Clinical Features and Outcomes of Patients with Posterior Reversible Encephalopathy Syndrome

Abstract

Aims:The aim of this study was to study the clinical features and outcomes of patients with posterior reversible encephalopathy syndrome (PRES) admitted to the Intensive Care Unit (ICU).Subjects and Methods:All adult patients admitted to our ICU with acute onset neurologic symptoms with focal vasogenic edema on magnetic resonance imaging (MRI) were included in the study. Data were collected on demography, coexisting illness, admission severity of illness, neurological symptoms, blood pressure, treatment initiated, and MRI findings. Outcome data collected included mortality, ICU average length of stay (ALOS), number of ventilator days, and neurological disability at discharge assessed by modified Rankin scale (MRS).Results:Fourteen patients were admitted with PRES. Thirteen patients were female, and their mean age was 31.5 ± 8.3 years. Etiology of PRES included eclampsia (64.2%), lupus nephritis (21.4%), CKD (7.1%), and hypertension (n = 1 [7.1%]). The most common presenting symptom was seizure (92.8%), followed by visual disturbance (42.8%), headache (42.8%), encephalopathy (14.2%), and status epilepticus (14.2%). The Glasgow coma scale on admission was 12.3 ± 2.9. High blood pressure was seen in 12 patients 85.7%; their mean systolic and diastolic pressures were 173 ± 10.2 and 110 ± 8.6 mmHg, respectively. MRI showed that parieto-occipital region was most commonly involved (92.8%), followed by frontal lobe (42.8%). ICU ALOS was 4.35 ± 2.4 days and mean ventilator days was 1.7 ± 2.0 days. One patient (1/14 [7.4%]) died of multiorgan failure and 13 patients were discharged with no residual neurological deficit (MRS, 0).Conclusions:PRES is a potentially reversible disorder with prompt recognition and control of blood pressure.

Seizure as an Initial Presentation for Posterior Reversible Encephalopathy Syndrome in Undiagnosed Systemic Lupus Erythematosus and Lupus Nephritis: A Case Report

“…In addition, renal dysfunction, hypoalbuminemia, and thrombocytopenia are independent risk factors of PRES, and potentially linked to the disease [2]. Kalaiselvan et al argue that the progression of PRES is caused by endothelial damage, exacerbated by vasoconstriction, and autoimmune activation [13]. All these conditions may be coinciding, creating a summative or multiplicative effect on the course of the disease.…”

“…Fluid-attenuated inversion recovery (FLAIR) is the imaging modality of choice to diagnose PRES and may display findings of white matter edema in the watershed areas of the posterior cerebrum. PRES has been shown to affect the posterior regions of the parietal and occipital lobes most commonly but has also been shown to affect the frontal and temporal regions with relative frequency [1,2,[4][5][6][7][8][9][10]13].…”

“Highlighting” red nuclei by atypical posterior reversible encephalopathy syndrome in a patient with systemic lupus erythematosus

“…High blood pressure was observed in over 85% of these patients. It was concluded that prompt recognition and blood pressure control were essential to patients’ survival and recovering rate as well as limitation of residual deficits . The study of 120 cases with PRES reports that 42% of patients were treated with immunosuppressive medications (cyclophosphamide, tacrolimus, cyclosporine, mycophenolate, bevacizumab, rituximab, vincristine, methotrexate, hydroxychloroquine, 5‐fluorouracil, sirolimus, thalidomide, gemcitabine, paclitaxel, carboplatin, sorafenib, infliximab, and hydroxyurea) and 45% had autoimmune disorders such as thrombotic thrombocytopenic purpura, systemic lupus erythematosus, hypothyroidism, scleroderma, Crohn’s disease, ulcerative colitis, primary sclerosing cholangitis, rheumatoid arthritis, and insulin‐dependent diabetes mellitus …”

“…This is why aggressive management of hypertension as a factor that further exacerbates endothelial permeability is essential to prevent subsequent damage and to facilitate prompt recovery . Authors Fugate and colleagues concluded that PRES is highly associated with autoimmune disorders and suggests that endothelial damage is the basis of the pathophysiologic progression of the disease …”

“…The frequency of neurological involvement in SLE is ranging from 12% to 95% . However, the prevalence of PRES was only 0.69% among patients with SLE . Neuropsychiatric manifestations are common in SLE first and may include, but not limited to SLE cerebritis, stroke, vasculopathy seizures, psychosis, cognitive disorder, headache, migraine, transverse myelitis, optic neuritis, meningitis, and neuropathies.…”