Predictors of intensive care unit utilization in patients with posterior reversible encephalopathy syndrome

Abstract

Posterior reversible encephalopathy syndrome (PRES) is an acute neurological syndrome that requires prompt, aggressive management to improve outcomes. Our aim was to identify factors that would necessitate care in the intensive care unit (ICU) in patients with PRES and the outcomes on discharge following ICU stay. We retrospectively reviewed the medical records and radiological data of adult PRES patients admitted to our tertiary care medical center. We dichotomized them into two groups based on their need for ICU care and compared their clinical, laboratory, imaging characteristics and discharge outcomes. Outcomes were defined using the modified Rankin Score (mRS) and Glasgow Outcome Score (GOS) on discharge. Out of 100 patients, 67 % required admission to the ICU. On univariate analysis, factors associated with ICU admission were atrial fibrillation (19.4 vs 0 %; p ≤ 0.05), encephalopathy from PRES (89.6 vs 66.7 %; p < 0.05), low Glasgow Coma Score (GCS) (11 ± 4 vs 14 ± 2; p = 0.01) and cortical involvement on imaging (89.6 vs 72.7 %, p = 0.03). On multivariate logistic regression analysis, encephalopathy (odds ratio 10.22; 95 % CI (1.14-91.55; p = 0.04) was the sole predictor of ICU utilization. This correlated with a GCS <12 (odds ratio 5.53; 95 % CI (1.05-29.22; p = 0.04). Despite worse functional outcomes following ICU care based on mRS (2.3 ± 2.1 vs 1.3 ± 1.4, p = 0.02) and GOS (3.9 ± 1.3 vs 4.6 ± 0.7, p ≤ 0.05), only a borderline increase in mortality was observed (10.4 vs 0 %, p = 0.05). The presence of PRES-related encephalopathy might aid in prompt identification of patients who require ICU care.

Alcohol withdrawal induced posterior reversible encephalopathy syndrome

“…Release and activation of endothelial factors in response to hypoxia promotes angiogenesis, increased membrane permeability, and breakdown of the blood-brain barrier causing vasogenic edema [4,5]. Findings that support this theory include the tendency of watershed areas to be affected, as evident in our patient's MRI.Radiologic evidence of bilateral and symmetric gray and white matter edema of parietal and occipital lobes is most common, although the frontal lobe and cerebellum may also be affected [1,2].PRES can occur in numerous conditions, including sepsis, highdose chemotherapy, immunosuppressant therapy, pre-eclampsia/ eclampsia, and acute hypertension [1]. PRES has been attributed to uncontrolled hypertension in nearly 75% of patients [2].…”

“…Patients can present with a myriad of symptoms ranging from headaches and confusion to seizures and focal neurologic deficits (hemiparesis, aphasia) [1][2][3]. We report a rare case of PRES induced by acute, malignant hypertension associated with alcohol withdrawal.…”

“…Radiologic evidence of bilateral and symmetric gray and white matter edema of parietal and occipital lobes is most common, although the frontal lobe and cerebellum may also be affected [1,2].…”

“…PRES can occur in numerous conditions, including sepsis, highdose chemotherapy, immunosuppressant therapy, pre-eclampsia/ eclampsia, and acute hypertension [1]. PRES has been attributed to uncontrolled hypertension in nearly 75% of patients [2].…”

Concomitant Acute Toxic Leukoencephalopathy and Posterior Reversible Encephalopathy Syndrome

“…This included a scoring system used to characterize the MRI severity grade of PRES based on FLAIR, those being grades “minimal” (grade 1), “mild” (grade 2), “moderate” (grade 3), or “severe” (grade 4); the acute findings of ATL (best visualized on DWI) were also characterized within the PVWM as “minimal” (grade 1), “mild” (grade 2), “moderate” (grade 3), or “severe” (grade 4), based on a prior ATL scoring system . Regarding clinical outcomes, a modified Rankin Scale (mRS) was recorded from the electronic record at least 3 months following the initial MRI examination as it was used in several other studies on PRES …”