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
- 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.
#PRES #Posterior #Reversible #Encephalopathy #Syndrome #diagnosis #management #neurology