Mesial Temporal Sclerosis as Late Consequence of Posterior Reversible Encephalopathy Syndrome in Pediatric Hemato-oncologic Patients

OBJECTIVES

Drug resistant epilepsy has rarely been reported following posterior reversible encephalopathy syndrome (PRES), with few cases of mesial temporal sclerosis (MTS). The aim of this study was to report clinical and neuroimaging features of MTS subsequent to PRES in hemato-oncologic/stem cell transplanted children.

MATERIALS AND METHODS

Among 70 children treated in 2 pediatric hemato-oncologic Italian centers between 1994 and 2018 and presenting an episode of PRES, we retrospectively identified and analyzed a subgroup of patients who developed epilepsy and MTS.

RESULTS

Nine of 70 patients (12.8%) developed post-PRES persistent seizures with magnetic resonance imaging evidence of MTS. One patient died few months after MTS diagnosis, because of hematologic complications; the remaining 8 patients showed unprovoked seizures over time leading to the diagnosis of epilepsy, focal in all and drug resistant in 4. At PRES diagnosis, all patients with further evidence of epilepsy and MTS suffered of convulsive seizures, evolving into status epilepticus in 3. In 3 patients a borderline cognitive level or intellectual disability were diagnosed after the onset of epilepsy, and 2 had behavioral problems impacting their quality of life.

CONCLUSIONS

MTS and long-term focal epilepsy, along with potential cognitive and behavioral disorders, are not uncommon in older pediatric patients following PRES.

Posterior reversible encephalopathy syndrome (PRES) in a patient with moyamoya disease: A case report

INTRODUCTION

Moyamoya disease (MMD) and posterior reversible encephalopathy syndrome (PRES) share similar pathophysiological characteristics of endothelial dysfunction and impaired cerebral autoregulation. However, there have never been any published studies to demonstrate the relationship between these 2 rare diseases.

PATIENT CONCERNS

A 26-year-old Asian man presented with a throbbing headache, blurred vision, and extremely high blood pressure. We initially suspected acute cerebral infarction based on the cerebral computed tomography, underlying MMD, and prior ischemic stroke. However, the neurological symptoms deteriorated progressively.

DIAGNOSIS

Cerebral magnetic resonance imaging indicated the presence of vasogenic edema rather than cerebral infarction.

INTERVENTIONS AND OUTCOMES

An appropriate blood pressure management prevents the patient from disastrous outcomes successfully. Cerebral magnetic resonance imaging at 2 months post treatment disclosed the complete resolution of cerebral edema. The patient's recovery from clinical symptoms and the neuroimaging changes supported the PRES diagnosis.

CONCLUSION

This report suggests that patients with MMD may be susceptible to PRES. It highlights the importance of considering PRES as a differential diagnosis while providing care to MMD patients with concurrent acute neurological symptoms and a prompt intervention contributes to a favorable clinical prognosis.

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 in Patients with Coronavirus Disease 2019: Two Cases and A Review of The Literature

INTRODUCTION

Encephalopathy is a common complication of coronavirus disease 2019. Although the encephalopathy is idiopathic in many cases, there are several published reports of patients with posterior reversible encephalopathy syndrome in the setting of coronavirus disease 2019.

OBJECTIVE

To describe the diverse presentations, risk factors, and outcomes of posterior reversible encephalopathy syndrome in patients with coronavirus disease 2019.

METHODS

We assessed patients with coronavirus disease 2019 and a diagnosis of posterior reversible encephalopathy syndrome at our institution from April 1 to June 24, 2020. We performed a literature search to capture all known published cases of posterior reversible encephalopathy syndrome in patients with coronavirus disease 2019.

RESULTS

There were 2 cases of posterior reversible encephalopathy syndrome in the setting of coronavirus 2019 at our institution during a 3-month period. One patient was treated with anakinra, an interleukin-1 inhibitor that may disrupt endothelial function. The second patient had an underlying human immunodeficiency virus infection. We found 13 total cases in our literature search, which reported modest blood pressure fluctuations and a range of risk factors for posterior reversible encephalopathy syndrome. One patient was treated with tocilizumab, an interleukin-6 inhibitor that may have effects on endothelial function. All patients had an improvement in their neurological symptoms. Interval imaging, when available, showed radiographic improvement of brain lesions.

CONCLUSIONS

Risk factors for posterior reversible encephalopathy syndrome in patients with coronavirus disease 2019 may include underlying infection or immunomodulatory agents with endothelial effects in conjunction with modest blood pressure fluctuations. We found that the neurological prognosis for posterior reversible encephalopathy syndrome in the setting of coronavirus disease 2019 infection is favorable. Recognition of posterior reversible encephalopathy syndrome in this patient population is critical for prognostication and initiation of treatment, which may include cessation of potential offending agents and tight blood pressure control.

Posterior Reversible Encephalopathy Syndrome Complicating Diabetic Ketoacidosis

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) is a benign disorder of reversible subcortical vasogenic cerebral edema.

CASE CHARACTERISTICS

A 13-yr-old girl presented 4 days after complete recovery from diabetic ketoacidosis with symptoms of headache, altered sensorium, seizures, and visual loss. There was no hypertension or biochemical abnormalities identified. MRI brain showed hyperintense areas in subcortical and periventricular white matter of bilateral fronto-parieto-occipetal lobes, with possible diagnosis of normotensive PRES.

OUTCOME

Full recovery without sequelae, following neuro-protection and expectant treatment.

MESSAGE

Identifying PRES in diabetic ketoacidosis assists appropriate treatment and prognostication.

Acute intermittent porphyria presenting with seizures and posterior reversible encephalopathy syndrome: Two case reports and a literature review

INTRODUCTION

Acute intermittent porphyria (AIP) is a rare and challenging hereditary neurovisceral disease with no specific symptoms. Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological syndrome with bilateral reversible posterior gyriform lesions that can be associated with many different conditions, including AIP. Usually, peripheral neuropathy is considered the most common neurological manifestation of AIP. However, AIP should also be considered when seizures and PRES are associated with unexplained abdominal pain.

CASE PRESENTATION

Both the patients were presented with seizures and PRES on brain magnetic resonance imaging (MRI). Unexplained abdominal pain occurred before the onset of seizures. The AIP diagnosis was made after repeated Watson-Schwartz tests. Hematin was not available for these 2 patients. However, supportive treatment including adequate nutrition and fluid therapy as well as specific antiepileptic drugs aided the patient's recovery and no acute attacks had occurred by the 3-year follow-up.

CONCLUSION

In contrast to other causes of PRES patients, seizure is the most common symptom in AIP patients with PRES. This is a strong diagnostic clue for AIP when ambiguous abdominal pain patients presented with seizures and PRES on brain MRI. A positive prognosis can be achieved with the combination of early recognition, supportive and intravenous hematin therapy, and withdrawal of precipitating factors, including some antiepileptic drugs.

Controversy of posterior reversible encephalopathy syndrome: what have we learnt in the last 20 years?

Over two decades have passed since posterior reversible encephalopathy syndrome (PRES) was first described in 1996. It has becoming increasingly recognised because of improved and more readily available imaging modality. The exact pathophysiological mechanism is not completely understood and remains controversial at present. Precise diagnosis is essential to guide prompt, proper management. Our ability of differentiating it from other acute neurological disorders is likely to improve as we learnt more about the spectrum of this entity in the last 20 years. We emphasise the importance of recognising its diagnostic criteria and biomarker, which would be of great relevance to either outcome evaluation or study design. PRES has a favourable prognosis generally, but neurological sequelae and even fatalities can occur, especially in severe forms that might cause substantial morbidity and even mortality, particularly when the syndrome is complicated by intracranial haemorrhage or brain infarction. In this review, the pathophysiology, approach to diagnosis, some controversies as to the prognosis, as well as the future research direction of PRES are described.

Posterior Reversible Encephalopathy Syndrome: A Comparative Study of Pediatric Versus Adult Patients

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) is an acute neurotoxic syndrome that, although characteristically reversible, can result in long-term disability. Our aim was to identify the clinical and radiological factors that are unique to children with PRES compared with adults with the syndrome in a single center.

METHODS

We retrospectively reviewed the clinical and radiological records of all patients with PRES admitted at a tertiary care medical center from 2007 to 2014. All patients who met the clinical and radiological criteria for PRES were dichotomized into children (less than 18 years) and adults (18 years or older) based on their age groups, and comparison of their baseline variables, clinical, laboratory, and imaging features was performed.

RESULTS

During this study period, 19 pediatric patients and 100 adult patients with PRES were identified. On univariate analysis, factors significantly associated with pediatric patients with the syndrome were multiorgan failure (84.2% vs 50%, P = 0.006), temporal lobe involvement (63.3% vs 39%, P = 0.04), restricted diffusion (42.1% vs 18%, P = 0.02), and less likelihood of cerebellar involvement (21.1% vs 57%, P = 0.004). On bivariate logistic regression analysis, all these factors remained significantly associated with pediatric PRES; multiorgan failure (odds ratio: 5.80, 95% confidence interval: 1.45 to 29.41, P = 0.03), temporal lobe involvement (odds ratio: 5.08, 95% confidence interval: 1.17 to 22.17, P = 0.03), restricted diffusion (odds ratio: 2.48, 95% confidence interval: 1.61 to 10.10, P = 0.02), and less likely to have cerebellar involvement (odds ratio: 0.08, 95% confidence interval: 0.002 to 0.39, P = 0.002).

CONCLUSIONS

Factors unique to PRES in children compared with adults include a greater propensity with multi-organ failure, involvement of the temporal lobe, and restricted diffusion on imaging.

Posterior Reversible Encephalopathy Syndrome (PRES) Presenting as Status Epilepticus: A Case Report and Literature Review

Posterior reversible encephalopathy syndrome (PRES) is one of many causes of status epilepticus (SE). Itis defined classically as a clinical radiographic entity, characterized by presentation of headache, altered mental status, visual disturbances, seizures, and typical neuroradiographic findings of symmetrical white-matter edema. Predisposing conditions include uncontrolled hypertension, eclampsia, and use of chemotherapeu- tic and immunosuppressant agents. Bevacizumab (Avastin), a monoclonal antibody against vascular endothelial growth factor (VEGF), is used in a combination with FOLFOX [FOL - Folinic acid; F - Fluorouracil (5-FU); OX - Oxaliplatin] as a first-line treatment for patients with metastatic colorectal cancer. We present a case of a 52-year-old male on systemic chemotherapy with FOLFOX and bevacizumab who presented with SE and was diagnosed with PRES. His symptoms resolved with intensive control of blood pressure and discontinuation of chemotherapy. Bevacizumab-induced vasospasm, endothelial and blood-brain-barrier dysfunction, in combination with elevated blood pressure, were likely the underlying mechanism of PRES in our patient.

[Posterior reversible encephalopathy syndrome]

Posterior reversible encephalopathy syndrome refers to a neurological disorder characterized by headache, disorders of consciousness, visual disturbances, epileptic seizures, and subcortical vasogenic edema. About two thirds of patients develop neurological symptoms, which are associated with blood pressure fluctuations. One hypothesis is that hypertensive episodes cause autoregulatory failure, and values above the upper limit of cerebral autoregulation result in a breakthrough followed by hyperperfusion and blood-brain barrier dysfunction. In another hypothesis, endothelial dysfunction triggered by numerous factors including preeclampsia, immunosuppressive agents, chemotherapeutics, sepsis, or autoimmune disorders is thought to be the key pathomechanism. Endo- or exogenic toxic agents including pharmacological substances, cytokines, or bacterial toxins are supposed to trigger endothelial activation and dysfunction resulting in the release of vasoconstrictors, pro-inflammatory mediators, and vascular leakage. Diagnosis is usually based on clinical and neuroimaging findings that frequently show a bilateral, symmetric, and parietooccipital pattern. However, the diagnosis can often only be confirmed during the course of disease after excluding important differential diagnoses. Currently, there is no specific treatment available. Lowering of arterial blood pressure and eliminating the underlying cause usually leads to an improvement of clinical and neuroradiological findings. Admission to a critical care unit is required in about 40 % of patients due to complicating conditions including status epilepticus, cerebral vasoconstriction, ischemia, or intracerebral hemorrhage. Prognosis is favorable; in the majority of patients neurological deficits and imaging findings resolve completely.

Posterior Reversible Encephalopathy Syndrome Complicating Traumatic Pancreatitis: A Pediatric Case Report

We are reporting a case of posterior reversible encephalopathy syndrome (PRES) developed in an unusual clinical scenario without the presence of the most described symptoms. PRES is a neurological and radiological syndrome described in many different clinical conditions. In children it has been mostly reported in association with hematological and renal disorders.Our patient was a 15 years old boy, admitted to our intensive care unit for pancreatitis after blunt abdominal trauma.During the stay in the intensive care unit, he underwent multiple abdominal surgical interventions for pancreatitis complications. He had a difficult management of analgesia and sedation, being often agitated with high arterial pressure, and he developed a bacterial peritonitis. After 29 days his neurological conditions abruptly worsened with neuroimaging findings consistent with PRES. His clinical conditions progressively improved after sedation and arterial pressure control.He was discharged at home with complete resolution of the neurological and imaging signs 2 months later.The pathophysiology of PRES is controversial and involves disordered autoregulation ascribable to hypertension and endothelial dysfunction. In this case both hypertension and endothelial activation, triggered by sepsis and pancreatitis, could represent the culprits of PRES onset. Even if there is no specific treatment for this condition, a diagnosis is mandatory to start antihypertensive and supportive treatment. We are therefore suggesting to consider PRES in the differential diagnosis of a neurological deterioration preceded by hypertension and/or septic state, even without other "typical" clinical features.

Features of infratentorial-predominant posterior reversible encephalopathy syndrome

Posterior reversible encephalopathy syndrome (PRES) is a neurotoxic process that typically occurs in the setting of immune dysregulation. In contrast to the characteristic pattern involving parieto-occipital and posterior frontal regions, predominant involvement of the infratentorial brain occurs in a minority of PRES patients. We examined six patients with infratentorial predominant posterior reversible encephalopathy syndrome (IPPRES) relative to those with typical PRES in terms of clinical factors of toxicity and outcomes. We review the current understanding of PRES pathophysiology. An institutional database of PRES patients was created through an IRB-approved search of the electronic record from 2007 to 2012. MR images were reviewed and classified by two neuro radiologists. Clinical data including laboratory data, blood pressure, and discharge outcome were collected through review of existing electronic medical records. Characteristics of the two groups were compared. Six cases among 80 PRES patients displayed an atypical distribution of signal abnormality predominantly involving the infratentorial brain. In IPPRES patients, signal abnormalities within the supratentorial brain, when present, showed a predominantly central distribution rather than the typical peripheral distribution. IPPRES patients showed higher rates of extreme hypertension, renal dysfunction, abnormal serum calcium, and abnormal serum magnesium relative to typical PRES patients. Outcomes were similar between the two groups. In our small series, IPPRES differs from typical PRES patients not only in the distribution of imaging abnormalities but also in rates of extreme hypertension and several laboratory indices. Despite these differences, clinical outcome in the IPPRES group was similar to that of typical PRES.

THE DIAGNOSTIC AND MANAGEMENT CHALLENGES FOR POSTERIOR REVERSIBLE LEUCOENCEPHALOPATHY SYNDROME

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological entity characterized by epileptic seizures, headaches, altered mental status and focal neurological signs. Hypertension is the second most common condition associated with PRES. The 50-year-old-male patient with, right-sided hemiparesis and speech disturbances admitted to our clinic. His blood pressure at the emergency service was 220/140 mmHg. A left putaminal hematoma was seen in his CT and MRI. In his brain MRI, FLAIR and T2 -weighted sequences showed bilateral symmetric diffuse hyperintensities in the brain stem, basal ganglia, and occipital, parietal, frontal, and temporal lobes. After the intense antihypertensive drug treatment, his blood pressure came to normal limits within a week. During his hospitalisation he had a recurrent speech disturbance lasting an hour. His electroencephalography was normal. In his repeated diffusion weighted MRI, an acute lacunary infarct was seen on right centrum semiovale. Two months later, the control MRI showed only the previous lacuner infarcts and the chronic putaminal hematoma. We presented a case developping either a cerebral hemorrhage or a lacunar infarction due to PRES. The main reason of the following complications of the disease was delayed diagnosis. Uncontrolled hypertension was guilted for the events.

[Post-partum posterior reversible encephalopathy syndrome]

Posterior reversible encephalopathy syndrome (PRES) is a complex clinical condition with vasogenic subcortical oedema caused by hypertension. Oedema is often seen on magnetic resonance imaging. The wide clinical spectrum ranges from headaches to vision loss and even death. Early diagnosis and treatment is important for the reversibility of the condition. In this case report we emphasize the importance of blood pressure control in a post-partum woman, who had a rather complicated pregnancy. The symptoms of PRES were not recognized immediately because of failure to use and acknowledge a blood pressure test.

Albuminocytologic Dissociation in Posterior Reversible Encephalopathy Syndrome

OBJECTIVES

To describe cerebrospinal fluid (CSF) findings in patients with posterior reversible encephalopathy syndrome (PRES) and to study its association with vasogenic edema.

PATIENTS AND METHODS

Retrospective review of 73 consecutive prospectively collected adults diagnosed with PRES from January 1, 2000, through December 31, 2014, who underwent lumbar puncture.

RESULTS

Seventy-three patients (mean age, 51±17 years), were included in the analysis; of these, 50 (69%) were women. The most common causes for PRES were hypertension (n=61 [84%]) and immunosuppression (n=22 [30%]). Renal failure was present in 42 (58%) patients. The median interval between clinical onset of PRES and CSF analysis was 1 day (interquartile range [IQR], 0-2 days). The median opening pressure was 23 cm H2O or 17 mm Hg (IQR, 18-28 cm H2O or 13-21 mm Hg), although it was available in only 27 patients. The median CSF protein level was 58 mg/dL (IQR, 44-81 mg/dL; normal value, <35 mg/dL). The median CSF protein level was higher in patients with more extensive vasogenic edema. The median white blood cell count was 1 cell/μL (IQR, 1-2 cells/μL).

CONCLUSION

Elevated CSF protein level without CSF pleocytosis commonly occurs in patients with PRES and is directly associated with the extent and topographical distribution of cerebral edema. Although mild CSF pleocytosis can also occur, it is an uncommon finding and may prompt consideration for further diagnostic testing.

[Posterior reversible encephalopathy: beyond the original description]

INTRODUCTION

Posterior reversible encephalopathy (PRE) is a clinical and radiological entity that is typically characterized by headache, visual disturbances and seizures associated with cortical and subcortical reversible vasogenic edema in neuroimaging.

AIM

To present a review of the pathophysiology of this entity, and also the associations of the PRE described in the literature.

DEVELOPMENT

Given its clinical presentation, often nonspecific and variable, magnetic resonance imaging is essential for diagnosis. There are a number of well-known triggers, such as hypertensive crisis, eclampsia or certain drugs. The description of increasingly atypical cases from clinical and radiological point of view, and possible new triggers, requires a redefinition of this entity.

CONCLUSIONS

The PRE is a set of clinical and radiological manifestations that may not be framed within the word 'syndrome'. Although, the PRE has been reported in some cases irreversible, reversibility concept should be maintained in the definition of this entity, since in most cases the rapid control of the triggering condition allows reversibility of the lesions.

[Posterior reversible encephalopathy syndrome after neurosurgery: A literature review]

Posterior reversible encephalopathy syndrome is a clinical-radiological characterized by decreased level of consciousness, seizures, and visual disturbances, as well as radiologically ras brain edema, predominantly in parieto-occipital white matter regions. There are many situations that can trigger the disorder, including the administration of immunosuppressants, chemotherapy agents, hypertensive disorders, and sepsis. The case is described of a patient diagnosed with stage IV prostate adenocarcinoma, receiving chemotherapy, andundergoing a posterior reversible encephalopathy syndrome after surgery for resection of brain metastasis.

[Blindness and symmetrical neurological deficit in a patient with colon cancer receiving adjuvant chemotherapy: is it always cancer?]

Posterior reversible leukoencephalopathy syndrome [PRES] is characterized by a symmetrical brain edema. It is rarely caused by chemotheraphy. While steroids can lead to deterioration in the condition of a PRES patient, they are still the drug of choice for the more common condition of brain edema secondary to metastases. We describe the case of a colon cancer patient who underwent adjuvant treatment with capecitabine and oxaliplatin and was admitted to the hospital with seizures and brain edema. On admission, the condition was attributed to brain metastases and hence a high dose steroid treatment was initiated. Later on, as the patient became comatose, the CT was revised and PRES was suggested as an alternative diagnosis. After tapering the steroids the patient gradually recovered. This report emphasizes the need to be alert and not to confuse PRES with brain metastasis in cancer patients.

Refractory intracranial hypertension in posterior reversible encephalopathy syndrome

INTRODUCTION

Posterior reversible encephalopathy syndrome (PRES) is a largely reversible disease with long-term favorable outcome. A minority of patients, however, may develop progressive cerebral edema and ischemia resulting in severe disability or death. We report a case of severe intracranial hypertension associated with PRES that was successfully treated according to intracranial pressure (ICP)- and cerebral perfusion pressure (CPP)-driven therapy.

METHODS

Case report.

RESULTS

A 42-year-old woman underwent bilateral lung transplantation for severe bronchiectasis. Her immunosuppressive regimen consisted of azathioprine, prednisone, and tacrolimus. She acutely developed an aggressive form of PRES that rapidly resulted in severe refractory intracranial hypertension despite discontinuation of potentially causative medications and adequate supportive therapy. Accordingly, second-tier therapies, including barbiturate infusion, were instituted and immunosuppression was switched to anti-thymocyte globulin followed by mycophenolate mofetil. Within 10 h of barbiturate administration, ICP dropped to 20 mmHg. Thiopental was administered for two days and then rapidly tapered because of severe urosepsis. Six months after discharge from the intensive care unit the patient returned to near-normal life, her only complaint being short-term amnesia.

CONCLUSIONS

The decision to undertake ICP monitoring in medical conditions in which no clear recommendations exist greatly relies on physicians' judgment. This case suggests that ICP monitoring may be considered in the setting of acute PRES among selected patients, when severe intracranial hypertension is suspected, provided that a multidisciplinary team of neurocritical care specialists is readily available.

Posterior reversible encephalopathy syndrome in a child with steroid-resistant nephrotic syndrome: a case report and review of literature

Posterior reversible encephalopathy syndrome (PRES) is a rare and serious syndrome of central nervous system that can develop in both adults and children. It is characterized by acute onset of headache, confusion, seizures or focal neurological deficits along with radiological findings of white matter abnormalities in the parietal and occipital lobes. In the past ten years, this syndrome has been described mainly in adults, rare in children. Here, we report a case of PRES presenting in a 12-year-old girl with steroid-resistant nephrotic syndrome. Her neurological symptom was rapidly recovered after control of hypertension without discontinuation of cyclosporine A.

Posterior reversible encephalopathy and cerebral vasoconstriction in a patient with hemolytic uremic syndrome

BACKGROUND

We report a patient with hemolytic uremic syndrome who presented with radiological manifestations suggestive of posterior reversible encephalopathy syndrome and reversible cerebral vasoconstriction syndrome.

PATIENT

A 13-year-old girl presented with fever and bloody diarrhea and progressed to develop hemolytic uremic syndrome. She subsequently developed encephalopathy, aphasia, and right-sided weakness.

RESULTS

Brain magnetic resonance imaging showed presence of vasogenic edema in the left frontal lobe, in addition to T2 and fluid-attenuated inversion recovery changes in white matter bilaterally, compatible with posterior reversible encephalopathy syndrome. Magnetic resonance angiography showed beading of the cerebral vessels. Neurological deficits reversed 8 days after symptom onset, with resolution of the beading pattern on follow-up magnetic resonance angiography after 3 weeks, suggesting reversible cerebral vasoconstriction syndrome.

CONCLUSIONS

Both posterior reversible encephalopathy syndrome and reversible cerebral vasoconstriction syndrome may represent manifestations of similar underlying pathophysiologic mechanisms. Recognition of the co-existence of these processes in patients with hemolytic uremic syndrome may aid in judicious management of these patients and avoidance of inappropriate therapeutic interventions.

Transient splenial lesion after recovery of cerebral vasoconstriction and posterior reversible encephalopathy syndrome: a case report of eclampsia

We describe a 34-year-old eclamptic woman with transient splenial lesion (TSL) after reversible cerebral vasoconstriction (RCV) and posterior reversible encephalopathy syndrome (PRES). She developed a headache, generalized convulsion and severe hypertension at an uncomplicated virginal delivery. Brain MRI disclosed T2-hyperintensity lesions in the posterior circulation territories. Two weeks later, T2-hyperintensity lesions had vanished. MR angiography (MRA) revealed segmental vasoconstriction in the right posterior, left internal and middle cerebral arteries. At one month after onset, MRA was normalized. T2-weighted imaging depicted asymptomatic isolated TSL. These radiological changes of the present patient highlighted the serial relationship between PRES, RCV and TSL in eclampsia.

Desmopressin-induced posterior reversible encephalopathy syndrome

We herein report the case of a patient who presented with an acute decrease of visual acuity, hypertension, focal seizures and transient mental dysfunction while undergoing desmopressin treatment. Neuroimaging revealed bilateral occipital-parietal lesions that presented with vasogenic edema. After controlling the hypertension and discontinuing the desmopressin treatment, the patient's condition improved. A follow-up imaging examination performed six months later showed complete resolution of the lesions. It is important to recognize posterior reversible encephalopathy syndrome (PRES) as a rare and serious complication of desmopressin administration. Both the blood pressure and water electrolyte balance should be carefully monitored in patients receiving desmopressin therapy.

Coincidence of apical ballooning syndrome (tako-tsubo/stress cardiomyopathy) and posterior reversible encephalopathy syndrome: potential common substrate and pathophysiology?

BACKGROUND

Apical ballooning syndrome (ABS) and posterior reversible encephalopathy syndrome (PRES) are recently described, seemingly unrelated, reversible conditions. The precise pathophysiology of these syndromes remains unknown. The aim of this study was to describe the clinical characteristics and outcomes of a unique series of patients with both ABS and PRES.

METHODS AND RESULTS

In a retrospective study of 224 consecutive patients diagnosed with ABS between 2002 and 2010, 6 (2.7%) were also diagnosed with PRES. All were female with a mean age of 63.7 ± 12.5 years. All patients had preceding medical comorbidities and physical stress triggers that precipitated ABS and PRES. Mean peak troponin T levels and left ventricular ejection fraction at presentation were 0.47 ± 0.48 mg/dL and 31.5 ± 8.2%, respectively. Characteristic left ventricular wall motion abnormalities (regional wall motion score index 2.22 ± 0.37) were noted in all patients, and magnetic resonance imaging of the brain was significant for vasogenic edema, predominantly in the posterior circulation. All patients recovered left ventricular (ejection fraction at follow-up 60.2 ± 6.0%) and neurologic function with supportive management. Two patients had recurrence of ABS and 1 of PRES during follow-up.

CONCLUSIONS

ABS and PRES can occur simultaneously during an acute illness. Patients with ABS who develop neurologic dysfunction should be evaluated for PRES and vice versa. Because transient sympathetic overactivity and microvascular dysfunction have been observed in both reversible syndromes, we speculate that they may represent the shared pathophysiologic mechanism.

First description of posterior reversible encephalopathy syndrome as a complication of glycerolnitrate patch following open cardiac surgery

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) affects predominantly the parietal and occipital lobes. Frequent clinical features are epileptic seizure, altered mental status and visual disturbances.

CLINICAL PRESENTATION

We present the first case of a patient with pericarditis and mitral valve insufficiency, who developed PRES after application of a glycerolnitrate patch day three post-operatively and whose neurological deficits improved within 2 days after withdrawal of patch therapy.

CONCLUSION

The precise pathomechanism of PRES is unknown. The lower sympathetic innervation of the posterior circulation may be one explanation for its particular vulnerability to vasodilatation caused by glycerolnitrate.

Reversible posterior leukoencephalopathy syndrome caused by blood transfusion: a case report

This is a case report of a 32-year-old woman with chronic severe anemia who developed headaches and seizures 5 days after receiving a blood transfusion of eight units (1600 ml) of packed red blood cells. Magnetic resonance imaging indicated vasogenic edematous lesions bilaterally over the occipital lobes that were consistent with reversible posterior leukoencephalopathy syndrome (RPLS). Her blood pressure was normal, and no other contributing factors for RPLS were found. It is likely that the initiator was the large volume of transfused blood, which disrupted cerebral autoregulation and damaged the vasculoendothelial system. Similar cases of RPLS following transfusion have been reported, and all reports involved middle-aged females with chronic severe anemia who received large volumes of transfused blood within a short period of time. Although blood transfusion is a common procedure with rare neurological complications, great caution should be taken with chronic severely anemic patients because a rapid elevation in hemoglobin may precipitate RPLS.

[Posterior leukoencephalopathy syndrome in children--clinical and neuroradiological findings]

We reported the clinical and neuroradiological findings of 8 patients (4 males; 4 females; age range; 3 - 14 years) with posterior leukoencephalopathy syndrome (PLES). Previous case reports suggested that one of the major factors leading to PLES was severe hypertension. We divided the patients into two groups with or without severe hypertension, and each group was divided furthermore into two corresponding to the reversibility of brain lesions. The four cases of PLES with severe hypertension were all due to renal hypertension, and half of them resulted in irreversible outcomes, which were considered to be associated with inappropriate treatment. On the other hand, the four cases of PLES without severe hypertension showed reversible change, suggesting intravascular endothelial dysfuncton in respect of their causing factors. We consider that PLES could be caused without sever hypertension, particularly in children. Those with severe hypertension must be treated immediately to prevent irreversible brain damage.

Gemcitabine-induced reversible posterior leukoencephalopathy syndrome: a case report and review of the literature

Gemcitabine is a commonly used chemotherapeutic agent for a variety of tumor types. Although this nucleoside analogue antineoplastic agent is similar in structure to cytarabine, central nervous system toxicities have rarely been attributed to gemcitabine. Reversible posterior leukoencephalopathy syndrome (RPLS) is a rare but increasingly identifiable clinicoradiologic process in cancer patients associated with cytotoxic and immunosuppressive agents. The syndrome is characterized by acute to subacute onset of headache, nausea, vomiting, altered mental status, seizures, stupor, and visual disturbances. The pathophysiology of RPLS continues to remain controversial but likely involves loss of cerebrovascular autoregulation leading to arteriole leakage. Radiologically, posterior occipital white matter edema is noted, with characteristic findings on magnetic resonance imaging. Often the syndrome is reversible with treatment of concurrent hypertension or removal of the causative agent; however, failure to quickly recognize the syndrome and discontinue the offending agent may result in profound and permanent central nervous system dysfunction or death. This article describes a case of RPLS attributed to gemcitabine use for pancreatic cancer. Such a descriptive case serves as a platform for the discussion of the syndrome, proposed mechanisms of central nervous system damage, and review of the currently available literature on the topic. With increased awareness of RPLS by oncologists and other medical providers, cancer patient care may be improved and further insight into this complication of therapy through continued research may be gained.

Reversible posterior leukoencephalopathy syndrome: a retrospective study in King Chulalongkorn Memorial Hospital

BACKGROUND

Reversible posterior leukoencephalopathy (RPLE) or reversible posterior cerebral edema syndrome is a syndrome characterized by transient focal or diffused neurological deficits and reversible neuroimaging changes. RPLE is often associated with hypertension and systemic illness. The classical Magnetic Resonance Imaging (MRl) feature of RPLE is predominately involvement of bilateral posterior cerebral white matter. Due to availability of MRI technology, this entity has been reported more frequently

MATERIAL AND METHOD

The clinical recordings were searched from data bases at King Chulalongkorn Memorial Hospital from 2003 to 2005. Keywords were "leukoencephalopathy" and "hypertensive encephalopathy". Neuroimaging criteria for the diagnosis of RPLE were bilateral symmetrical cortical-subcortical white matter lesions predominantly affecting the occipital lobe. The data were reviewed. Cases with RPLE were recruited and analyzed.

RESULTS

Nine patients (female:male, 8:1), ranged in age from 17 to 39 years (average, 26 years) were analyzed. Five patients had acute hypertension associated with renal failure, 1 had acute hypertension without renal impairment, 2 had eclampsia and 1 was associated with cyclosporine therapy. Most common clinical symptoms were seizure and cortical blindness. MRI revealed bilateral occipital white matter edema in 7/8 patients while computerized tomography demonstrated this feature in 3/9 patients. Other MRI abnormalities were detected in frontal lobes, parietal lobes, deep grey nuclei, brainstem and cerebellum. The patients were treated with antihypertensive drugs, antiepileptics and withdrawal from immunosuppressive therapy. In 8 patients, the neurological deficits recovered within 2 weeks. The case with cyclosporine therapy had residuals in the form of limb weakness and spasticity.

CONCLUSION

RPLE is associated with hypertension, systemic autoimmune diseases, renal impairment, immunosuppressive therapy or eclampsia. The neuroimaging findings reveal characteristic white matter vasogenic edema in occipital lobes as well as other cortical areas and deep grey matter. Good clinical outcomes occur after prompt symptomatic treatment with antihypertensive drugs, antiepileptics or withdrawal from immunosuppressive therapy and repeated neuroimaging may not be necessary.