Eclampsia and posterior reversible encephalopathy syndrome (PRES): A retrospective review of risk factors and outcomes

Corticosteroids in posterior reversible encephalopathy syndrome: Friend or foe? A systematic review

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) is a complex neurological disorder characterized by symptoms such as headaches, seizures, confusion, and visual disturbances. The pathophysiology of PRES involves endothelial dysfunction, disrupted cerebral autoregulation, and resulting vasogenic edema. Hypertension and other factors that alter cerebral autoregulation are critical in its development. Corticosteroids, widely used for their anti-inflammatory and immunosuppressive properties, play a controversial role in PRES.

AIM

To elucidate the dual role of corticosteroids in the context of PRES by critically evaluating the existing literature. Specifically, it seeks to assess the results of PRES induced by corticosteroid therapy and the efficacy and safety of corticosteroids in the treatment of PRES. By synthesizing case reports and series, this review aims to provide a comprehensive understanding of the mechanisms, clinical presentations, and management strategies associated with corticosteroid-related PRES.

METHODS

The review was carried out according to the PRISMA guidelines. The databases searched included Science Direct, PubMed, and Hinari. The search strategy encompassed terms related to corticosteroids and PRES. Studies were included if they were peer-reviewed articles examining corticosteroids in PRES, excluding non-English publications, reviews, and editorials. Data on patient demographics, clinical characteristics, imaging findings, corticosteroid regimens, and outcomes were extracted. The risk of bias was evaluated using the Joanna Briggs Institute tool for case reports.

RESULTS

A total of 56 cases of PRES (66.1% women, 33.9% men) potentially induced by corticosteroids and 14 cases in which corticosteroids were used to treat PRES were identified. Cases of PRES reportedly caused by corticosteroids showed a mean age of approximately 25.2 years, with seizures, headaches, hypertension, and visual disturbances being common clinical sequelae. Magnetic resonance findings typically revealed vasogenic edema in the bilateral parieto-occipital lobes. High-dose or prolonged corticosteroid therapy was a significant risk factor. On the contrary, in the treatment cases, corticosteroids were associated with positive outcomes, including resolution of vasogenic edema and stabilization of symptoms, particularly in patients with underlying inflammatory or autoimmune diseases.

CONCLUSION

Corticosteroids have a dual role in PRES, capable of both inducing and treating the condition. The current body of literature suggests that corticosteroids may play a greater role as a precipitating agent of PRES rather than treating. Corticosteroids may induce PRES through hypertension and subsequent increased cerebral blood flow and loss of autoregulation. Corticosteroids may aid in the management of PRES: (1) Enhancing endothelial stability; (2) Anti-inflammatory properties; and (3) Improving blood-brain barrier integrity. Mechanisms which may reduce or mitigate vasogenic edema formation.

Persistent Vegetative State Following a Cardiac Arrest in a Patient With Preeclampsia and Posterior Reversible Encephalopathy Syndrome: A Case Report

We report the case of a 35-year-old female patient who presented to a tertiary referral hospital in a persistent vegetative state (PVS) following a cardiac arrest that occurred approximately one hour after an elective cesarean delivery for a postterm pregnancy complicated by preeclampsia. Magnetic resonance imaging (MRI) of the brain performed seven days after the cardiac arrest showed findings consistent with posterior reversible encephalopathy syndrome (PRES). Following transfer to our hospital, the patient was carefully evaluated, stabilized, and successfully weaned off mechanical ventilation. However, due to the lack of neurological recovery, the decision was made to transfer her to a neurorehabilitation center for further management. This case report explores the potential link between PRES and PVS.

Fetomaternal outcome in preeclampsia and eclampsia with posterior reversible encephalopathy syndrome

Introduction

Preeclampsia and eclampsia are hypertensive disorders of pregnancy associated with significant maternal and fetal morbidity and mortality. Posterior reversible encephalopathy syndrome (PRES) is a neurological complication observed in these conditions, yet its impact on fetomaternal outcomes remains underexplored. The aim of this study is to investigate the association between PRES and fetomaternal outcomes in women with preeclampsia and eclampsia.

Methods

This prospective cohort study enrolled 64 singleton pregnant women beyond 20 weeks of gestation with preeclampsia and eclampsia having neurological symptoms. Participants underwent clinical evaluation and radiological assessment, including non-contrast computed tomography (NCCT) and magnetic resonance imaging (MRI). Maternal outcomes, including high dependency unit (HDU)/intensive care unit (ICU) stay, intubation, mode of delivery and maternal mortality. Fetal outcomes, i.e., stillbirth, prematurity, and neonatal intensive care unit (NICU) stay, were recorded. Statistical analysis was performed to compare outcomes between PRES and non-PRES groups.

Results

The majority (92.18%) of participants were unscheduled and (56.2%) were primigravida. PRES was diagnosed in 62.5% of cases, predominantly associated with antepartum eclampsia (47.5%). Neurological symptoms such as headache (85.9%) and blurring of vision (68.8%) were common in PRES cases. Cesarean section rate was significantly higher in PRES group (75%), along with adverse outcomes including increased HDU/ICU stay, intubation, postpartum haemorrhage (PPH), abruption, maternal mortality, stillbirth, prematurity, fetal growth restriction (FGR), meconium-stained liquor (MSL), and NICU stay, which were observed significantly higher in women with PRES (p < 0.001) and low Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) scores (p < 0.05). However, no significant association was observed between PRES and early neonatal death (ENND).

Conclusion

PRES is associated with adverse fetomaternal outcomes in women with preeclampsia/eclampsia, including higher cesarean section rate and increased maternal and neonatal morbidity. Early recognition and management of PRES are crucial for improving outcomes in these high-risk pregnancies. Further research with larger sample sizes is warranted to validate these findings and explore potential interventions.

Reversible postoperative vision loss (POVL): A tale of four patients

Background

Posterior reversible encephalopathy syndrome (PRES) is a clinic-imaging entity. PRES is rarely reported in the perioperative period to cause reversible postoperative vision loss (POVL). It is reported in the literature in the form of case reports for spinal and cardiac surgeries and eclampsia patients. The suggested diagnostic criteria for PRES are: (i) acute onset of neurological symptoms and signs; (ii) specific findings of vasogenic cerebral edema upon imaging studies; and (iii) reversibility of signs and symptoms as well as image study findings. We report a case series of four patients undergoing other than spinal, cardiac, or orthopedic surgeries who developed PRES and had reversible POVL.

Cases

The first case was a young female who had laparoscopic sleeve gastrectomy, had extreme hypertension at induction of anesthesia, had surgery and developed POVL after a few hours in the postoperative period, and had convulsions diagnosed to have PRES after computed tomography (CT) and magnetic resonance imaging (MRI). Managed with blood pressure and seizure control, vision returned gradually from 2nd postoperative day. The second case was also a young female who had appendicitis, requiring an appendectomy. Complicated by septic shock. Post-surgery, she was extubated after 1 day and immediately complained of total blindness. Local causes were ruled out, and an MRI diagnosed PRES. With supportive therapy, her vision started to return by Day 3 with improved normal vision. The third case was a female with recently diagnosed diabetes mellitus who presented with right upper limb embolic ischemia and had an embolectomy with a return of circulation. Her blood pressure was high and reached up to 200 mmHg after induction of anesthesia, which was controlled with deep anesthesia and a labetalol infusion in the perioperative period. After 8 h in the postoperative period, she was awake but searching for available objects. Relatives complained that she was unable to see. Local and fundus examinations were normal. She was awake but blind. Imaging studies confirmed PRES. Blood pressure was controlled using a labetalol infusion and continued supportive therapy. By Day 3, her vision became normal. The fourth case was an elderly patient who had hypertension, type 2 diabetes mellitus, and coronary artery disease. He underwent a right carotid endarterectomy under general anesthesia. He had severe hypertension in the perioperative area and blood pressure was controlled using a labetalol infusion. The surgery went smoothly. After 3 h, he had a loss of vision. Imaging studies confirmed PRES. His blood pressure was kept normal. After 2 days, his vision gradually returned to normal. Follow-up MRIs in the outpatient clinic for all four patients normalized in due time.

Conclusion

Extremes of hypertension and/or hypotension in the perioperative period can cause PRES, which may lead to reversible POVL.

Unusual Presentation of Reversible Transient Vision Loss After Caesarean Section Under Subarachnoid Block: A Case Report

A transient vision loss is not commonly encountered during the postoperative period following a caesarean section. Although numerous causes have been suggested for transient vision loss, when loss of vision is associated with seizures and headaches, the differential diagnoses include hemolysis, elevated liver enzymes, low platelet syndrome, reversible cerebral vasoconstriction syndrome, posterior reversible encephalopathy syndrome (PRES), dural venous thrombosis, and central retinal arteriolar occlusion. We report a case of a 35-year-old patient who underwent an elective caesarean section under spinal anaesthesia and developed a headache followed by loss of vision and seizures during the postoperative period. An MRI scan of the brain on the same day revealed subtle hyperintensity in bilateral parieto-occipital lobes in the cortical and subcortical areas and bilateral cerebral hemispheres, which indicates PRES. Rapid and complete resolution of symptoms was observed with supportive treatment. Therefore, prompt suspicion and effective management of PRES are of paramount importance to prevent short- and long-term neurological deficits.

Eclampsia-Associated Posterior Reversible Encephalopathy Syndrome (PRES) Complicated by Intracerebral Hemorrhage: A Case Report and Review of Management Strategies

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological syndrome that is being increasingly recognized due to the advancements in brain imaging, specifically MRI. This syndrome is characterized by symptoms including, but not limited to, headache, seizures, altered mental status, and vision loss. There are various underlying etiologies which lead to PRES occurrence; the etiology of focus in this report is preeclampsia and eclampsia. PRES is associated with the development of various types of intracerebral hemorrhage which can lead to detrimental and even fatal consequences in a patient. In our case, a 22-year-old female developed PRES within one week postpartum, which was complicated by parenchymal hemorrhage development in the fronto-parietal lobe. MRI findings were characteristic for PRES with multiple subcortical hyperintensities within the bilateral occipital lobe. The patient improved symptomatically after management with intravenous fluids, antihypertensives, antiepileptics, and antibiotics. This report aims to explore the association between preeclampsia/eclampsia (PE/E) and PRES and underscore the importance of prompt diagnosis and treatment, which can lead to recovery within a week and significantly reduce morbidity and mortality.

Neurological Complications in Pregnancy and the Puerperium: Methodology for a Clinical Diagnosis

Neurological complications in pregnancy and the puerperium deserve particular attention from specialists due to the worsening of the clinical picture for both the mother and the fetus. This narrative review of existing data in the literature aims to analyze the most common "red flag symptoms" attributable to neurological complications such as pre-eclampsia (PE), eclampsia, HELLP syndrome, posterior reversible encephalopathy syndrome (PRES), cerebral vasoconstriction syndrome (RCVS), stroke, CVS thrombosis, pituitary apoplexy, amniotic fluid embolism and cerebral aneurysm rupture, with the aim of providing a rapid diagnostic algorithm useful for the early diagnosis and treatment of these complications. The data were derived through the use of PubMed. The results and conclusions of our review are that neurological complications of a vascular nature in pregnancy and the puerperium are conditions that are often difficult to diagnose and manage clinically. For the obstetrics specialist who is faced with these situations, it is always important to have a guide in mind in order to be able to unravel the difficulties of clinical reasoning and promptly arrive at a diagnostic hypothesis.

Atypical Presentation of Antenatal Eclampsia

Most women who develop eclampsia have preceding preeclampsia (proteinuria and hypertension). This is especially true for otherwise healthy nulliparous women. However, recently, there has been a paradigm shift in this philosophy. There is mounting evidence that preeclampsia can develop even in the absence of proteinuria and hypertension and that eclampsia itself may be the initial manifestation of hypertensive disorder during pregnancy. We report a rare case of a 24-year-old primigravida at 30 weeks of gestation who presented with new-onset generalised tonic-clonic seizures without prior hypertension or proteinuria in her antenatal records. A thorough workup revealed this presentation to be the initial feature of atypical eclampsia. She was managed appropriately and discharged with an excellent outcome. This experience highlights some of the difficulties in managing a case of atypical eclampsia, namely, erratic onset and an unpredictable course, all of which interfere with timely diagnosis and treatment and contribute to maternal and fetal morbidity and mortality.