Risk factors for poor outcome in posterior reversible encephalopathy syndrome: systematic review and meta-analysis

Chen, Zheng; Zhang, Gang; Lerner, Alexander; Wang, Anhui; Gao, Bo; Liu, Jie

doi:10.21037/qims.2018.05.07

Cited by 47 publications

(44 citation statements)

References 45 publications

(66 reference statements)

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“…Hyperintensity on DWI and hypointensity on ADC maps, which are called restricted diffusion, can reflect cytotoxic edema. The presence of cytotoxic edema may suggest progression to infarction and eventual irreversible damage, which may be associated with poor outcome (30,31). In our study, 34 (23.0%) patients showed cytotoxic edema, but only two patients had a residual infarction.…”

Section: Discussionmentioning

confidence: 46%

Clinical and MRI Features of Posterior Reversible Encephalopathy Syndrome With Atypical Regions: A Descriptive Study With a Large Sample Size

Yang²,

Guo

et al. 2020

Front. Neurol.

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Background: Accurate diagnosis and timely treatment for posterior reversible encephalopathy syndrome (PRES) with atypical regions are very important in clinical practice. However, until now, little has been known about the clinical and MRI manifestations of this disease. Therefore, the aim of this study is to investigate the clinical and MRI features of PRES to promote clinical management and deepen our understanding of this disease. Materials and Methods: Data from six PRES patients with atypical regions were collected from our hospital. Data from another 550 cases were obtained by searching the PubMed, EMBASE and Web of Science databases with the keywords "posterior reversible encephalopathy syndrome" "PRES" "reversible posterior leukoencephalopathy" "RPLS" "hypertensive encephalopathy" "hyperperfusion encephalopathy" or "reversible posterior cerebral edema encephalopathy." The clinical and MRI features of these 556 cases were analyzed together. Results: A total of 305 patients were female, and 248 were male, with a median age of 34 years. The information on sex and age of three patients was not available. The most common symptom was headache (282/556, 50.7%), followed by altered mental status (243/556, 43.7%), seizures (233/556, 41.9%), visual disturbances (194/556, 34.9%), nausea/vomiting (130/556, 23.4%), and focal neurological deficits (101/556, 18.2%). Hypertension (425/556, 76.4%), renal diseases (152/556, 27.3%), immunosuppressant drugs (79/556, 14.2%), and chemotherapy/chemoradiotherapy (59/556, 10.6%) were the major predisposing factors. The atypical regions of the lesions were the cerebellum (331/556, 59.5%), basal ganglia (135/556, 24.3%), periventricular/deep white matter (125/556, 22.5%), pons (124/556, 22.3%), brainstem (115/556, 20.7%), thalamus (114/556, 20.5%), midbrain (48/556, 8.6%), spinal cord (33/556, 5.9%), and medulla (29/556, 5.2%). Additionally, the following typical regions were observed: occipital (278/556, 50.0%), parietal (234/556, 42.1%), frontal (150/556, 27.0%), and temporal (124/556, 22.3%) lobes. The major treatments were antihypertensives (358/515, 69.5%), antiepileptics/sedation (126/515, 24.5%), discontinuation/switching agents (67/515, Li et al. PRES With Atypical Regions 13.0%), and steroids (54/515, 10.5%). The median time of the clinical state improved and abnormal neuroimaging resolved is 2-3 weeks after appropriate treatment. Conclusion: The common symptoms of PRES with atypical regions include headaches, altered mental status, seizures, visual disturbances, nausea or vomiting, and focal neurological deficits. The frequent predisposing factors include hypertension, renal diseases, immunosuppressant drugs and chemotherapy/chemoradiotherapy. MRI features are mainly characterized by vasogenic edema in central zones always accompanied by typical regions. Most cases can be reversed in 2-3 weeks when promptly recognized and properly treated.

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Section: Discussionmentioning

confidence: 46%

Clinical and MRI Features of Posterior Reversible Encephalopathy Syndrome With Atypical Regions: A Descriptive Study With a Large Sample Size

Yang²,

Guo

et al. 2020

Front. Neurol.

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“…Studies have reported that patients with preeclampsia-eclampsia have less severe cerebral edema, hemorrhage, contrast enhancement with a tendency for complete resolution on imaging and good functional outcome (10, 29). A recent systemic review and meta-analysis which included 448 PRES patients showed good outcomes in patients with PRES related to preeclampsia/eclampsia (p < 0.00001) (76). Other factors that have been associated with poor outcome include severe encephalopathy, hypertensive etiology, hyperglycemia, neoplastic etiology, longer time to control the causative factor, the presence of multiple comorbidities, elevated CRP, low CSF glucose, and coagulopathy (9, 10, 47, 77).…”

Section: Prognosismentioning

confidence: 99%

“…Various imaging features that are associated with poor outcome include corpus callosum involvement, extensive cerebral edema or worsening imaging severity, hemorrhage, subarachnoid hemorrhage, and restrictive diffusion on imaging (47,60,(76)(77)(78). The type, location and severity of hemorrhage that is associated with poor outcome are inconsistent across various studies (47,76,79). While small hemorrhages do not have an impact on outcome, multiple or massive hemorrhages might be associated with poor outcome.…”

Section: Prognosismentioning

confidence: 99%

Posterior Reversible Encephalopathy Syndrome: Clinical Features and Outcome

2020

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Background: Posterior reversible encephalopathy syndrome (PRES) is an acute neurotoxic syndrome that is characterized by a spectrum neurological and radiological feature from various risk factors. Common neurological symptoms includes headache, impairment in level of consciousness, seizures, visual disturbances, and focal neurological deficits. Common triggering factors include blood pressure fluctuations, renal failure, eclampsia, exposure to immunosuppressive or cytotoxic agents and autoimmune disorders. The classic radiographic findings include bilateral subcortical vasogenic edema predominantly affecting the parieto-occipital regions but atypical features include involvement of other regions, cortical involvement, restricted diffusion, hemorrhage, contrast enhancement. This review is aimed to summarize the updated knowledge on the typical and atypical clinical and imaging features, prognostic markers and identify gaps in literature for future research. Methods: Systematic literature review using PUBMED search from 1990 to 2019 was performed using terms PRES was performed. Results: While clinical and radiographic reversibility is common, long-standing morbidity and mortality can occur in severe forms. In patients with malignant forms of PRES, aggressive care has markedly reduced mortality and improved functional outcomes. Although seizures were common, epilepsy is rare. Various factors that have been associated with poor outcome include altered sensorium, hypertensive etiology, hyperglycemia, longer time to control the causative factor, elevated C reactive protein, coagulopathy, extensive cerebral edema, and hemorrhage on imaging. Conclusion: Large prospective studies that accurately predict factors that are associated with poor outcomes, determine the pathophysiology, and targeted therapy are required.

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“…The association between contrast-enhancement (CE) pattern and prognosis in PRES is still debated (44), but recent studies reported a link among poor outcome, hemorrhage, and cytotoxic edema (54,62). Contrast enhancement shows the breakdown or an augmented permeability of the BBB (63), but being a temporal phenomenon, it could be transitory, suggesting different stages in the integrity of the BBB (44).…”

Section: Presmentioning

confidence: 99%

Posterior Reversible Encephalopathy Syndrome and Reversible Cerebral Vasoconstriction Syndrome: Clinical and Radiological Considerations

2020

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Posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS) are relatively uncommon neurological disorders, but their detection has been increasing mainly due to clinical awareness and spreading of magnetic resonance imaging (MRI). Because these syndromes share some common clinical and radiologic features and occasionally occur in the same patient, misdiagnosis may occur. PRES is characterized by varied neurological symptoms including headache, impaired visual acuity or visual field deficit, confusion, disorders of consciousness, seizures, and motor deficits often associated to peculiar neuroradiological pattern even if uncommon localization and ischemic or hemorrhagic lesions were described. RCVS is a group of diseases typically associated with severe headaches and reversible segmental vasoconstriction of cerebral arteries, often complicated by ischemic or hemorrhagic stroke. Pathophysiological basis of PRES and RCVS are still debated but, because they share some risk factors and clinical features, a possible common origin has been supposed. Clinical course is usually self-limiting, but prognosis may fluctuate from complete recovery to death due to complications of ischemic stroke or intracranial hemorrhage. Neuroradiological techniques such as digital angiography and MRI are helpful in the diagnostic pathway and a possible prognostic role of MRI has been suggested. This review will serve to summarize clinical, neuroradiological features and controversies underlying both syndromes that may mislead the diagnostic pathway and their possible relationship with pathophysiology, clinical course, and prognosis.

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Risk factors for poor outcome in posterior reversible encephalopathy syndrome: systematic review and meta-analysis

Abstract: PRES patients with hemorrhage or cytotoxic edema are likely to have poor outcomes. Pre-eclampsia/eclampsia is associated with reduced risk of poor outcome in patients with PRES.

Cited by 47 publications

References 45 publications

Clinical and MRI Features of Posterior Reversible Encephalopathy Syndrome With Atypical Regions: A Descriptive Study With a Large Sample Size

Clinical and MRI Features of Posterior Reversible Encephalopathy Syndrome With Atypical Regions: A Descriptive Study With a Large Sample Size

Posterior Reversible Encephalopathy Syndrome: Clinical Features and Outcome

Posterior Reversible Encephalopathy Syndrome and Reversible Cerebral Vasoconstriction Syndrome: Clinical and Radiological Considerations

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