Clinical profile and outcome of posterior reversible encephalopathy syndrome (PRES)

Abstract

Background: Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiographic syndrome of multiple etiologies. Still, the exact pathophysiology of PRES is not clear. Aims and Objectives: To study demographic, etiological, and clinic-radiological profiles of patients presenting with PRES and their outcome at the tertiary care teaching hospital. Materials and Methods: A retrospective observational and non-interventional study was conducted at tertiary care center in from January 2009 to December 2013 at Krishna Institute of Medical Sciences, Karad. Inclusion Criteria: The clinical history of acute neurologic change including headache, encephalopathy, seizure, visual disturbance, or focal deficit with magnetic resonance imaging (MRI) brain imaging findings of focal vasogenic edema with clinical or radiologic proof of reversibility. Results: Of a total 43 patients with suspected diagnosis of PRES, 29 patients were included fulfilling all inclusion criteria of PRES. Of total the 29 patients with confirmed diagnosis of PRES, 22 (75.86%) were female and 7 (24.13%) were male patients, predominated by female population (relative risk [RR]: 3.14; odds ration [OR]: 9.87; 'P' < 0.001). The overall mean age was 33.65 years (±15.26) and mean duration of stay was 10.13 days (±4.98). The most common clinical presentation was generalized tonic-clonic seizures, seen in 23 (79.31%) patients, headache in 21 (72.41%) patients, and visual disturbances 13 (44.82%) patients. A total of 18 (62.06%) patients were hypertensive and 11 (37.93%) were normotensive [RR: 1.63]. A total of 6 (27.27%) females and 5 (71.42%) males were normotensive and total 16 (72.72%) females and 2 (28.57%) males were hypertensive (RR: 1.12). Of a total of 22 female patients with PRES, 19 (86.36%) were in a postpartum state, one (4.45%) had systemic lupus erythematous (SLE), one (4.54%) had community-acquired pneumonia (CAP) with acute respiratory distress syndrome (ARDS) with septicemia and one (4.54%) had chronic hypertension in accelerated phase. Postpartum state was significantly associated with PRES ('P' < 0.001). A total of 15 (68.18%) female patients had pregnancy-induced hypertension (PIH)/eclampsia. Of a total of 7 male patients with a diagnosis of PRES. two (28.57%) were had chronic kidney disease (CKD), two (28.57%) had chronic hypertension, one (14.28%) had alcohol intoxication, one (14.28%) had rheumatoid arthritis (RA), and one (14.28%) had septicemia with septicemic shock. Of a total three (10.34%) deaths, two were females (6.89%) and one (3.44%) was male. Total 26 (89.65%) patients were discharged after successful treatment. A total of three patients succumbed during treatment with case fatality rate of 10.34% (RR: 1.06). The most commonly involved location was the parieto-occipital and cerebellum brain region, which was seen in 23 (79.31%) patients and the lesions were asymmetric in 27 (93.10%) and symmetric in 2 (6.89%) cases. All 29 (100%) patients had bilateral affection. Conclusion: The present study revealed the significant numbers of patients in postpartum state with PRES syndrome with good prognosis. The present study highlighted affection of young, female population with history of hypertension with predominant affection of parieto-occipital and cerebellar involvement in PRES. Autoimmune disease, infection, alcohol intoxication, and CKD were less common factors associated with PRES. The history of hypertension in clinical scenario with neuro-imaging, we should consider the possibility of PRES and aggressively treat based on the clinical presentation. Brain imaging plays an important role in diagnosis of PRES. The early diagnosis, prompt treatment including maintenance of hydration control of blood pressure and seizure and removal of precipitating factors is mandatory for a good outcome of PRES with minimal or no residual neuro-deficit.