Atypical posterior reversible encephalopathy syndrome associated with chemotherapy with Bevacizumab, Gemcitabine and Cisplatin

Dersch, Rick; Stich, Oliver; Goller, Kristina; Meckel, Stephan; Dechent, F.; Doostkam, Soroush; Weiller, Cornelius; Bardutzky, Juergen

doi:10.1007/s00415-013-6866-6

Cited by 17 publications

(17 citation statements)

References 7 publications

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“…An association with cisplatin administration in cancer patients has been widely reported in previous studies (Table I) (5,(16)(17)(18)(19)(20)(21)(22)(23), predominantly occurring within the first 3 cycles of chemotherapy, with the exception of one late-onset case in the 7th cycle (16). In the majority of cases, patients develop hypertension, and additionally present with headaches, seizures, altered mental status and visual disturbances, whilst normotension is only observed in a few cases (5,(16)(17)(18). Cranial CT/MRI usually indicates cortical/subcortical edema in the bilateral occipital and parietal lobes; uncommon areas in which to observe legions include the thalamus, the cerebellum, the periventricular regions, and the frontal and temporal lobes.…”

Section: Discussionmentioning

confidence: 55%

Reversible posterior leukoencephalopathy syndrome following combinatorial cisplatin and pemetrexed therapy for lung cancer in a normotensive patient: A case report and literature review

Xie

Jones

2015

Oncology Letters

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Abstract. Reversible posterior leukoencephalopathy syndrome (RPLS) is a rare neurological syndrome of the brain, causing symptoms such as headaches, seizures, altered mental status and visual disturbances. The condition is predominantly associated with hypertension, eclampsia, renal impairment, cytotoxic drugs, immunosuppressive agents and molecular targeted agents, but the precise underlying mechanism of RPLS is not fully understood. The present study describes the case of a 65-year-old female patient with stage IIA non-small cell lung cancer who received cisplatin/pemetrexed treatment at the Leo W. Jenkins Cancer Center. Following 3 cycles of this therapy, the patient was referred to the Emergency Department of Vidant Medical Center with an altered mental status, subsequently presenting with epileptic seizures, a fever and a headache. A neurological examination revealed generalized hyperreflexia and paraparesis, with extensor posturing of the bilateral lower extremities. The lumbar puncture and electroencephalography results were normal, but cranial computed tomography (CT) scans revealed attenuation abnormalities in the bilateral parietal region and the left occipital lobe, with suspected metastasis. Cranial T2-weighted magnetic resonance imaging (MRI) indicated bilateral regions of increased signal intensity in the occipital, temporal and periventricular white matter. The patient was treated with anticonvulsants, steroids and antihypertensive drugs, recovered gradually from the symptoms and regained full consciousness. However, the patient reported residual weakness, presenting with an Eastern Cooperative Oncology Group score of 3, reflective of an inability to independently perform daily activities and self-care. A brain MRI performed 10 days later demonstrated that the subcortical edema had partially subsided. The patient was discharged on day 15 post-admission. A follow-up cranial CT examination 1 month later indicated a partial resolution of the abnormalities. The present report reviews similar associated cases, and also discusses the clinical features and mechanisms underlying RPLS. Although it is typically reversible, RPLS is a serious and potentially life-threatening adverse condition if left untreated. Early recognition of this condition is crucial for the prompt control of the patient's blood pressure or withdrawal of cytotoxic drugs in order to reverse this syndrome. IntroductionReversible posterior leukoencephalopathy syndrome (RPLS) was first described by Hinchey et al (1) as an acute illness that causes symptoms such as hypertension, headaches, seizures, altered mental status and visual disturbances, and which is usually reversible following the removal of the causative agents and the control of the patient's blood pressure. RPLS is characterized by white matter edema, particularly involving the bilateral occipital and posterior parietal lobes of the brain (1). Involvement of other areas of the brain, including the frontal lobes, cerebellum, basal ganglia and brain stem, has also been reported.R...

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Section: Discussionmentioning

confidence: 55%

Reversible posterior leukoencephalopathy syndrome following combinatorial cisplatin and pemetrexed therapy for lung cancer in a normotensive patient: A case report and literature review

Xie

Jones

2015

Oncology Letters

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“…Weakness and loss of coordination of limbs are rare. Arterial hypertension is frequent, but PRES has been reported in normotensive patients (66)(67)(68)(69). MRI demonstrates edema without infarction of the sub-cortical white matter of bilateral temporo-parieto-occipital lobes.…”

Section: Resultsmentioning

confidence: 99%

Delayed Posterior Reversible Leukoencephalopathy Syndrome Triggered by FLOT Chemotherapy

2020

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Posterior reversible encephalopathy syndrome (PRES) is a potentially severe disorder of the autoregulation of cerebral perfusion. The major clinical manifestations are headache, seizures, altered mental status, and visual loss. The typical radiological finding is vasogenic edema predominating in the white matter of occipital and parietal lobes. PRES is increasingly recognized as a clinico-radiological entity owing to improvements and fast availability of brain imaging, especially magnetic resonance imaging (MRI). We present the exceptional case of a 67-year-old female patient with a gastric adenocarcinoma at stage IIB (T3N0M0) treated by FLOT chemotherapy (5-fluorouracil, oxaliplatin, docetaxel, and folinic acid). Two months after the unique administration of FLOT regimen, she developed sudden posterior headache and visual loss. Blood pressure values were normal. Cerebral tomography showed ischemic-like occipital bilateral lesions, and angiographic sequences revealed breakdown of the blood-brain barrier (BBB). MRI revealed bilateral parieto-occipital T1 hypointensity and T2 hyperintensity, which demonstrated vasogenic edema. The rest of the parts of the lesions were T1 hyperintensity, T2 hyperintensity, and diffusion-weighted imaging (DWI) hyperintensity, which indicate cortical laminar necrosis. After injection of gadolinium, a linear enhancement of the cortex was observed. She was treated with oral nimodipine. Follow-up was characterized by permanent visual sequelae and tetraparesis. PRES represents an urgent neurological condition. Our observation highlights that PRES should be considered in patients under chemotherapy, even when their blood pressure remains within normal range. This is the first report of PRES triggered by FLOT chemotherapy and with a silent window of 2 months between chemotherapy and PRES, widening further the spectrum of chemotherapy-induced PRES. Our case highlights the potential role of FLOT regimen in the pathogenesis of PRES and the need for a novel approach in terms of prevention of this potentially fatal complication when patients receive chemotherapy.

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“…[ 1 ] Chemotherapy-induced PRES is no exception to this association. [ 9 – 11 , 16 , 17 ] Several theories attempt to explain the pathogenesis of PRES as it relates to both hypertension and chemotherapy. The vasogenic theory suggests that elevated mean arterial pressure overcomes cerebral auto-regulation leading to elevated hydrostatic pressures within the cerebral vasculature, dysfunctional tight junctions, and subsequent edema.…”

Section: Discussionmentioning

confidence: 99%

“…Patients often present with headaches, seizures, visual changes, or altered mental status hours to months after the inciting insult. [ 9 – 12 , 15 , 17 ] Diagnosis of PRES relies on history, clinical examination, and radiologic findings of symmetric bilateral hyper-intensities on T2-weighted magnetic resonance imagings (MRIs) representing vasogenic edema. [ 1 , 4 , 9 , 15 ] This edema most commonly affects the posterior occipital and parietal lobes but may be seen throughout the frontal and temporal lobes, cerebellum, or brainstem.…”

Section: Introductionmentioning

confidence: 99%

A case report of posterior reversible encephalopathy syndrome in a patient receiving gemcitabine and cisplatin

Cherniawsky

Merchant²,

Sawyer³

et al. 2017

Medicine

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Rationale:Posterior reversible encephalopathy syndrome (PRES) is a subacute syndrome causing characteristic neurologic and radiologic findings. PRES is predominantly caused by malignant hypertension though it has been associated with immunosuppressive treatments such as chemotherapy.Patient Concerns:We describe a case of a 58 year old female who developed fluctuant level of consciousness, agitation.Diagnosis:MRI findings were in keeping with posterior reversible encephalopathy syndrome following cycle 6 of palliative gemcitabine and cisplatin therapy for metastatic cholangiocarcinoma.Interventions:The patient was managed with magnesium supplementation for hypomagnesemia and amlodipine.Outcomes:The patient's level of consciousness returned to normal though she had residual neurologic deficits impairing her ability to drive and impacting her balance.Conclusions:Cisplatin is a documented causative agent of PRES though gemcitabine is rarely associated with the syndrome. Combination cisplatin and gemcitabine therapy causing radiologically proven PRES has been documented in only 3 previous case reports. Gemcitabine's poor blood-brain barrier penetration makes it an unlikely culprit of central nervous system (CNS) toxicities. Our case and previous reports suggest higher doses may contribute to CNS toxicities such as PRES. Additionally, an emerging trend of hypomagnesemia associated with PRES has been documented inside and outside the context of malignancy and suggests a possible target for treatment and prevention warranting further investigation.

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Atypical posterior reversible encephalopathy syndrome associated with chemotherapy with Bevacizumab, Gemcitabine and Cisplatin

Cited by 17 publications

References 7 publications

Reversible posterior leukoencephalopathy syndrome following combinatorial cisplatin and pemetrexed therapy for lung cancer in a normotensive patient: A case report and literature review

Reversible posterior leukoencephalopathy syndrome following combinatorial cisplatin and pemetrexed therapy for lung cancer in a normotensive patient: A case report and literature review

Delayed Posterior Reversible Leukoencephalopathy Syndrome Triggered by FLOT Chemotherapy

A case report of posterior reversible encephalopathy syndrome in a patient receiving gemcitabine and cisplatin

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