndrome induced by bevacizumab plus chemotherapy in colorectal cancer. World J Gastroenterol 2014; 20:6691-6697. [PMID: 24914397 PMCID: PMC4047361 DOI: 10.3748/wjg.v20.i21.6691] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Accepted: 03/19/2014] [Indexed: 02/06/2023] Open
Abstract
Reversible posterior leukoencephalopathy syndrome (RPLS) is a rare brain-capillary leak syndrome, characterized by clinical symptoms of headache, visual loss, seizures and altered mental functioning. This syndrome is usually reversible and is associated with hypertension, nephropathy, and use of immunosuppressive medication and cytotoxic agents. We describe two rare cases of RPLS occurring in colorectal cancer, both of which presented with coma, that we believe can be directly attributed to bevacizumab, a monoclonal antibody that inhibits the angiogenesis of tumours by specifically blocking vascular endothelial growth factor. We analysed the clinical features, risk factors and outcomes of RPLS in these two patients, and although no typical finding was identified on imaging examination, we found that inadequate blood pressure control was one of the risk factors leading to RPLS and that supportive treatment including intensive blood pressure control improved outcomes. Due to the increasing use of bevacizumab in colorectal cancer, clinicians should be aware of this potential complication.
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Junewar V, Verma R, Sankhwar PL, Garg RK, Singh MK, Malhotra HS, Sharma PK, Parihar A. Neuroimaging features and predictors of outcome in eclamptic encephalopathy: a prospective observational study. AJNR Am J Neuroradiol 2014; 35:1728-34. [PMID: 24722310 DOI: 10.3174/ajnr.a3923] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Posterior reversible encephalopathy syndrome is associated with eclampsia. We assessed the distribution and nature of typical and atypical cranial MR imaging findings in these patients and their correlation with clinical and laboratory data and predictors of outcome. MATERIALS AND METHODS Forty-five clinically confirmed cases of eclampsia were included in this prospective observational study. Subjects with hemolysis, elevated liver enzymes, and low platelets syndrome (n = 9) and pre-existing neurologic conditions (1 with cerebral solitary cysticercus granuloma) were excluded. Patients underwent blood investigations and cranial MR imaging. RESULTS Twenty-seven patients had abnormal while 8 had normal MR imaging findings. Involvement of brain regions was as follows: frontal, 88.89%; temporal, 44.44%; parietal, 100%; occipital, 100%; deep gray matter, 29.63%; cerebellum, 22.22%; brain stem, 14.81%. Cytotoxic edema was present in 33.33% of cases; 66.67% of patients had mild posterior reversible encephalopathy syndrome; 25.92% had moderate posterior reversible encephalopathy syndrome; and 7.41% had severe posterior reversible encephalopathy syndrome. Abnormal neuroimaging findings were significantly associated with altered sensorium; visual disturbances; status epilepticus; and elevated serum creatinine, uric acid, and lactate dehydrogenase (P=.006, P=.018, P=.015, P=.019, P=.003, and P=.001, respectively). Serum creatinine, uric acid, and lactate dehydrogenase values and the presence of moderate or severe posterior reversible encephalopathy syndrome were significantly associated with mortality (P<.001, P<.001, P=.009, and P=.027, respectively). CONCLUSIONS Neuroimaging in eclampsia demonstrates a higher incidence of atypical distributions and cytotoxic edema than previously thought. Altered sensorium; visual disturbances; status epilepticus; and elevated serum uric acid, lactate dehydrogenase, and creatinine are associated with abnormal neuroimaging findings. Higher serum creatinine, uric acid, and lactate dehydrogenase levels and moderate and severe forms of posterior reversible encephalopathy syndrome are possible predictors of poor outcome.
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Affiliation(s)
- V Junewar
- From the Departments of Neurology (V.J., R.V., R.K.G., M.K.S., H.S.M., P.K.S.)
| | - R Verma
- From the Departments of Neurology (V.J., R.V., R.K.G., M.K.S., H.S.M., P.K.S.)
| | | | - R K Garg
- From the Departments of Neurology (V.J., R.V., R.K.G., M.K.S., H.S.M., P.K.S.)
| | - M K Singh
- From the Departments of Neurology (V.J., R.V., R.K.G., M.K.S., H.S.M., P.K.S.)
| | - H S Malhotra
- From the Departments of Neurology (V.J., R.V., R.K.G., M.K.S., H.S.M., P.K.S.)
| | - P K Sharma
- From the Departments of Neurology (V.J., R.V., R.K.G., M.K.S., H.S.M., P.K.S.)
| | - A Parihar
- Radiodiagnosis (A.P.), King George's Medical University, Lucknow, India
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Mima A, Matsubara T, Endo S, Murakami T, Hashimoto Y. Use of a polysulfone hemodialysis membrane may prevent recurrent posterior reversible encephalopathy syndrome in a patient undergoing hemodialysis. Int Urol Nephrol 2013; 46:255-60. [DOI: 10.1007/s11255-013-0434-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Accepted: 03/27/2013] [Indexed: 11/24/2022]
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Gungor O, Kircelli F, Kitis O, Asci G, Toz H, Ok E. Can strict volume control be the key for treatment and prevention of posterior reversible encephalopathy syndrome in hemodialysis patients? Hemodial Int 2012; 17:107-10. [DOI: 10.1111/j.1542-4758.2012.00672.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Ozkan Gungor
- Division of Nephrology; Ege University School of Medicine; Izmir; Turkey
| | - Fatih Kircelli
- Division of Nephrology; Ege University School of Medicine; Izmir; Turkey
| | - Omer Kitis
- Division of Radiology; Ege University School of Medicine; Izmir; Turkey
| | - Gulay Asci
- Division of Nephrology; Ege University School of Medicine; Izmir; Turkey
| | - Huseyin Toz
- Division of Nephrology; Ege University School of Medicine; Izmir; Turkey
| | - Ercan Ok
- Division of Nephrology; Ege University School of Medicine; Izmir; Turkey
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Spiegel DR, Varnell C. A case of catatonia due to posterior reversible encephalopathy syndrome treated successfully with antihypertensives and adjunctive olanzapine. Gen Hosp Psychiatry 2011; 33:302.e3-5. [PMID: 21601735 DOI: 10.1016/j.genhosppsych.2011.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Revised: 01/19/2011] [Accepted: 01/20/2011] [Indexed: 10/18/2022]
Abstract
Catatonia is a distinct neuropsychiatric syndrome with prominent motor manifestations. Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiologic syndrome usually precipitated by malignant hypertension. Given the overlapping neuropathology in both syndromes, we present a case of catatonia precipitated by PRES, with full resolution of the former after successful treatment of the latter.
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Affiliation(s)
- David R Spiegel
- Eastern Virginia Medical School, Department of Psychiatry and Behavioral Sciences, 825 Fairfax Avenue, Norfolk, VA 23507, USA.
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