Unexpected Seizure Attack in a Patient with Spinal Metastasis Diagnosed as Posterior Reversible Encephalopathy Syndrome

Abstract

A 52-year-old woman with advanced gastric cancer, which was diagnosed 7 months prior to admission, presented with low back pain and radiculopathy in the left leg. The primary tumor was not resectable, and 10 cycles of chemotherapy with FOLFOX (5-Fluoruracil/Oxaliplatin) had been completed 23 days prior to admission. A metastatic tumor with an epidural extension was detected at the 4th lumbar vertebra (Fig. 1A). As a result, elective surgical decompression and stabilization were scheduled. Two days before the surgery, a generalized tonic clonic seizure occurred. She did not have a history of hypertension and had normal blood pressure at admission, but her systolic blood pressure was 166 mmHg at the time of the seizure. No electrolyte abnormality was observed. After emergency treatment for seizure (iv. lorazepam 4 mg), a brain computed tomography was conducted. However, no definite abnormality was observed. An antiepileptic drug was administered (valproate sodium 1,200 mg/day). After subsidence of the seizure, brain INTRODUCTIONPain and neurological deficits are common presenting symptoms in patients with spinal metastasis. For the most part, seizure is not a foreseeable risk if there is no evidence of brain metastasis. However, we observed an unexpected seizure attack in a patient with spinal metastasis. Although posterior reversible encephalopathy syndrome (PRES) is a well-known syndrome that is usually associated with hypertension or chemotherapy, it is not familiar with neurosurgeon due to limited experience and report 1,3,4,17) . With the development of chemotherapy, the possibility of PRES is increasing in cancer patients 1,3,4,17) . If physicians are aware of this possibility of PRES, a diagnosis could be easily made using imaging. Moreover, PRES is reversible and can be managed with conservative treatment 4,15) . The aim of this report is to make neurosurgeons aware of this potential medical Seizure is a foreseeable risk in patients with brain lesion. However, seizure during treating non-brain lesion is not a familiar situation to neurosurgeon. Posterior reversible encephalopathy syndrome (PRES) is a relatively common situation after systemic chemotherapy. The aim of this study is to make neurosurgeons aware of this potential medical problem. A 52-year-old woman with advanced gastric cancer, presented with low back pain due to spinal metastasis at the 4th lumbar vertebra. Ten cycles of chemotherapy with FOLFOX (5-Fluoruracil/Oxaliplatin) had been completed 23 days ago. Two days before the planned operation, a generalized tonic clonic seizure occurred. She did not have a history of hypertension or seizure. The seizure was stopped with lorazepam 4mg. The brain magnetic resonance (MR) imaging showed high signal changes in both parieto-occipital lobes on the T2-weighted images, and these were partially enhanced, suggesting PRES. The surgery was preceded by treatment with an antiepileptic drug. The MR images, taken 1.5 months after the seizure, showed that the lesion was no longer present. At 3 month follow-up,...

Posterior Reversible Encephalopathy Syndrome (PRES) After Treatment With Oxaliplatin and 5-Fluorouracil

“…17 We have found 4 other cases of PRES associated with oxaliplatin [18][19][20][21] and 1 other case similar to ours after treatment with both oxaliplatin and 5-fluorouracil. 22…”

Folfox encephalopathy: A rare case series

“…They are posterior reversible encephalopathy, Wernicke's encephalopathy, and hyperammonemic encephalopathy. [ 2 3 ] It is the diagnosis of exclusion.…”

Posterior Reversible Encephalopathy Syndrome Associated with FOLFOX Chemotherapy

“…In a review performed in Pubmed, we found two cases that showed the use of FOLFOX preceding this syndrome [8, 9]. …”

“…As a result of typical imaging features, PRES was diagnosed. An antiepileptic drug was administered and no more seizures were reported [9]. …”