Determinants of recovery from severe posterior reversible encephalopathy syndrome

Frequency of ischaemic stroke and intracranial haemorrhage in patients with reversible cerebral vasoconstriction syndrome (RCVS) and posterior reversible encephalopathy syndrome (PRES) - A systematic review

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS) may cause ischaemic stroke and intracranial haemorrhage. The aim of our study was to assess the frequency of the afore-mentioned outcomes.

METHODS

We performed a PROSPERO-registered (CRD42022355704) systematic review and meta-analysis accessing PubMed until 7 November 2022. The inclusion criteria were: (1) original publication, (2) adult patients (≥18 years), (3) enrolling patients with PRES and/or RCVS, (4) English language and (5) outcome information. Outcomes were frequency of (1) ischaemic stroke and (2) intracranial haemorrhage, divided into subarachnoid haemorrhage (SAH) and intraparenchymal haemorrhage (IPH). The Cochrane Risk of Bias tool was used.

RESULTS

We identified 848 studies and included 48 relevant studies after reviewing titles, abstracts and full text. We found 11 studies on RCVS (unselected patients), reporting on 2746 patients. Among the patients analysed, 15.9% (95% CI 9.6%-23.4%) had ischaemic stroke and 22.1% (95% CI 10%-39.6%) had intracranial haemorrhage. A further 20.3% (95% CI 11.2%-31.2%) had SAH and 6.7% (95% CI 3.6%-10.7%) had IPH. Furthermore, we found 28 studies on PRES (unselected patients), reporting on 1385 patients. Among the patients analysed, 11.2% (95% CI 7.9%-15%) had ischaemic stroke and 16.1% (95% CI 12.3%-20.3%) had intracranial haemorrhage. Further, 7% (95% CI 4.7%-9.9%) had SAH and 9.7% (95% CI 5.4%-15%) had IPH.

CONCLUSIONS

Intracranial haemorrhage and ischaemic stroke are common outcomes in PRES and RCVS. The frequency reported in the individual studies varied considerably.

Posterior reversible encephalopathy syndrome associated with antibiotic therapy: a case report and systematic review

Posterior reversible encephalopathy syndrome (PRES) is an acute neurological condition associated with different etiologies, including antibiotic therapy. To date, most data regarding antibiotic-related PRES are limited to case reports and small case series. Here, we report a novel case description and provide a systematic review of the clinico-radiological characteristics and prognosis of available cases of PRES associated with antibiotic therapy. We performed a systematic literature search in PubMed and Scopus from inception to 10 January 2024, following PRISMA guidelines and a predefined protocol. The database search yielded 12 subjects (including our case). We described the case of a 55-year-old female patient with PRES occurring one day after administration of metronidazole and showing elevated serum neurofilament light chain protein levels and favorable outcome. In our systematic review, antibiotic-associated PRES was more frequent in female patients (83.3%). Metronidazole and fluoroquinolones were the most reported antibiotics (33.3% each). Clinical and radiological features were comparable to those of PRES due to other causes. Regarding the prognosis, about one third of the cases were admitted to the intensive care unit, but almost all subjects (90.0%) had a complete or almost complete clinical and radiological recovery after prompt cessation of the causative drug. Antibiotic-associated PRES appears to share most of the characteristics of classic PRES. Given the overall good prognosis of the disease, it is important to promptly diagnose antibiotic-associated PRES and discontinue the causative drug.

Experimental Models of Posterior Reversible Encephalopathy Syndrome: A Review From Pathophysiology to Therapeutic Targets

Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiological entity characterized by nonspecific symptomatology (eg, headache, visual disturbances, encephalopathy, and seizures) and classically cortical and subcortical vasogenic edema predominantly affecting the parietooccipital region. PRES etiologies are usually dichotomized into toxic PRES (eg, antineoplastic drugs, illicit drugs) and clinical condition-associated PRES (eg, acute hypertension, dysimmune disorders). Although the pathophysiology of PRES remains elusive, 2 main pathogenic hypotheses have been suggested: cerebral hyperperfusion due to acute hypertension and cerebral hypoperfusion related to endothelial dysfunction. Research into the pathogenesis of PRES has emerged through the development of animal models in the last decade. The motivation for developing a suitable PRES model is 2-fold: to fill in knowledge gaps of the pathophysiological mechanisms involved, and to open new perspectives for clinical assessment of pharmacological targets to improve therapeutic management of PRES. All current models of PRES have a hypertensive background, on which other triggers (acute hypertension, inflammatory, drug toxicity) have been added to address specific facets of PRES (eg, seizures). The initial model consisted in inducing a reduced uterine perfusion pressure that mimics preeclampsia, a leading cause of PRES. More recently, a model of stroke-prone spontaneously hypertensive rats on high-salt diet, originally developed for hypertensive small vessel disease and vascular cognitive impairment, has been studied in PRES. This review aims to discuss, depending on the research objective, the benefits and limitations of current experimental approaches and thus to define the desirable characteristics for studying the pathophysiology of PRES and developing new therapies.

Imaging of Reversible Cerebral Vasoconstriction Syndrome and Posterior Reversible Encephalopathy Syndrome

PRES and RCVS are increasingly recognized due to the wider use of brain MRI and increasing clinical awareness. Imaging plays a crucial role in confirming the diagnosis and guiding clinical management for PRES and RCVS. Imaging also has a pivotal role in determining the temporal progression of these entities, detecting complications, and predicting prognosis. In this review, we aim to describe PRES and RCVS, discuss their possible pathophysiological mechanisms, and discuss imaging methods that are useful in the diagnosis, management, and follow-up of patients.

Pediatric posterior reversible encephalopathy syndrome: Can MR imaging features predict outcomes in non-oncologic patients?

PURPOSE

Identify MR features predictive of poor outcomes in non-oncologic pediatric PRES.

METHOD

A six-year search of all non-oncologic pediatric patients with clinical and MR features of PRES was performed. Modified Rankin scores were used to classify clinical outcomes into good versus poor, then clinical and MR features were compared among groups. Univariate and multivariate analysis was performed to identify MR predictors of poor outcomes for various imaging features, and p-values < 0.05 were considered statistically significant.

RESULTS

One hundred and forty-one patients (mean age 10.1 ± 3.0 years, male to female ratio 1:1.1) were included. Clinically, nephrotic syndrome (p = 0.03), focal deficits (p = 0.04), longer hospitalization (p < 0.001), and mechanical ventilation (p < 0.001) were significantly associated with poor outcomes. Univariate analysis revealed that deep grey matter nuclei (OR = 5.29, 95 % CI: 1.6-18.0) and cerebellar edema patterns (OR = 3.49, 95 % CI: 1.3-9.5), cytotoxic edema (OR = 63.6, 95 % CI:16.5-244.2), hemorrhage (OR = 16.58, 95 % CI: 4.3-64.2), and severe PRES patterns (OR = 11.0, 95 % CI: 3.5-34.7) on MR were all significantly associated with poor outcomes (p-values = 0.008 and 0.014, <0.001, <0.001, and < 0.001, respectively). This remained true for cytotoxic edema (OR = 84.26, 95 % CI: 17.3-410.9, p-value < 0.001) and hemorrhage (OR = 44.56, 95 % CI: 6.9-289.7, p-value < 0.001) on multivariate analysis.

CONCLUSION

Diffusion restriction and hemorrhage on initial MR scans were the two independent predictors of poor outcomes in non-oncologic pediatric patients.

Long-term outcome of status epilepticus-related to systemic lupus erythematosus: An observational study and a systematic review

OBJECTIVES

Status epilepticus-related to systemic lupus erythematosus (SE-SLE) is in general attributed to fulminate neuropsychiatric lupus disease activity, yet the long-term outcome of SE-SLE is not well recognized. This is an observational study of 40 SE-SLE patients pooled from 8 cases at a single tertiary care hospital, and 32 SE-SLE patients identified on a systematic review, with focus on electro-clinical characteristics, imaging studies and the underlying etiology of SE-SLE in correlation with long-term outcome.

RESULTS

Clinical phenotypes of SE-SLE were heterogeneous, ranging from patients with aura continua to patients in coma. Convulsive SE-SLE occurred among patients with heightened global lupus disease activity and increased cortical and subcortical brain lesion burden localized mostly in the frontal and temporal regions. There were no specific neuroimaging or laboratory abnormalities that allowed early SE-SLE diagnosis where a cluster of cases were of unclear etiology (17.5%). Most SE-SLE cases evolved to refractory SE-SLE with resistance to multiple anti-seizure medications and intravenous anesthetics requiring aggressive immune therapy that led to resolution of SE-SLE active phase. Seizure freedom occurred in 60.0% of patients and the median time to cessation of SE-SLE seizure activity after aggressive therapy was 14 days. Poor long-term outcomes were apparent in SE-SLE patients with one-year mortality (12.5%), recurrent SE-SLE (25.0%), subsequent epilepsy (37.5.1%), poor functional outcome (55.0%) and cognitive impairment (47.5%). A prolonged time to cessation of SE-SLE seizure activity was associated with unfavorable long-term outcome.

CONCLUSIONS

Diagnostic accuracy of SE-SLE requires better understanding of the etio-pathogenesis and the spectrum of clinical presentations of SE-SLE. Prompt initiation of immune therapy improve SE-SLE outcome, yet optimal therapeutic strategies remain to be determined. Identifying novel biomarkers that distinguish between different forms of SE-SLE and target cellular inflammatory response will help with specific SE-SLE treatment guidelines and prevent poor outcome.

Pediatric Posterior Reversible Encephalopathy Syndrome: A Review With Emphasis on Neuroimaging Characteristics

Posterior reversible encephalopathy syndrome (PRES) is a neurological disorder characterized by the sudden onset of seizures, headaches, and visual disturbances. Its exact cause is unknown, but several triggers and associated conditions are identified, including high blood pressure, kidney dysfunction, and various medications. Magnetic resonance imaging (MRI) plays a crucial role in diagnosis due to its high sensitivity and specificity for detecting characteristic features. Pediatric PRES exhibit age-dependent differences in triggers, radiological findings, and clinical course. The lesions typically involve the posterior cortical and subcortical white matter, but atypical locations and features are also observed. While generally reversible with appropriate treatment, PRES carries a risk of permanent neurological damage. Despite increasing cases, the current literature on pediatric PRES remains limited. This review highlights the need for further research to understand the mechanisms, delineate distinct clinical and radiological features, and develop precise diagnostic and management strategies for pediatric patients.

Posterior reversible encephalopathy syndrome in children with malignancies - a single-center retrospective study

Background

Posterior reversible encephalopathy syndrome (PRES) diagnosis relies on clinical and radiological characteristics. Clinical manifestations include focal neurologic deficits, hemiparesis, seizures with symptoms of intracranial hypertension, headache, nausea, vomiting, and visual field disturbances. The majority of patients have typical changes in magnetic resonance imaging. The epidemiology and outcomes of PRES in the pediatric cancer population have not been well described. Most of the available data are from retrospective analyses.

Objective

The aim of our study was to evaluate the clinical and radiological presentation as well as the outcome of PRES in children treated for cancers in a single center.

Methods

We analyzed data from 1,053 patients diagnosed with malignancies in a single center over 15 years to determine the incidence of PRES.

Results

19/1053 (1.8%) patients developed PRES. The diagnosis was accompanied by a range of clinical symptoms including hypertension, seizures, altered mental status, and headaches. Magnetic resonance imaging was performed in all patients, and 14/19 (73.7%) exhibited typical findings consistent with PRES. Four patients (21.0%) required treatment in the Intensive Care Unit.

Conclusion

Posterior reversible encephalopathy syndrome (PRES) is a rare but significant complication in children with cancer.There is a clear need to establish clinical criteria for PRES to improve the diagnosis and treatment of patients with PRES, particularly in the pediatric oncological population.Further studies are needed to identify the risk factors for recurrent PRES, particularly in pediatric cancer patients undergoing chemotherapy or immunosuppressive treatment.

Demographic Disparities in the Incidence, Clinical Characteristics, and Outcome of Posterior Reversible Encephalopathy Syndrome in the United States

OBJECTIVES

To estimate age-specific, sex-specific, and race-specific incidence of posterior reversible encephalopathy syndrome (PRES) in the United States.

METHODS

We conducted a retrospective cohort study using the State Inpatient Database of Florida (2016-2019), Maryland (2016-2019), and New York (2016-2018). All new cases of PRES in adults (18 years or older) were combined with Census data to compute incidence. We evaluated the generalizability of incident estimates to the entire country using the 2016-2019 National Readmissions Database (NRD).

RESULTS

Across the study period, there were 3,716 incident hospitalizations for PRES in the selected states. The age-standardized and sex-standardized incidence of PRES was 2.7 (95% CI 2.5-2.8) cases/100,000/y. Incidence in female patients was >2 times that of male patients (3.7 vs 1.6 cases/100,000/y, p < 0.001). Incidence increased with age in both sexes (p-trend <0.001). Similar demographic distribution of first hospitalization for PRES was also noted in the entire country using the NRD. Age-standardized and sex-standardized PRES incidence in Black patients (4.2/100,000/y) was significantly greater than in Non-Hispanic White (2.7/100,000/y) and Hispanic patients (1.2/100,000/y) (p < 0.001 for pairwise comparisons).

DISCUSSION

The incidence of PRES in the United States is approximately 3/100,000/y, but incidence in female patients is >2 times that of male patients. PRES incidence is higher in Black compared with non-Hispanic White and Hispanic patients.

Is decompressive craniectomy necessary in malignant posterior reversible encephalopathy syndrome with brain edema caused uncal herniation? A case report of reversible coma without surgical decompression

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) is considered a benign entity and is usually reversible with only medical management, but persistent neurologic deficits and disability or death can occur without adequate treatment. Favorable outcomes have been associated with surgical decompression in malignant-type PRES in which hemorrhagic transformation or brain stem compression has developed.

CASE DESCRIPTION

Here we report a case of malignant PRES in a 61-year-old female of Asian descent in which the disease rapidly progressed to coma and a near-fatal condition with uncal herniation caused by severe brain edema; however, this patient achieved a dramatic recovery without surgical decompression.

CONCLUSION

After reviewing previous reports regarding malignant PRES, we propose that hemorrhagic transformation is a crucial indicator for surgical decompression and an important prognostic factor in malignant PRES.

Tonic-Clonic Seizure in Patient With SLE: Posterior Reversible Encephalopathy Syndrome, or a Neuropsychiatric Manifestation of SLE?

Posterior reversible encephalopathy syndrome (PRES) is a clinically and radiologically diagnosed reversible sudden onset disease with many neurological symptoms. SLE is the most common cause of PRES among autoimmune diseases. Many factors, such as SLE activity, hypertension, hematological and renal diseases, lymphopenia dyslipidemia, and immunosuppressive treatments, can trigger PRES in SLE. We wanted to draw attention to the difference between neuropsychiatric systemic lupus erythematosus (SLE) and PRES in a patient with SLE and the triggers for developing PRES in SLE by presenting a hypertensive patient on immunosuppressive therapy who had just started haemodialysis treatment and had generalised tonic-clonic seizures.

Posterior reversible encephalopathy syndrome: A rare complication of rituximab therapy in rheumatoid arthritis

Rituximab, a murine-human chimeric monoclonal antibody targeting CD20-positive B lymphocytes, has established itself as an effective and relatively safe biologic therapy for patients with refractory rheumatoid arthritis. Most common side effects associated with its use include infusion related reactions and cytopenia. Rare adverse effects such as progressive multifocal leukoencephalopathy and posterior reversible encephalopathy syndrome (PRES) have also been reported. Diagnosis of PRES following rituximab treatment requires a high index of suspicion correlated with clinical and radiological features in individuals at risk. Early diagnosis and prompt treatment is associated with a favorable prognosis. We present a case of a young man who developed PRES following rituximab administration on account of active rheumatoid arthritis. Timely diagnosis and prompt treatment ensured his uneventful recovery without residual neurological deficit.

A Fatal Case of Neuroblastoma Complicated by Posterior Reversible Encephalopathy with Rapidly Evolving Transplantation-Associated Thrombotic Microangiopathy

Background: Transplantation-associated thrombotic microangiopathy (TA-TMA) is a severe complication of hematopoietic stem cell transplantation and is sometimes fatal. Observations: A 4-year-old, male patient with stage M neuroblastoma (NBL) who had received an allogeneic bone marrow transplantation (BMT) from his sibling five months previously presented with rapidly progressive posterior reversible encephalopathy (PRES) complicated with TA-TMA. Although the patient was transferred to the pediatric intensive care unit, he died within one week after the onset of the latest symptoms. Conclusions: This is the first description of a fatal case of NBL complicated by PRES with rapidly evolving TA-TMA after an allogenic BMT.

Long-term risk of seizure after posterior reversible encephalopathy syndrome

OBJECTIVE

Patients with posterior reversible encephalopathy syndrome (PRES) can develop seizures during the acute phase. We sought to determine the long-term risk of seizure after PRES.

METHODS

We performed a retrospective cohort study using statewide all-payer claims data from 2016-2018 from nonfederal hospitals in 11 US states. Adults admitted with PRES were compared to adults admitted with stroke, an acute cerebrovascular disorder associated with long-term risk of seizure. The primary outcome was seizure diagnosed during an emergency room visit or hospital admission after the index hospitalization. The secondary outcome was status epilepticus. Diagnoses were determined using previously validated ICD-10-CM codes. Patients with seizure diagnoses before or during the index admission were excluded. We used Cox regression to evaluate the association of PRES with seizure, adjusting for demographics and potential confounders.

RESULTS

We identified 2095 patients hospitalized with PRES and 341,809 with stroke. Median follow-up was 0.9 years (IQR, 0.3-1.7) in the PRES group and 1.0 years (IQR, 0.4-1.8) in the stroke group. Crude seizure incidence per 100 person-years was 9.5 after PRES and 2.5 after stroke. After adjustment for demographics and comorbidities, patients with PRES had a higher risk of seizure than patients with stroke (HR, 2.9; 95% CI, 2.6-3.4). Results were unchanged in a sensitivity analysis that applied a two-week washout period to mitigate detection bias. A similar relationship was observed for the secondary outcome of status epilepticus.

INTERPRETATION

PRES was associated with an increased long-term risk of subsequent acute care utilization for seizure compared to stroke.

Posterior reversible encephalopathy syndrome after anlotinib treatment for small cell lung cancer: A case report and literature review

Anlotinib is an oral multi-targeted tyrosine kinase inhibitor as a third-line and subsequent treatment for patients with small cell lung cancer (SCLC) in China. The neurotoxicity is less reported. Posterior reversible encephalopathy syndrome (PRES) is characterized by headaches, seizures, encephalopathy, and visual disturbances, as well as focal reversible vasogenic edema seen on neuroimages. Here, we presented a case of PRES in a small cell lung cancer (SCLC) patient associated with anlotinib. A 37-year-old female patient, who had a history of diabetes, with extensive-stage SCLC received anlotinib after third-line chemotherapy. Ten cycles of anlotinib later, the patient experienced visual disturbance and was diagnosed with PRES based on the typical demyelination of white matter obtained in the brain magnetic resonance. During anlotinib therapy, the patient did not develop anti-VEGF therapy-induced hypertension. Subsequently, the patient stopped anlotinib, but she did not recover from symptoms. We also summarized the characteristics of fifty-four cases of PRES caused by antiangiogenic drugs in the literature. Based on our experience and the literature review, the incidence of PRES induced by antiangiogenic drugs is low, and the symptom can resolve upon stopping the medications. However, some cases still have a poor prognosis and the underlying mechanism requires further investigation. In addition, early detection and treatment of PRES are essential for physicians.

Drugs associated with posterior reversible encephalopathy syndrome, a worldwide signal detection study

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) can occur in a variety of clinical conditions, such as severe hypertension, pregnancy, inflammatory diseases, hematopoietic stem cells or solid organ transplantation. Apart increased blood pressure levels and altered renal function, several drugs have been reported as potential triggering factor. These descriptions are nevertheless limited to case reports or small case series. Systematic analysis of drugs associated with PRES using global pharmacovigilance database is lacking and can be useful.

METHODS

We performed a disproportionality analysis using VigiBase, the World Health Organization pharmacovigilance database, using the information component (IC). The IC compares observed and expected values to find associations between drugs and PRES using disproportionate Bayesian reporting. An IC_0.25 (lower end of the IC 95% credibility interval) > 0 is considered statistically significant.

RESULTS

Here we present an analysis of 3278 cases of PRES reported in VigiBase. These results identified 73 molecules statistically associated with PRES using full database as background with an IC_0.25 > 0. Only 34% (N = 25/73) of them had this information written in the summary of product characteristics. The main drug classes involved were antineoplastic and immunomodulating agents and the drugs with the greatest number of cases were tacrolimus, cyclosporin, bevacizumab, methotrexate, and vincristine. An overall mortality of 8.1% (N = 267/3278) was identified in cases of drug-associated PRES.

CONCLUSION

These results will help clinicians identify potential suspected drugs associated with PRES and decide which drug to discontinue and eventually lead to a re-evaluation of drug labels for some molecules.

The Placental Function Beyond Pregnancy: Insights from Latin America

Currently, more than 100,000 papers had been published studying the placenta in both physiological and pathological contexts. However, relevant health conditions affecting placental function, mostly found in low-income countries, should be evaluated deeper. This review will raise some - of what we think necessary - points of discussion regarding challenging topics not fully understood, including the paternal versus maternal contribution on placental genes imprinting, placenta-brain communication, and some environmental conditions affecting the placenta. The discussions are parts of an international effort to fulfil some gaps observed in this area, and Latin-American research groups currently evaluate that.

Posterior Reversible Encephalopathy Syndrome in a Male With Polysubstance Abuse: A Case Report

Posterior reversible encephalopathy syndrome (PRES) is a neurologic disorder with multiple etiologies. The signs and symptoms of PRES are non-specific, making the differential diagnosis broad. Although PRES is suspected clinically, a diagnosis requires characteristic findings on imaging. In patients with undiagnosed PRES, the coexistence of substance abuse can divert the care provider from pursuing imaging studies, leading to a missed diagnosis. We describe the case of a 51-year-old male who presented with altered mental status and was diagnosed with PRES despite having a positive urine drug screen.

RCVS: by clinicians for clinicians-a narrative review

BACKGROUND/OBJECTIVE

Reversible cerebral vasoconstriction syndrome may be underdiagnosed. It can be accompanied by various complications, mainly intracerebral hemorrhage and ischemic stroke. The clinical presentation of this condition varies according to its localization. The aims of this review are to raise awareness of the disease, especially in the presence of corresponding risk factors; to connect its precipitating factors, pathophysiology, and complications; and to compare various differential diagnoses of vasoconstriction.

METHODS

A review of the literature in PubMed/MEDLINE and Google Scholar was conducted from May 1997 until May 2022.

RESULTS

Reversible cerebral vasoconstriction syndrome, which is a clinical-radiological syndrome, is mainly characterized by the occurrence of thunderclap headache and widespread vasoconstriction. The most common precipitating factors are the use of vasoactive substances and postpartum status. The pathophysiology is currently assumed to include two mechanisms: sympathetic overactivity and endothelial dysfunction. From these mechanisms, it is possible to derive potential complications as well as the most important differential diagnoses: posterior reversible encephalopathy syndrome, convexity subarachnoid hemorrhage, ischemic and hemorrhagic stroke, and primary angiitis of the central nervous system.

CONCLUSION

In general, the outcome of reversible cerebral vasoconstriction syndrome is very good. Vasospasm as well as thunderclap headache attacks can be fully reversible, and > 90% of patients are functionally independent at discharge.

Clinical Features and Risk Factors of Mortality in Patients with Posterior Reversible Encephalopathy Syndrome

Objective. Although the prognosis of posterior reversible encephalopathy syndrome (PRES) is usually favourable and most patients wholly recover, the disorder can result in death in some patients. To date, the data on clinical features and risk factors for death are still lacking; therefore, we aim to investigate the clinical features and long-term prognostic risk factors of PRES in the present study. Methods. The patients with PRES were identified from the First Affiliated Hospital of Zhengzhou University from June 2011 to June 2020. Clinical characteristics, laboratory tests, magnetic resonance imaging examinations, and treatment of all patients were analyzed retrospectively. All patients were followed up by telephone. Finally, the patients were divided into the survival group and death group for prognosis analysis. Results. A total of 92 patients with PRES were included; 84.8% of whom were female, with an average age of 25.4 (5–66) years at the onset of PRES. Epilepsy was the main clinical manifestation (72.8%). The in-hospital mortality rate was 2.17%. The 3-year all-cause survival rate for PRES patients was 86%. In univariate analysis, patients with systemic lupus erythematosus ( $P=0.027$ ) and blood transfusion history within 1 month before onset ( $P=0.027$ ), need for dialysis ( $P\le 0.001$ ), nephritis ( $P=0.010$ ), stroke ( $P=0.016$ ), and heart failure ( $P=0.016$ ) were associated with death. In multivariate analysis, we found that heart failure ( $\text{OR}=0.095$ , 95% CI 0.020 to 0.441) and stroke ( $\text{OR}=0.033$ , 95% CI 0.002 to 0.467) were independent risk factors for death in PRES patients, while pregnancy was a protective factor for death in PRES patients ( $\text{OR}=7.978$ , 95% CI 1.446 to 44.006). Conclusions. Our results indicate that PRES could be considered as a sign of a very high-risk patient. We also demonstrated that heart failure and stroke were independent risk factors for death in patients with PRES; moreover, pregnancy was a protective factor.

Early Readmissions After Hospitalization for Posterior Reversible Encephalopathy Syndrome

BACKGROUND AND OBJECTIVES

To evaluate the frequency, etiologies, and risk factors for 90-day readmissions after hospitalization for posterior reversible encephalopathy syndrome (PRES).

METHODS

Data were obtained from the Nationwide Readmissions Database 2016-2018. Patients with a primary diagnosis of PRES, survival to discharge, and known discharge disposition were included. The primary outcome was nonelective readmission within 90 days of discharge. Survival analysis was performed, and independent predictors of readmission were analyzed using multivariable Cox proportional hazards regression.

RESULTS

Based on the study inclusion criteria, 6,155 eligible patients were included (mean ± SD age: 55.9 ± 17.3 years, female: 71.0%). Nonelective readmission within 90 days of discharge occurred for 1,922 (31.2%) patients. Of these, 617 readmissions were due to PRES-related or neurologic etiologies and the remaining 1,305 readmissions were due to non-neurologic conditions. In multivariable analysis, age was inversely associated with the risk of readmission (hazards ratio [HR] 0.92 for every 10 years increase in age, 95% CI 0.88-0.97). Patients with diabetes (HR 1.21, 95% CI 1.04-1.42), systemic lupus erythematosus (HR 1.42, 95% CI 1.03-1.96), acute kidney injury (HR 1.28, 95% CI 1.11-1.47), and a higher Charlson comorbidity index score (HR 1.09, 95% CI 1.06-1.13) were more likely to be readmitted. Furthermore, patients admitted at large bed size hospitals (HR 1.19, 95% CI 1.03-1.39), those with a longer length of stay (HR 1.01, 95% CI: 1.00-1.02), and those not discharged to home (HR 1.33, 95% CI: 1.14-1.55) during the index hospitalization were also at a higher risk for readmission.

DISCUSSION

Nearly one-third of patients hospitalized because of PRES are readmitted within 90 days of discharge, and approximately one-third of these readmissions are due to PRES-related or neurologic etiologies. Younger age, a higher comorbidity burden, a longer length of hospital stay, and discharge disposition other than to home are independently associated with the risk of readmission.

Central Variant Posterior Reversible Encephalopathy Syndrome in a Pregnant Woman With Eclampsia: A Case Report

Posterior Reversible Encephalopathy Syndrome (PRES) is a clinico-radiological diagnosis characterized by acute or subacute neurological symptoms. A 27-year-old woman at 35 weeks of pregnancy, who presented with generalized tonic-clonic seizures had persistently low Glasgow Coma Scale (GCS) score after delivery of the baby. Magnetic Resonance Imaging (MRI) of the brain showed T-2 Fluid Attenuated Inversion Recovery (FLAIR) hyperintensities in the brainstem, bilateral medial cerebellar hemispheres, bilateral medial temporal lobes, bilateral thalami, lentiform and caudate nuclei, and bilateral fronto-parieto-occipital lobes. There was diffusion restriction in bilateral caudate nuclei, left thalamus and right frontal lobe, and microhemorrhages in the left thalamus. These findings were suggestive of central variant PRES. She improved with strict blood pressure control and anti-edema measures. A repeat MRI brain on day 10 showed significant improvement, and she had no residual neurological deficits. The central variant of PRES is a rare entity that has to be considered in a patient presenting with neurological deficits in the setting of uncontrolled blood pressure, eclampsia, immunomodulatory medication use, or renal failure. While most patients with PRES fully recover with timely therapy targeted at reversing the primary cause, some may have residual neurological deficits or rarely, die.

Factors associated with acute symptomatic seizure occurrence among patients with posterior reversible encephalopathy syndrome

OBJECTIVES

We aimed to define the factors associated with acute symptomatic seizure occurrence in posterior reversible encephalopathy syndrome (PRES) in the Thai-Asian population.

MATERIALS AND METHODS

We conducted a retrospective cohort study enrolling patients with PRES admitted to the hospital between 2006 and 2019. In addition to seizure characteristics, baseline characteristics, clinical presentations, precipitating factors, neuroimaging characteristics, hospital complications, and hospital outcomes were compared between the seizure and non-seizure groups. Factors with p-value <0.05 in the univariate analysis were entered into the first model of multivariate logistic regression analysis to determine the factors associated with seizure occurrence if the p-value <0.05. The interaction of associated factors was also analyzed in the final multiple logistic regression analysis model.

RESULTS

Acute symptomatic seizure, which is mainly based on the clinical documentation without electroencephalography, occurred in 50.0% of 136 patients with PRES. Of these, early seizures within 14 days of PRES occurred in 98.5% which mostly developed at presentation (82.4%) with a single seizure attack (55.9%). Convulsive seizures (77.9%) were the most common seizure semiology. The seizure group was significantly younger (median [interquartile range: IQR] 36.00 years old (21.75-48.50) vs 46.50 years old (31.25-61.00), p = 0.003). In univariate analysis, the seizure group had a higher prevalence of consciousness impairment (61.76% vs 26.47%, p < 0.001), Glasgow coma scale (GCS) score of 0-13 (42.46% vs 13.23%, p < 0.001), preeclampsia (20.58% vs 4.41%, p = 0.004), autoimmune disease (17.65% vs 5.88%, p = 0.033), and frontal lesions (25.00% vs 11.76%, p = 0.046) than those in the non-seizure group. In contrast, the seizure group had a lower prevalence of headache (27.94% vs 61.76%, p < 0.001). In the final multivariate logistic regression analysis which included the interaction terms, the acute symptomatic seizure occurrence directly associated with preeclampsia (adjusted odds ratio (aOR) 6.426, 95% confidence interval (CI) 1.450-27.031, p = 0.016) and autoimmune disease (aOR 4.962, 95% CI 1.283-18.642, p = 0.025), while headache showed a reverse association (aOR 0.310, 95% CI = 0.158-0.721, p = 0.008).

CONCLUSIONS

Acute symptomatic seizure occurred in a half of patients with PRES in this cohort. Preeclampsia and autoimmune disease were directly associated with seizure occurrence, while headache showed a reverse association.

Comparison of Clinical Manifestations, Laboratory, Neuroimaging Findings, and Outcomes in Children With Posterior Reversible Encephalopathy Syndrome (PRES) in Children With and Without Renal Disease

BACKGROUND

To demonstrate and compare the clinical manifestations, laboratory findings, and neuroimaging findings of posterior reversible encephalopathy syndrome (PRES) in children with and without underlying renal disease.

METHODS

The study included 23 children with a diagnosis of PRES from January 2009 to March 2019. All data, including clinical manifestations, laboratory findings, underlying medical illness, and neuroimaging results, were obtained.

RESULTS

Sixteen had underlying renal disease. The median age of PRES onset was 10.3 years in children with renal disease and 9.8 years in children without renal disease. Higher blood pressure at the baseline, on admission, and at the onset of PRES was found in the renal disease group more than in the nonrenal disease group (P < 0.05). Seizures were likely seen in the renal disease group compared with the nonrenal disease group (P = 0.03). Generalized tonic-clonic seizures were the most common seizure type in both groups. An initial CT scan revealed vasogenic edema in 75% of the renal group and 85.7% of the nonrenal group. During a long-term follow-up, all children recovered without significant neurological deficits or subsequent epilepsy.

CONCLUSIONS

Hypertension and higher baseline blood pressure are more common in children with renal disease who develop PRES compared with nonrenal disease. Seizures are more common in the renal disease group. A computed tomographic (CT) scan can help with PRES diagnosis when magnetic resonance imaging is not available. All children with PRES recovered without significant neurological deficits or subsequent epilepsy.

A Case Report of Posterior Reversible Encephalopathy Syndrome (PRES) in a Nonsevere Case of COVID-19

Posterior reversible encephalopathy syndrome (PRES) is a rare complication that the exact pathophysiological mechanism of which is still unclear. PRES most often occurs in connection with severe hypertension and autoimmune diseases. It can also appear during chemotherapy or immunosuppressive treatment. A 38-year-old woman with a negative medical history was admitted to the local hospital due to loss of consciousness accompanied by seizures and high values of blood pressure, and a PCR test for COVID-19 was positive. The patient’s condition was preceded by weakness, wet cough, runny nose, and low-grade fever for three days. Due to the conducted diagnostics after negative CT scans and angio CT studies, an MRI of the head with contrast was performed, where changes characteristic of PRES syndrome were found. During the hospitalization, the patient did not require invasive ventilation and did not receive antiviral drugs or tocilizumab as a result of treatment for her high blood pressure values, and after establishing the diagnosis, the patient was discharged home with a significant improvement in her well-being. In the literature, there are discussions as to whether COVID-19 predisposes patients to PRES. Isolated cases have been described, but its frequency is not yet established. Case reports in the literature appear to be specifically associated with a severe course of the disease, unlike in our patient. Even with a mild course of COVID, the diagnosis of PRES should be taken into account in patients with seizures, visual disturbances, or other focal neurological deficits.

Neurological complications in Egyptian children with nephrotic syndrome

AIM

This study aimed at describing the incidence, risk factors and outcomes for neurological manifestations in Egyptian children with nephrotic syndrome (NS) and determining correctable factors that could lower the risk for these complications.

METHODS

The medical records of all children with NS who presented to Nephrology clinic, Ain Shams University Children hospital (a tertiary hospital) from April 2018 to April 2020 were reviewed retrospectively for the clinical progression of NS with special emphasis on neurological manifestations, contributory risk factors and outcomes.

RESULTS

Among 67 children with NS, 13 children had neurological events. Seven patients had posterior reversible encephalopathy syndrome (PRES), four patients suffered from cerebral sinovenous thrombosis (CSVT) and two patients presented with arterial strokes. Hypertension was significantly higher in patients with NS and neurological manifestations (NS/N+) when compared to patients with NS without neurological manifestations (NS/N-) (76.9% vs. 40.7%; P = 0.019). NS/N+ group had significantly higher levels of triglycerides and cholesterol (209.7 ± 41.4 and 323.6 ± 40.7 in NS/N+ vs. 181.96 ± 31.8 and 243.8 ± 38.8 in NS/N-). Prothrombotic tendency was significantly higher in NS/N+ group as compared to NS/N- group. All patients recovered totally except patients with arterial strokes who had residual hemiparesis.

CONCLUSION

Neurological complications in form of PRES, CSVT and arterial strokes were detected in children with NS. The outcome was favourable in most of the cases. Investment in parental education about the importance of follow up of blood pressure, dietary modification and good hydration could help in minimising the risk of patients with NS to develop neurological complications.

Predictors of hospital outcomes among patients with posterior reversible encephalopathy syndrome

OBJECTIVES

We aimed to identify independent predictors of the clinical outcomes of posterior reversible encephalopathy syndrome (PRES) in the Thai-Asian population.

MATERIALS AND METHODS

This retrospective cohort study recruited PRES patients admitted in the hospital between 2006 and 2019. The baseline characteristics, clinical presentations, precipitating factors, neuroimaging characteristics, hospital complications, and hospital outcomes were compared between the groups with favourable (modified Rankin scale [mRS] score, 0-2) and unfavourable (mRS score, 3-6) clinical outcomes. Factors presenting with p-values < 0.5 in univariate analysis were analysed in the multiple logistic regression model to determine independent predictors of outcome.

RESULTS

Among 136 PRES patients, 22.80% experienced unfavourable outcomes (mRS score, 3-6), and the mortality rate was 7.35%. The common presenting symptoms in the unfavourable clinical outcome group were impairment of consciousness (90.32%) and seizures (67.74%). Sepsis as a hospital complication (adjusted odds ratio [aOR], 32.95; 95% confidence interval [CI], 4.44-244.22, p = 0.001), acute kidney injury as a hospital complication (aOR, 9.94; 95% CI, 1.71-57.66; p = 0.010), and impairment of consciousness (aOR, 10.85; 95% CI, 1.72-68.53, p = 0.011) were independent predictors of unfavourable outcomes. On the other hand, headache was an independent protective factor (aOR, 0.164; 95% CI, 0.03-0.91; p = 0.039).

CONCLUSIONS

Impairment of consciousness, sepsis as a hospital complication, and acute kidney injury were independent predictors of unfavourable clinical outcomes, whereas headache showed a preventive effect.

The Management of Hypertensive Emergencies-Is There a "Magical" Prescription for All?

Hypertensive emergencies (HE) represent high cardiovascular risk situations defined by a severe increase in blood pressure (BP) associated with acute, hypertension mediated organ damage (A-HMOD) to the heart, brain, retina, kidneys, and large arteries. Blood pressure values alone do not accurately predict the presence of HE; therefore, the search for A-HMOD should be the first step in the management of acute severe hypertension. A rapid therapeutic intervention is mandatory in order to limit and promote regression of end-organ damage, minimize the risk of complications, and improve patient outcomes. Drug therapy for HE, target BP, and the speed of BP decrease are all dictated by the type of A-HMOD, specific drug pharmacokinetics, adverse drug effects, and comorbidities. Therefore, a tailored approach is warranted. However, there is currently a lack of solid evidence for the appropriate treatment strategies for most HE. This article reviews current pharmacological strategies while providing a stepwise, evidence based approach for the management of HE.

Clinical features and prognostic analysis of posterior reversible encephalopathy syndrome in children

BACKGROUND

We aimed to investigate the clinical features and prognosis of posterior reversible encephalopathy syndrome (PRES) in children.

METHODS

Clinical data of children with PRES diagnosed at the Children's Hospital of Chongqing Medical University from June 2015 to May 2019 were retrospectively analyzed.

RESULTS

The study enrolled 47 patients with a mean age at diagnosis of 8.79 ± 3.72 years (range, 2-15 years). PRES causes included renal disorder (29/47), hematological disease (13/47), and hypertension (5/47). PRES manifested as seizure (43/47), headache (28/47), visual impairment (18/47), dizziness (18/47), vomiting (18/47), and mental and behavioral abnormalities (17/47). Forty-six children had hypertension (46/47) at PRES onset. Magnetic resonance imaging (MRI) mainly involved the parietal and occipital lobes (42/47), 38 cases were mild (38/47), 7 were moderate (7/47), and 2 were severe (2/47). The clinical symptoms of 41 patients (41/47) were relieved within 1-2 weeks. Thirty-seven children were followed up for 7-54 months (modified Rankin Scale). Twenty-five children had favorable outcomes (25/37). Twelve children had adverse outcomes (12/37), including epilepsy, disorders of consciousness, visual impairment, and mental decline. Analysis of single factors revealed that severity on MRI, length of in-hospital stay, and mental and behavioral abnormalities were related to adverse outcomes after PRES. Analysis of multiple factors revealed that severity on MRI and length of in-hospital stay were independent risk factors for PRES.

CONCLUSION

Pediatric PRES is a clinical radiographic syndrome with multiple etiologies. Most patients have a good prognosis. Severity on MRI and length of in-hospital stay are independent risk factors.

Posterior reversible encephalopathy syndrome (PRES): diagnosis and management

Posterior reversible encephalopathy syndrome (PRES) may present with diverse clinical symptoms including visual disturbance, headache, seizures and impaired consciousness. MRI shows oedema, usually involving the posterior subcortical regions. Triggering factors include hypertension, pre-eclampsia/eclampsia, renal failure, cytotoxic agents and autoimmune conditions. The mechanism underlying PRES is not certain, but endothelial dysfunction is implicated. Treatment is supportive and involves correcting the underlying cause and managing associated complications, such as seizures. Although most patients recover, PRES is not always reversible and may be associated with considerable morbidity and even mortality.

Posterior Reversible Encephalopathy Syndrome: A Review of the Literature

Posterior reversible encephalopathy syndrome (PRES) is a group of clinical syndromes typically characterized by bilateral reversible vasogenic edema of the subcortical white matter in the parieto-occipital region on neuroimaging that causes a wide variety of acute or subacute neurological symptoms, including headache, mental status alteration, seizures, and visual dysfunction. PRES is classically suspected in patients with severe hypertension, renal failure, autoimmune disorders, eclampsia, or immunosuppressant medications. Frequent neurological evaluations and neuroimaging examinations by computed tomography or magnetic resonance imaging are required for both the diagnosis and assessment of the condition. Early detection of the disease is key for a rapid recovery and good prognosis.

Blood transfusion-induced posterior reversible encephalopathy syndrome presenting severe brain atrophy: A report of two cases

Several cases of posterior reversible encephalopathy syndrome (PRES) after blood transfusion have been reported, but the long-term prognosis is unknown. Here, we report two cases of blood transfusion-associated PRES with severe brain atrophy at 1 year after onset. We report the case with a discussion of pathological mechanisms.

Seizures in posterior reversible encephalopathy syndrome: blood pressure management in normotensive patients

Posterior reversible encephalopathy syndrome (PRES) is a rare clinical disease that refers to the subcortical vasogenic edema involving bilateral parieto-occipital regions, with a usually reversible syndrome when causes are eliminated or controlled. Hypertension or blood pressure fluctuations are most common causes of PRES, but other contributors like chemotherapy and autoimmune disorders have also been reported. PRES has rapid onset of symptoms. Therefore, it is of major importance to determine whether blood pressure management plays an important role in prognosis. We presented two PRES patients who developed non-convulsive seizure but had normal baseline blood pressure at the time of presence of cause. The diagnosis of PRES was made by neurologists. The patients had no history of seizure or hypertension, but during the disease course they presented with temporal elevation of blood pressure with different durations. The second patients without instant blood pressure control developed residual symptoms of seizure at 90- and 120-day follow-up. Although the exact pathophysiology of PRES remains to be fully understood, primary and secondary prolonged blood pressure fluctuations may be associated with the prognosis of this syndrome. Early blood pressure management would be critical to favorable outcome.

Posterior Reversible Encephalopathy Syndrome: A Narrative Review for Emergency Clinicians

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiologic disorder characterized by seizures, headache, altered mental status, and visual disturbances, and is often associated with acute hypertension.

OBJECTIVE

This narrative review provides a focused description of the presentation, diagnostic evaluation, and management of PRES.

DISCUSSION

PRES is associated with a variety of factors, including acute rise in blood pressure, renal disease, preeclampsia/eclampsia, and immunosuppressive therapy. The pathophysiology is theorized to involve dysfunction of cerebral autoregulation leading to vascular leak or endothelial dysfunction resulting in vasogenic edema. In the emergency department (ED), clinical findings suggestive of PRES should prompt diagnostic testing focused on confirming the diagnosis and excluding other conditions that may present similarly. Laboratory studies are primarily useful for excluding alternative diagnoses. Computed tomography (CT) and, in particular, magnetic resonance imaging (MRI) are the recommended neuroimaging modalities for diagnosis. CT and MRI may demonstrate cerebral vasogenic edema, most often in the distribution of the posterior circulation. Treatment involves management of seizures, control of blood pressure if elevated, and treatment of any underlying trigger.

CONCLUSION

PRES is a neurological disorder that is typically reversible if recognized on presentation and promptly and appropriately managed. This narrative review characterizes this condition for emergency clinicians.

Clinical Presentation and Risk Factors for Poor Outcomes Among Adult Patients With Posterior Reversible Encephalopathy Syndrome: A Retrospective Cohort Study

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) is an acute neurological condition with unknown global incidence, variable clinical presentation, and prognosis.

OBJECTIVES

To describe a cohort of patients with PRES with a focus on brain magnetic resonance imaging (MRI) patterns and their relationship with short-term clinical outcomes.

METHODS

Retrospective cohort study. The authors included patients if they were older than 15 years and had a PRES diagnosis on the basis of a positive brain MRI at any time during the in-hospital stay.

RESULTS

Forty-four patients were included in the present analysis. The median age was 57 years (interquartile range, 32.0-68.5) and 70.5% were women. Hypertension (59.1%), history of transplantation (27.3%), previous chemotherapy (27.3%), chronic renal failure (38.6%), and autoimmune disease (15%) were the main comorbid conditions present. The classic triad of seizures, headache, and visual impairment was present in 18.0% of the cases. Eighty-six percent of patients were admitted to the intensive care unit, with 36.0% needing invasive life support. Brain MRI showed a dominant parieto-occipital pattern in 26 patients, whereas cytotoxic edema and bleeding were present in 27.3% and 29.6%, respectively. In-hospital mortality was 11.4%. The median modified Rankin Scale at hospital discharge was 1 (0-2.5). Risk factors associated with low modified Rankin Scale scores were: headache, visual impairment, and parieto-occipital pattern. Decreased level of consciousness and mechanical ventilation requirement were associated with greater discharge disability.

CONCLUSIONS

Characteristic symptoms and signs of PRES and classic MRI patterns are associated with better clinical outcomes.

Management of hypertensive emergencies: a practical approach

Background: Acute increases of high blood pressure values, usually described as 'hypertensive crises', 'hypertensive urgencies' or 'hypertensive emergencies', are common causes of patients' presentation to emergency departments. Owing to the lack of ad hoc randomized clinical trials, current recommendations/suggestions for treatment of these patients are not evidenced-based and, therefore, the management of acute increases of blood pressure values represent a clinical challenge. However, an improved understanding of the underlying pathophysiology has changed radically the approach to management of the patients presenting with these conditions in recent years. Accordingly, it has been proposed to abandon the terms 'hypertensive crises' and 'hypertensive urgencies', and restrict the focus to 'hypertensive emergencies'. Aims and Methods: Starting from these premises, we aimed at systematically review all available studies (years 2010-2020) to garner information on the current management of hypertensive emergencies, in order to develop a novel symptoms- and evidence-based streamlined algorithm for the assessment and treatment of these patients.Results and Conclusions: In this educational review we proposed the BARKH-based algorithm for a quick identification of hypertensive emergencies and associated acute organ damage, to allow the patients with hypertensive emergencies to receive immediate treatment in a proper setting.

A case report of reversible posterior encephalopathy syndrome with intracranial hemorrhage in a child

INTRODUCTION

The objective is to analyze the clinical diagnosis and treatment of children with rescindable posterior encephalopathy syndrome (PRES) and intracranial hemorrhage (ICH) to improve the pediatrician's understanding of PRES combined with ICH in children.

PATIENT CONCERNS AND DIAGNOSIS

After liver transplantation, the patient developed symptoms of epilepsy and coma. Meanwhile, massive necrosis of acute cerebral infarction and small hemorrhage was observed in the left cerebellar hemisphere and left occipital lobe, respectively. The above symptoms were initially diagnosed as PRES.

INTERVENTIONS AND OUTCOMES

After adjusting the anti-rejection drug regimen, it was found that the child's neurological symptoms were relieved, and the limb motor function gradually recovered during follow-up. Imaging examination showed significant improvement on abnormal signals in brain.

CONCLUSION

In general, children with PRES may further develop ICH and contribute to a poor prognosis. Early diagnosis, detection of risk factors and timely adjustment of medication regimen are the keys to prevent irreversible brain damage.

Posterior Reversible Encephalopathy Syndrome

Purpose of Review

This review provides an updated discussion on the clinical presentation, diagnosis and radiographic features, mechanisms, associations and epidemiology, treatment, and prognosis of posterior reversible encephalopathy syndrome (PRES). Headache is common in PRES, though headache associated with PRES was not identified as a separate entity in the 2018 International Classification of Headache Disorders. Here, we review the relevant literature and suggest criteria for consideration of its inclusion.

Recent Findings

COVID-19 has been identified as a potential risk factor for PRES, with a prevalence of 1–4% in patients with SARS-CoV-2 infection undergoing neuroimaging, thus making a discussion of its identification and treatment particularly timely given the ongoing global pandemic at the time of this writing.

Summary

PRES is a neuro-clinical syndrome with specific imaging findings. The clinical manifestations of PRES include headache, seizures, encephalopathy, visual disturbances, and focal neurologic deficits. Associations with PRES include renal failure, preeclampsia and eclampsia, autoimmune conditions, and immunosuppression. PRES is theorized to be a syndrome of disordered autoregulation and endothelial dysfunction resulting in preferential hyperperfusion of the posterior circulation. Treatment typically focuses on treating the underlying cause and removal of the offending agents.

Predictors of posterior reversible encephalopathy syndrome in women with hypertension in pregnancy: A prospective observational study

OBJECTIVES

Posterior reversible encephalopathy syndrome (PRES) is a clinical neuro-radiologic abnormality associated with eclampsia and is diagnosed with magnetic resonance imaging (MRI). However, MRI scans to detect PRES may be difficult to obtain routinely. Thus, it would be useful to see whether standard demographic, clinical and laboratory parameters are predictive of PRES.

STUDY DESIGN

Prospective observational cohort study.

MAIN OUTCOME MEASURE

Prediction of PRES with standard parameters.

RESULTS

30 hypertensive pregnant women were enrolled. Brain MRI scans were performed after delivery till 7 days post-partum. Area under curves (AUC)s for clinical and laboratory parameters were generated for PRES prediction. A total of 8 women (5 with eclampsia and 3 with preeclampsia with features of severity) had PRES features in MRI. The most specific parameters for predicting PRES were age (<24 years), platelet count (<0.69 lacs/mm³), serum ALT (>129 IU/L) and AST (>55 IU/L), total bilirubin (>1.3 mg/dl), low hemoglobin (<8.7 g/dl) and presence of seizures. The most sensitive predicting parameters were serum uric acid > 5.2 mg/dl, systolic blood pressure (SBP) > 164 mm Hg, diastolic blood pressure > 100 mmHg and serum creatinine > 0.8 mg/dl. The best AUCs > 70% and good Youden indices were obtained for age < 24 years, SBP > 164 mm Hg, total bilirubin > 1.3 mg/dl, AST > 55 IU/L, hemoglobin < 8.7 mg/dl and uric acid > 5.2 mg/dl.

CONCLUSION

In women with preeclampsia, younger age, raised SBP, elevated serum total bilirubin, uric acid and AST and low hemoglobin best predict PRES.

Eclampsia-Induced Posterior Reversible Encephalopathy Syndrome in a Donor Oocyte Recipient

Objective: Posterior reversible encephalopathy syndrome (PRES) has been robustly associated with preeclampsia, hyperperfusion or endothelial dysfunction suggested as possible mechanisms. In this article, we report an illustrative case of this complication in a patient with risk factors for hypertensive disorders in pregnancy, including advanced maternal age and donor oocyte fertilization.

Case report: We present a case of a 40-year-old pregnant, donor oocyte recipient with sudden decreased visual acuity accompanied by hypertension, proteinuria and tonic-clonic seizures. Magnetic resonance imaging (MRI) of the brain showed bilateral lesions in the parieto-occipital regions suggestive of vasogenic edema, leading us to suspect posterior reversible encephalopathy syndrome. The patient underwent an emergency cesarean section and labetalol and magnesium sulfate were administered intravenously. The neurological symptoms and radiological findings resolved following delivery and the patient’s blood pressure normalized, supporting the diagnosis of posterior reversible encephalopathy syndrome.

Conclusion: Pregnancy by donor oocyte fertilization may entail a higher risk of eclampsia and associated posterior reversible encephalopathy syndrome.

Management and Clinical Outcome of Posterior Reversible Encephalopathy Syndrome in Pediatric Oncologic/Hematologic Diseases: A PRES Subgroup Analysis With a Large Sample Size

This study investigated the management and clinical outcomes along with associated factors of posterior reversible encephalopathy syndrome (PRES) in childhood hematologic/oncologic diseases. We present data from children with hematologic/oncologic diseases who developed PRES after treatment of the primary disease with chemotherapy and hematopoietic stem cell transplantation (HSCT) at 3 medical centers in Changsha, China from 2015 to 2020, and review all previously reported cases with the aim of determining whether this neurologic manifestation affects the disease prognosis. In the clinical cohort of 58 PRES patients, hypertension [pooled odds ratio (OR) = 4.941, 95% confidence interval (CI): 1.390, 17.570; P = 0.001] and blood transfusion (OR = 14.259, 95% CI: 3.273, 62.131; P = 0.001) were significantly associated with PRES. Elevated platelet (OR = 0.988, 95% CI: 0.982, 0.995; P < 0.001), hemoglobin (OR = 0.924, 95% CI: 0.890, 0.995; P < 0.001), and blood sodium (OR = 0.905, 95% CI: 0.860, 0.953; P < 0.001), potassium (OR = 0.599, 95% CI: 0.360, 0.995; P = 0.048), and magnesium (OR = 0.093, 95% CI: 0.016, 0.539; P = 0.008) were protective factors against PRES. Data for 440 pediatric PRES patients with hematologic/oncologic diseases in 21 articles retrieved from PubMed, Web of Science, and Embase databases and the 20 PRES patients from our study were analyzed. The median age at presentation was 7.9 years. The most common primary diagnosis was leukemia (62.3%), followed by solid tumor (7.7%) and lymphoma (7.5%). Most patients (65.0%) received chemotherapy, including non-induction (55.2%) and induction (44.8%) regimens; and 86.5% used corticosteroids before the onset of PRES. Although 21.0% of patients died during follow-up, in most cases (93.2%) this was not attributable to PRES but to severe infection (27.3%), underlying disease (26.1%), graft-vs.-host disease (14.8%), multiple organ dysfunction syndrome (8.0%), and respiratory failure (3.4%). PRES was more common with HSCT compared to chemotherapy and had a nearly 2 times higher mortality rate in patients with oncologic/hematologic diseases than in those with other types of disease. Monitoring neurologic signs and symptoms in the former group is therefore critical for ensuring good clinical outcomes following treatment of the primary malignancy.

Posterior Reversible Encephalopathy Syndrome in infants and young children

AIM

The aim of this study was to describe the characteristics of Posterior Reversible Encephalopathy Syndrome (PRES) in infants and young children (<6 years) and to compare them with the older pediatric population affected by PRES.

METHODS

we retrospectively reviewed records of 111 children (0-17 years) diagnosed with PRES from 2000 to 2018 in 6 referral pediatric hospitals in Italy. The clinical, radiological and EEG features, as well as intensive care unit (ICU) admission rate and outcome of children aged <6 years were compared to those of older children (6-17 years). Factors associated with ICU admission in the whole pediatric cohort with PRES were also evaluated.

RESULTS

Twenty-nine patients younger than 6 years (26%) were enrolled with a median age at onset of PRES of 4 years (range: 6 months-5 years). Epileptic seizures were the most frequent presentation at the disease onset (27/29 patients). Status epilepticus (SE) was observed in 21/29 patients: in detail, 11 developed convulsive SE and 10 presented nonconvulsive SE (NCSE). SE was more frequent in children <6 years compared with older children (72% vs 45%) as well as NCSE (35% vs 10%). Seventeen children aged <6 years required ICU admission. Prevalence of ICU admissions was higher within younger population compared to older (59% vs 37%). In the whole study population SE was significantly associated with ICU admission (p = 0.001).

CONCLUSIONS

PRES in children < 6 years differs from older children in clinical presentation suggesting a more severe presentation at younger age.

Posterior reversible encephalopathy syndrome: A neuropsychiatric manifestation of systemic lupus erythematosus

Posterior Reversible Encephalopathy Syndrome (PRES) is an acute neurological syndrome clinically characterized by seizures, altered mental status, headache, and visual disturbances. It is caused by a variety of abnormalities in the endothelial function that ultimately result in vasogenic edema in the circulation of the central nervous system. This is reflected by the neuroimaging findings, that most often show reversible parieto-occipital edema. An important proportion of patients with PRES present with Systemic Lupus Erythematosus (SLE), and its complications, as their sole risk factors. This review describes the relationship between these two clinical entities and explains the pathophysiological models that have been proposed to describe the development of PRES. We explain how SLE can cause alterations in every pathway implicated in the development of PRES. Given the relatively high frequency and the distinct clinical course, PRES in the setting of SLE might be best described as a distinct neuropsychiatric syndrome associated with SLE.

Detecting the Uncommon Imaging Manifestations of Posterior Reversible Encephalopathy Syndrome (PRES) in Adults: a Comprehensive Illustrated Guide for the Trainee Radiologist

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.

Clinico-radiological Profile of Posterior Reversible Encephalopathy Syndrome and Its Associated Risk Factors in PICU: A Single-center Experience from a Tertiary Care Hospital in Bhubaneswar, Odisha

OBJECTIVE

Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiographic entity of heterogeneous etiologies having similar clinical and neuroimaging features. Pediatric data are sparse, making early diagnosis challenging, which needs a high index of suspicion. So, we conducted this study to evaluate clinico-radiological features, associated risk factors, etiology, and outcome in children.

MATERIALS AND METHODS

This is a retrospective case series of patients, diagnosed as having PRES and followed up at a tertiary care hospital in Eastern India between September 2016 and December 2019.

RESULTS

Among 16 patients with a median age of 9.5 years [interquartile range (IQR) 8-13.75] and a male preponderance (75%), common underlying diseases were post-streptococcal glomerulonephritis (56.3%) and renovascular hypertension (12.5%). Acute elevation of blood pressure was found in all patients (n = 16). The neurological symptom was seizure (87.5%), mental changes (68.75%), headache (43.8%), vomiting (31.3%), and visual disturbances (31.3%). The most common triggering factor was hypertension (100%), use of mycophenolate mofetil and prednisolone (12.5%), and hemodialysis (12.5%). Anemia was present in 15 (93.4%) patients at the time of admission. All showed abnormal neuroimaging with 55% having atypical involvement. The most common site was the parietal-occipital cortex (88%), frontal and temporal lobe (44% cases each), and the cerebellum (13%). Clinical recovery was followed by a radiological resolution in all survived except in one, who developed visual impairment.

CONCLUSION

Posterior reversible encephalopathy syndrome should be considered in the differential diagnosis of patients who present with acute neurological disturbances and underlying diseases such as renal disorders, vasculitis, malignancy, and use of immunosuppressant accompanied by hypertension. Early diagnosis and treatment of comorbid conditions are of paramount importance for the early reversal of the syndrome.

HOW TO CITE THIS ARTICLE

Behera CK, Jain MK, Mishra R, Jena PK, Dash SK, Sahoo RK. Clinico-radiological Profile of Posterior Reversible Encephalopathy Syndrome and Its Associated Risk Factors in PICU: A Single-center Experience from a Tertiary Care Hospital in Bhubaneswar, Odisha. Indian J Crit Care Med 2020;24(12):1223-1229.

Clinico-radiological Profile of Posterior Reversible Encephalopathy Syndrome and Its Associated Risk Factors in PICU: A Single-center Experience from a Tertiary Care Hospital in Bhubaneswar, Odisha

OBJECTIVE

Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiographic entity of heterogeneous etiologies having similar clinical and neuroimaging features. Pediatric data are sparse, making early diagnosis challenging, which needs a high index of suspicion. So, we conducted this study to evaluate clinico-radiological features, associated risk factors, etiology, and outcome in children.

MATERIALS AND METHODS

This is a retrospective case series of patients, diagnosed as having PRES and followed up at a tertiary care hospital in Eastern India between September 2016 and December 2019.

RESULTS

Among 16 patients with a median age of 9.5 years [interquartile range (IQR) 8-13.75] and a male preponderance (75%), common underlying diseases were post-streptococcal glomerulonephritis (56.3%) and renovascular hypertension (12.5%). Acute elevation of blood pressure was found in all patients (n = 16). The neurological symptom was seizure (87.5%), mental changes (68.75%), headache (43.8%), vomiting (31.3%), and visual disturbances (31.3%). The most common triggering factor was hypertension (100%), use of mycophenolate mofetil and prednisolone (12.5%), and hemodialysis (12.5%). Anemia was present in 15 (93.4%) patients at the time of admission. All showed abnormal neuroimaging with 55% having atypical involvement. The most common site was the parietal-occipital cortex (88%), frontal and temporal lobe (44% cases each), and the cerebellum (13%). Clinical recovery was followed by a radiological resolution in all survived except in one, who developed visual impairment.

CONCLUSION

Posterior reversible encephalopathy syndrome should be considered in the differential diagnosis of patients who present with acute neurological disturbances and underlying diseases such as renal disorders, vasculitis, malignancy, and use of immunosuppressant accompanied by hypertension. Early diagnosis and treatment of comorbid conditions are of paramount importance for the early reversal of the syndrome.

HOW TO CITE THIS ARTICLE

Behera CK, Jain MK, Mishra R, Jena PK, Dash SK, Sahoo RK. Clinico-radiological Profile of Posterior Reversible Encephalopathy Syndrome and Its Associated Risk Factors in PICU: A Single-center Experience from a Tertiary Care Hospital in Bhubaneswar, Odisha. Indian J Crit Care Med 2020;24(12):1223-1229.