Cerebrospinal Fluid Hypovolemia and Posterior Reversible Encephalopathy Syndrome

Abstract

Posterior reversible encephalopathy syndrome (PRES) is a reversible neuroradiological syndrome characterized by reversible vasogenic edema. The pathophysiological mechanism is still unclear, but PRES may be triggered by various etiologies. To date, only a few PRES cases linked to cerebrospinal fluid (CSF) hypovolemia were reported. The association between PRES and CSF hypovolemia needs to be explored. We presented a case of PRES with CSF hypovolemia as a result of an inadvertent dural puncture and reviewed the literature to identify the clinical characterization and pathophysiological mechanism of PRES following CSF hypovolemia. A total of 31 cases of PRES-CSF hypovolemia was included for analysis. The median age was 33 years, with a notable female predominance (87.1%). Fifteen patients (48.4%) didn't have either a history of hypertension nor an episode of hypertension. The most common cause of CSF hypovolemia was epidural or lumbar puncture (n = 21), followed by CSF shunt (n = 6). The median interval between the procedure leading to CSF hypovolemia and PRES was 4 days. Seizure, altered mental state, and headache were the most frequent presenting symptom. The parietooccipital pattern was most frequent (71.0%). Conservative management remains the mainstay of treatment with excellent outcomes. Three patients had a second episode of PRES. CSF hypovolemia is a plausible cause of PRES via a unique pathophysiologic mechanism including arterial hyperperfusion and venous dysfunction. Patients with CSF hypovolemia is more susceptible to PRES, which is potentially life-threatening. Given that CSF hypovolemia is a common complication of anesthetic, neurological, and neurosurgical procedures, PRES should be early considered for prompt diagnosis and appropriate management.

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

“…PEPT2 dysfunction: The PEPT2*2 variant has a lower affinity for ALA than PEPT2*1, which might cause a diminished ALA efflux in the choroid plexus and a more significant ALA neurotoxicity in the brain ( 80 ). Electrolyte disorders (hyponatremia, hypocalcemia, hypomagnesemia), low CSF ( 81 ), and lack of ATP might also reduce PEPT2 function. These cascades lead to vasogenic cerebral edema, and certain precipitants are probably necessary to cause PRES and CNS dysfunction.…”

Postpartum complications following neuraxial anaesthesia for obstetric physicians

“…Eighteen cases have been described postpartum in the setting of PDPH, ten following epidural blocks, six following spinal anaesthesia, and two following CSE. 42 Initial presentation was with typical PDPH, with the subsequent development of seizures (83%), visual changes (50%), altered conscious state (28%) and focal weakness/sensory loss (17%) 2–7 days later. Diagnosis is by MRI.…”