Abstract
Although the term posterior reversible encephalopathy syndrome (PRES) was popularized because of the typical presence of vasogenic edema in the parietal and occipital lobes, other regions of the brain are also frequently affected. We evaluated lesion distribution with CT and MR in a large cohort of patients who experienced PRES to comprehensively assess the imaging patterns identified. The locations of the PRES lesion at toxicity were comprehensively identified and tabulated in 136 patients by CT (22 patients) and MR (114 patients) imaging including the hemispheric, basal ganglial, and infratentorial locations. Clinical associations along with presentation at toxicity including blood pressure were assessed. Vasogenic edema was consistently present in the parietal or occipital regions (98%), but other locations were common including the frontal lobes (68%), inferior temporal lobes (40%), and cerebellar hemispheres (30%). Involvement of the basal ganglia (14%), brain stem (13%), and deep white matter (18%) including the splenium (10%) was not rare. Three major patterns of PRES were noted: the holohemispheric watershed (23%), superior frontal sulcal (27%), and dominant parietal-occipital (22%), with additional common partial or asymmetric expression of these primary PRES patterns (28%). Involvement of the frontal lobe, temporal lobe, and cerebellar hemispheres is common in PRES, along with the occasional presence of lesions in the brain stem, basal ganglia, deep white matter, and splenium. Three primary PRES patterns are noted in the cerebral hemispheres, along with frequent partial or asymmetric expression of these PRES patterns. Awareness of these patterns and variations is important to recognize PRES neurotoxicity more accurately when present.
Highlights
AND PURPOSE: the term posterior reversible encephalopathy syndrome (PRES) was popularized because of the typical presence of vasogenic edema in the parietal and occipital lobes, other regions of the brain are frequently affected
Three primary PRES patterns are noted in the cerebral hemispheres, along with frequent partial or asymmetric expression of these PRES patterns
Five major clinical subgroups of conditions were recognized in 129 (94.8%) of these 136 patients: 1) postinfection, sepsis, or shock associated with multiple organ dysfunction; 2) posttransplantation neurotoxic syndrome; 3) postchemotherapy; 4) autoimmune diseases; and 5) eclampsia
Summary
The locations of the PRES lesion at toxicity were comprehensively identified and tabulated in 136 patients by CT (22 patients) and MR (114 patients) imaging including the hemispheric, basal ganglial, and infratentorial locations. We searched the radiology report data base for January 1998 to August 2006 for any patients in whom PRES or posterior reversible encephalopathy was cited on brain MR imaging. Brain MR imaging along with CT imaging studies were reviewed in the identified patients for features consistent with the characteristics of cyclosporine/FK-506 neurotoxic syndrome, eclampsia, or PRES. Patients with clinical neurotoxic reactions and imaging features consistent with PRES were tabulated and combined with the PRES neurotoxicity data base of one of the authors (January 1991-June 2002), and the result of these 2 data bases was pooled. The pooled data represented patients originating from or referred to a tertiary care university regional medical center and associated hospitals with longstanding focus on solid organ transplantation (SOT), obstetrics, rheumatology, and oncology. We obtained approval from the Institutional Review Board for this retrospective study
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