Involvement of the cervical cord and medulla in posterior reversible encephalopathy syndrome

A case report of Posterior reversible encephalopathy syndrome with spinal cord involvement (PRES-SCI) as an atypical presentation of PRES in children: A case report and review of the literature

Posterior reversible encephalopathy syndrome (PRES) has a broad spectrum of clinical presentations and radiological features. Diagnosis of PRES is established based on reversible clinical manifestations and sequential neuroimaging findings. Atypical MRI features include hemorrhage, restricted diffusion or contrast enhancement of lesions, and involvement of the temporal and frontal lobes, brainstem, basal ganglia, corpus callosum, cerebellum, and spine. Atypical PRES, with or without spinal cord involvement, is a rare presentation, especially in children. Until 2020, only five cases of PRES with spinal cord involvement (PRES-SCI) were reported in the pediatric population.

CASE REPORT

Here, we present the youngest diagnosed case of PRES-SCI so far. According to the literature, all six cases of PRES-SCI showed high signal intensities on T2-weighted images of the brainstem and cervical cord, which had completely resolved in the follow-up MRI of the brain and spinal cord. All six patients had hypertension due to renal disease, except one girl with chemotherapy-induced hypertension. Headache, altered mental status, seizure, and visual impairment were the most common symptoms, respectively. Facial palsy was a remarkable warning sign in some patients before hospitalization.Although PRES-SCI is rare in children, since it is a reversible condition, prompt diagnosis and management can positively affect its prognosis.

Posterior reversible encephalopathy syndrome coexists with acute cerebral infarction: challenges of blood pressure management

Hypertension is the most common cause of posterior reversible encephalopathy syndrome (PRES) and acute cerebral infarction. Due to the lack of randomized controlled clinical trials (RCTs), early antihypertensive methods are diverse, even contradictory. So far, there is no consensus on the method of blood pressure (BP) management when the 2 diseases coexist. Generally, antihypertensive therapy should be initiated quickly in the acute phase of PRES, as most patients have elevated BP. However, various factors must be considered before the administration of early antihypertensive therapy in acute cerebral infarction. The coexistence of PRES and acute cerebral infarction is uncommon clinically, and more complicated subsequent BP management. This article reports a case of PRES coexisting with acute lacunar cerebral infarction, which was caused by hypertension. We have analyzed and summarized the antihypertensive principles in PRES and different phases of acute cerebral ischemic injury. We assert that when PRES and acute cerebral infarction coexist, the antihypertensive treatment should be individualized, and careful consideration should be given to the various influencing factors.

Posterior reversible encephalopathy syndrome with isolated infratentorial involvement: A case report

Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiological entity of acute neurological symptoms associated with characteristic MRI finding. Vasogenic edema in the white matter of parieto-occipital regions is the classical MRI findings. Spinal cord involvement in PRES is extremely rare and frequently underrecognized condition. Recently, a variant-type PRES with isolated involvement of infratentorial structures is getting more attention. Herein, we present a case of hypertensive emergency and associated radiological features of PRES with isolated involvement of the brain stem, cerebellum, and spinal cord.

Posterior reversible encephalopathy syndrome with spinal cord involvement but without hemisphere lesions: A case report

RATIONALE

Posterior reversible encephalopathy syndrome (PRES) was termed by Hinchey in 1996. Patients have a reversible vasogenic brain edema in imaging and acute neurological symptoms such as headache, seizures, encephalopathy, and visual disturbances when suffering from hypertension, pre-eclampsia/eclampsia, renal failure, immunosuppressive medications, autoimmune disorders, sepsis, thrombocytopaenia, hypocalcaemia, alcohol withdrawal, and many other potential causes. de Havenon A et al have proposed a new syndrome named PRES with spinal cord involvement (PRES-SCI). The patients with PRES-SCI have similar symptoms these of PRES. Patients have neurologic signs with the spinal cord involved and lesions in magnetic resonance imaging (MRI) extending to the cervicomedullary junction, usually with extreme elevation in blood pressure and a history of hypertensive retinopathy. We administrated a young patient whose condition was consistent with PRES-SCI except for the hemisphere lesions.

PATIENT CONCERNS

A 20-year-old Asian male patient was admitted for a 1 week history of blurred vision and weakness of the limbs. He has had poorly controlled hypertension for 1 year before admission. In emergency room, his blood pressure could raise to 260/140mmHg. Neurological examinations and cerebral spinal fluid tests were negative. The MRI of the brain and spinal cord showed reversible lesions in the medulla and upper cervical spinal cord that extended to the lower thoracic spine.

DIAGNOSIS

Taking into account the characteristic lesions in the MRI as well as the reversible course upon treatment, he was diagnosed PRES-SCI.

INTERVENTIONS

He was treated with medicines for the hypertension.

OUTCOMES

His symptoms rapidly improved and finally the lesions on the MRI of the brain and spianl cord disappeared.

LESSONS

Clinicians should suspect PRES-SCI when patients have mild or no neurologic signs accompanied with extreme elevation in blood pressure and lesions in spinal cord. Spinal lesions alone may be a subtype of PRES-SCI.

Posterior Reversible Encephalopathy Syndrome With Spinal Cord Involvement in Children

We characterized a cohort of patients with posterior reversible encephalopathy syndrome with spinal cord involvement. We encountered 2 children and identified an additional 19 patients from the internet databases. Of the 21 patients analyzed, 8 were children. The mean peak systolic blood pressure in adults was significantly higher than in children (221.8 ± 14.3 vs 191.4 ± 31.3 mm Hg; P < .01). Regardless of age, the most common clinical symptom was headache (90%) and the least common clinical symptom was seizures (28%). Atypical neuroimaging was more common in children (63%) than in adults (8%). Abnormal cerebrospinal fluid results were frequently found in children (83%). All children recovered uneventfully, but 3 adults had sequelae. A broader clinicoradiologic spectrum makes the diagnosis of children more complex than in adults. Awareness of the atypical features with a meticulous management of hypertension is imperative to avoid unnecessary invasive workups and to achieve an uneventful recovery.

[Research advances of posterior reversible encephalopathy syndrome in children]

Posterior reversible encephalopathy syndrome (PRES) is a clinico-neuroradiological entity affecting the posterior brain, i.e. occipital and parietal lobes. The syndrome are characterized by headaches, altered mental status, seizures, and visual disturbances. Although the pathogenesis remains unclear, endothelial dysfunction may be a key factor. The basic disease may play a crucial role in the incidence of PRES. In most cases, PRES resolves spontaneously and patients show both clinical and radiological improvements. In severe forms, PRES might cause substantial morbidity with sequel and even mortality, as a result of acute hemorrhage or massive posterior fossa edema causing obstructive hydrocephalus or brainstem compression. Early identification, active and appropriate treatment is very important.

[Research advances of posterior reversible encephalopathy syndrome in children]

Posterior reversible encephalopathy syndrome (PRES) is a clinico-neuroradiological entity affecting the posterior brain, i.e. occipital and parietal lobes. The syndrome are characterized by headaches, altered mental status, seizures, and visual disturbances. Although the pathogenesis remains unclear, endothelial dysfunction may be a key factor. The basic disease may play a crucial role in the incidence of PRES. In most cases, PRES resolves spontaneously and patients show both clinical and radiological improvements. In severe forms, PRES might cause substantial morbidity with sequel and even mortality, as a result of acute hemorrhage or massive posterior fossa edema causing obstructive hydrocephalus or brainstem compression. Early identification, active and appropriate treatment is very important.

PRES with asymptomatic spinal cord involvement. Is this scenario more common than we know?

INTRODUCTION

Posterior reversible encephalopathy syndrome (PRES) is an entity characterized by neurologic symptoms such as headaches, altered mental status, seizures and visual changes, and it is associated with white matter vasogenic edema predominantly affecting the posterior occipital and parietal lobes of the brain.

CASE REPORT

A 19-year-old patient developed PRES after the use of chemotherapy for a testicular teratocarcinoma and after the development of a blood pressure elevation.

DISCUSSION

Few cases described the involvement of the spinal cord in this syndrome. In the majority of these cases, the spinal cord involvement was asymptomatic or with few symptoms of spinal cord disease.

Posterior reversible leukoencephalopathy syndrome with spinal cord involvement in a 9-year-old girl

We report the youngest pediatric case of posterior reversible leukoencephalopathy syndrome confined to brainstem and spinal cord. At presentation bicytopenia, renal derangement, visual disturbances, magnetic resonance imaging findings, increased protein content, IgG index and cell count in the cerebrospinal fluid led us to extensive search for myelitis. She received a short course of steroid treatment. The final diagnosis was hypertension due to reflux nephropathy. Severe hypertension that exceeds the range of autoregulation in anterior spinal territory may result in spinal posterior reversible leukoencephalopathy syndrome. Clinicians should be aware of spinal posterior reversible leukoencephalopathy syndrome when cases have extensive lesions in the brainstem and spinal cord with none or minimal clinical findings, so called "clinical radiologic dissociation".

Posterior reversible encephalopathy syndrome with spinal cord involvement (PRES-SCI): A case report

Posterior reversible encephalopathy syndrome with spinal cord involvement (PRES-SCI) is a recently described entity with a handful of cases reported in literature. We describe a case of PRES in setting of Henoch-Schönlein purpura (HSP) with involvement of brain stem and spinal cord.

Posterior reversible encephalopathy syndrome: clinical and radiological manifestations, pathophysiology, and outstanding questions

Almost two decades have elapsed since posterior reversible encephalopathy syndrome (PRES) was described in an influential case series. This usually reversible clinical syndrome is becoming increasingly recognised, in large part because of improved and more readily available brain imaging. Although the pathophysiological changes underlying PRES are not fully understood, endothelial dysfunction is a key factor. A diagnosis of PRES should be considered in the setting of acute neurological symptoms in patients with renal failure, blood pressure fluctuations, use of cytotoxic drugs, autoimmune disorders, or eclampsia. Characteristic radiographic findings include bilateral regions of subcortical vasogenic oedema that resolve within days or weeks. The presence of haemorrhage, restricted diffusion, contrast enhancement, and vasoconstriction are all compatible with a diagnosis. In most cases, PRES resolves spontaneously and patients show both clinical and radiological improvements. The range of symptoms that can comprise the syndrome might be broader than usually thought. In its mild form, this disorder might cause only one clinical symptom (headache or seizure) and radiographically might show few areas of vasogenic oedema or even normal brain imaging in some rare cases. In severe forms, PRES might cause substantial morbidity and even mortality, most often as a result of acute haemorrhage or massive posterior fossa oedema causing obstructive hydrocephalus or brainstem compression.

Posterior reversible encephalopathy syndrome with involvement of the cervical cord and medulla: a case report

Posterior reversible encephalopathy syndrome (PRES) is a neurotoxic state, which is associated with symmetrical subcortical areas of vasogenic oedema that are preferentially parieto-occipital, and it typically resolves within a few weeks after appropriate treatment, We hereby report a case of a female with adrenal tumour presenting with PRES, who was featured by a very rare neuroimaging manifestation, the involvement of cervical cord and medulla.

Atypical presentation of posterior reversible encephalopathy: in a child with bilateral grade IV vesicoureteric reflux

Posterior reversible encephalopathy, better known as potential reversible encephalopathy syndrome (PRES), is a clinicoradiological entity mostly described in adult populations manifesting predominantly as bilateral symmetrical diffuse white matter vasogenic oedema in parieto-occipital regions. Rarely it may also present as patchy reversible areas of involvement in the basal ganglia, brainstem and deep white matter. It is reported scarcely in childhood populations. Frequent association with acute hypertension (67-80%) is reported in many studies. Involvement of the brainstem and cervical cord (apart from the typical parieto-occipital lesions) is an extremely rare imaging manifestation of PRES and its recognition is important to avoid misdiagnosis as myelitis or acute disseminated encephalomyelitis by proper clinical correlation. We hereby report a case of PRES in a 7-year-old child showing an uncommon pattern on imaging study involving the brain as well as the brainstem and cervical spinal cord.

Reversible confluent deep white matter abnormalities: a new variant of posterior reversible encephalopathy syndrome

We describe a confluent deep white matter abnormalities variant of PRES, further strengthening the notion that PRES is a disorder of radiological heterogeneity. We present 2 cases of PRES with findings of diffuse but reversible vasogenic edema located in the deep periventricular white matter regions of bilateral hemispheres without a clearly posterior distribution. We feel that this represents a rare variant of PRES on imaging, thus adding to the existing radiological spectrum for this entity. Both of our patients presented with malignant hypertension (mean arterial blood pressure of 200 mmHg) and developed neurological symptoms that included encephalopathy, seizure, headache, and vision changes. Additionally, both patients presented with significant subcortical white matter edema that improved dramatically on follow-up imaging. The clinical and radiological improvement in both patients occurred following successful blood pressure management. It is possible that the deep white matter changes of PRES are seen exclusively in the setting of severe accelerated hypertension. Our case reports reveal that, in patients with hypertensive encephalopathy, a deep white matter pattern of diffuse signal changes may not necessarily indicate chronic ischemic changes and follow-up imaging studies are essential to rule out a diagnosis of PRES.

Can clinical and MRI findings predict the prognosis of variant and classical type of posterior reversible encephalopathy syndrome (PRES)?

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) is characterized by clinical symptoms that are associated with bilateral and symmetric vasogenic edema in the parietal and occipital lobes. However, this is rarely present with predominant involvement of the brain stem and cerebellum (variant).

PURPOSE

To evaluate which clinical or magnetic resonance imaging (MRI) findings can help to predict the prognosis of variant and classical type of PRES and whether or not there is difference between two types of PRES.

MATERIAL AND METHODS

We retrospectively evaluated MRI and clinical findings from 49 patients with PRES. These patients were divided into two groups. In group I, patients had atypical distribution of lesions. In group II, patients had typical distribution of lesions. Follow-up MRI was performed on 26 patients. We assessed the MRI features, clinical data, and the patients' outcomes.

RESULTS

The mean blood pressure (BP) was significantly higher in group I (195.52/121.09 mmHg and 156.78/99.53 mmHg for groups I and II, respectively). The other factors assessed were not significantly different between the two groups. Lesions in 24 of 26 patients reversed upon follow-up. Sequelae were observed in 11 patients (group I, 7; group II, 4). However, there were no significant differences between the two groups. Except for those patients who died, seven of the nine patients with sequelae upon follow-up imaging had hemorrhage or irreversibility of lesions.

CONCLUSION

Even though BP influences the involvement of the brain stem, involvement of the brain stem is not influential on the prognosis. It seems that the influential factor to prognosis is the reversibility of lesions and hemorrhage.

A patient with moderate post-operative hypertension presenting with posterior reversible encephalopathy syndrome: a case report

Posterior reversible encephalopathy Syndrome (PRES) is a rare syndrome that is reversible in most cases but can rarely lead to irreversible brain damage and death. Most cases occur after rapid rise in blood pressure. We report a 56 year-old Caucasian male with metastatic adenocarcinoma of the lung who presented with a pleural effusion for which thoracocentesis and thoracotomy were performed. He developed PRES on the third post-operative day following relatively moderate increase in blood pressure. It was diagnosed with diffuse weighted imaging (DWI) MRI. He eventually fully recovered from the event. PRES is a reversible syndrome, in most cases, that can be diagnosed with appropriate imaging studies such as MRI with DWI. This case report is of clinical importance to surgeons as well as neurologists. We speculate that post surgical patients are more prone to developing PRES at lower blood pressures than blood pressures required in healthy individuals to develop PRES. Patients' post surgical blood pressure should be monitored closely and maintained at lower levels to prevent PRES. It is essential to control and diagnose PRES at an early stage since it can be easily prevented and some cases proceed to irreversible damage. It should also be differentiated from an acute cerebrovascular event since its treatment and prognosis are markedly different from PRES.