PRES - Posterior Reversible Encephalopathy Syndrome

PRES - Posterior Reversible Encephalopathy Syndrome
 • Clinico-radiological syndrome characterized by: headache, seizures, altered mental status, visual disturbance, white matter vasogenic edema affecting the posterior occipital and parietal lobes of the brain
 • Clinical Presentation: Altered mental status, Headache, Seizures, Vision changes, Hypertensive crisis may precede the neurologic syndrome by 24 hours or longer/BP fluctuations
 • PRES-associated clinical conditions: Preeclampsia, Eclampsia, Infection/Sepsis/Shock, Autoimmune disease, Cancer chemotherapy, Immunosuppressive agents, Renal failure, Transplantation including bone marrow or stem cell transplantation, Hypertension/Hypertensive emergency, Blood transfusion, Hypercalcemia
 • ETIOLOGY: Pathophysiology remains unclear, endothelial dysfunction is key, with hypertension being the most common precipitating factor.
    1. Neurological symptoms: Acute onset
    2. Risk factors
    3. Imaging: T2 FLAIR-Vasogenic edema in the subcortical white matter in the posterior brain
    4. Reversible course
 • Differential Diagnosis: Infection, electrolyte abnormality, medication/drug toxicity, metabolic disturbance, external lines/devices, constipation, seizures, stroke, paraneoplastic syndrome, ADEM, Acute toxic leukoencephalopathy, Cerebral venous thrombosis
 • Testing:
   - IMAGING: white matter vasogenic edema affecting the posterior occipital and parietal lobes of the brain
   - CSF: modestly elevated protein level (mean 58 mg/dL in one study) but no pleocytosis - An elevated white blood cell count in the CSF should prompt consideration of other diagnoses.
   - EEG: with persistent altered level of consciousness to exclude non-convulsive status epilepticus
 • Treatment - Address the underlying cause:
   - Treatment of HTN is the mainstay of therapy in pts
   - BP: 10 to 25 % reduction initially, Avoid overaggressive BP lowering
   - Lower the diastolic pressure to 100- 105 mmHg within 2 to 6 hours
   - Use easily titratable parenteral agents: clevidipine, nicardipine, or labetalol.
   - Magnesium correction: Levels 2-3 mEq/L
   - Seizures: Treat with AEDS until cause identified.

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Contributed by

Dr. Ravi Singh K
Academic Hospitalist and APD @SinaiBmoreIMRes, Clinical reasoning,Simulation and POCUS enthusiast -
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