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posterior reversible encephalopathy syndrome (PRES)
Etiology:
- hypertension
- cytotoxic drugs
- sepsis
- thrombotic thrombocytopenic purpura
- preeclampsia/eclampsia
- obstructive uropathy [2]
- comorbidities
a) renal failure in 57% of patients
b) autoimmune disease in 45% of patients
Pathology:
- endothelial dysfunction (putative)
- breakdown in cerebral autoregulation (putative)
Clinical manifestations:
1) acute neurological changes
a) seizures (74%)
b) headaches
c) encephalopathy
- confusion, cognitive impairment [2]
d) visual disturbance
e) focal neurologic deficit
2) hypertension
- acute rise in blood pressure (mean = 191/104 mm Hg)
3) clinically reversible
Laboratory:
- basic metabolic panel
- serum creatinine
- serum PSA
- urinalysis
- CSF analysis
Special laboratory:
- ophthalmoscopy may reveal Flame hemorrhages & papilledema
- lumbar puncture [2]
- ultrasound of bladder for post-void residual volume
- renal ultrasound
Radiology:
- magnetic resonance imaging
a) focal vasogenic edema
b) radiological reversibility
c) parietal-occipital involvement (~100%)
d) frontal lobe (77%)
e) temporal lobe (64%)
f) cerebellum (53%)
g) basal ganglia ( 34%)
h) brainstem (27%
Management:
- supportive, treat signs/symptoms
- prognosis
- resolution in ~90% of cases
General
encephalopathy
syndrome
References
- Fugate JE et al.
Posterior reversible encephalopathy syndrome:
Associated clinical and radiologic findings.
Mayo Clin Proc 2010 May; 85:427.
PMID: 20435835
http://dx.doi.org/10.4065/mcp.2009.0590
- Blum SM, Prust ML, Patel R et al
Stream of Consciousness.
N Engl J Med 2018; 378:1336-1342. April 5, 2018
PMID: 29617591
http://www.nejm.org/doi/full/10.1056/NEJMcps1714950