Utility and Significance of Gadolinium-Based Contrast Enhancement in Posterior Reversible Encephalopathy Syndrome

Abstract

BACKGROUND AND PURPOSE Posterior reversible encephalopathy syndrome is a clinicoradiologic syndrome. Literature regarding associated factors and the prognostic significance of contrast enhancement in posterior reversible encephalopathy syndrome is sparse. This study set out to evaluate an association between the presence of enhancement in posterior reversible encephalopathy syndrome and various clinical factors in a large series of patients with this syndrome. MATERIALS AND METHODS From an MR imaging report search that yielded 176 patients with clinically confirmed posterior reversible encephalopathy syndrome between 1997 and 2014, we identified 135 patients who had received gadolinium-based contrast. The presenting symptoms, etiology, clinical follow-up, and maximum systolic and diastolic blood pressures within 1 day of MR imaging were recorded. MRIs were reviewed for parenchymal hemorrhage, MR imaging severity, and the presence and pattern of contrast enhancement. Statistical analyses evaluated a correlation between any clinical features and the presence or pattern of enhancement. RESULTS Of 135 included patients (67.4% females; age range, 7–82 years), 59 (43.7%) had contrast enhancement on T1-weighted MR imaging, the most common pattern being leptomeningeal (n=24, 17.8%) or leptomeningeal plus cortical (n=21, 15.6%). Clinical outcomes were available in 96 patients. No significant association was found between the presence or pattern of enhancement and any of the variables, including sex, age, symptom, MR imaging severity, blood pressure, or outcome (all P >.05 after Bonferroni correction). CONCLUSIONS The presence or pattern of enhancement in posterior reversible encephalopathy syndrome is not associated with any of the tested variables. However, an association was found between MR imaging severity and clinical outcome.

Reply:

“…Because no such associations were found, we suggested that gadolinium-based contrast may not be necessary in diagnosing or assessing the degree of severity of PRES. 1 As noted, however, our results did show a significant association between clinical outcomes and the extent of the T2 signal abnormalities used to grade the radiologic severity.…”

Neuroimaging features in posterior reversible encephalopathy syndrome: A pictorial review

“…Contrast enhancement is reported in a variable incidence, ranking from 23 to 43%. 22,24,62 Leptomeningeal enhancement superficially above the brain surface is the most common pattern 62 (Fig.13). Occasionally, a marked gyriform cortical enhancement can be observed.…”

Controversy of posterior reversible encephalopathy syndrome: what have we learnt in the last 20 years?

“…In a recent retrospective chart review, the authors found that pre-existing diabetes mellitus and corpus callosum involvement of PRES-associated lesions were strong predictors of poor outcome 55. Although the presence and degree of elevated blood pressure have been shown in many studies, these do not correlate with either the clinical outcome or MRI severity or grading of vasogenic oedema 3 7 10 56. Accordingly, Singer and colleagues have observed a complete resolution of neurological signs and symptoms in 84% of cancer patients with PRES, with the neuroimaging being reversible in 81%; notably, the mortality rate in that cohort was reported to be 19% but, none of the deaths were directly associated with PRES 57 58.…”