Ondansetron-related hemorrhagic posterior reversible encephalopathy syndrome (PRES) following gastric bypass.

M Alain Babi,Marilyn J Cipolla,Gilman Allen,Christopher Commichau,Ryan Clouser,Salman Al Jerdi,Mark J Gorman

doi:10.1186/s40064-015-1644-9

Abstract

BackgroundPosterior reversible encephalopathy syndrome (PRES) is a clinical-radiographic syndrome formally recognized in 1996, which describes specific changes noted on neuroimaging thought to be related to impaired cerebral blood flow autoregulation and endothelial dysfunction. We report a case of PRES in the setting of increased ingestion of ondansetron; complicated by hemorrhagic transformation and refractory intracranial hypertension. We hypothesize an association of 5-HT3 antagonism and PRES.FindingsThis is a case study report; with review of previously published literature through PubMed search. We describe the case of a 25 year old man following bariatric surgery who increased his ingestion of ondansetron, taking up to 40 tablets/day due to excessive nausea and vomiting. The patient was hospitalized for progressively more severe headache of 1 week’s duration. Computed tomography (CT) revealed bilateral cerebral edema in the parietal and occipital lobes in the setting of elevated blood pressure (BP). Three days into his admission, following improvement in his BP with oral anti-hypertensive but continued use of the ondansetron, the patient developed near complete blindness. CT head imaging revealed progression of the posterior cerebral edema and intraparenchymal hemorrhage. He was admitted to our ICU and despite supportive treatment, his neurological examination worsened while CT head imaging findings remained stable. Invasive multimodality monitoring revealed elevated intracranial pressure. The patient was aggressively treated and after a prolonged hospitalization and rehabilitation course, made a significant recovery.ConclusionThis case highlights a very rare potential neurological complication of ondansetron, a commonly used medication. We hypothesize an underlying association between PRES and 5-HT3 antagonism, via the latter’s potential role in endothelial dysfunction. Prompt recognition and treatment of PRES is essential, in order to prevent secondary cerebral injury and the associated potentially grave consequences.

Highlights

Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiographic syndrome formally recognized in 1996, which describes specific changes noted on neuroimaging thought to be related to impaired cerebral blood flow autoregulation and endothelial dysfunction
Endothelial dysfunction has been implicated, in PRES associated with pre-eclampsia, immunosuppressive and cytotoxic therapies (Hinchey et al 1996; Stott et al 2005; Staykov and Schwab 2012)
We describe a case of PRES complicated by intracerebral hemorrhage in the setting of excessive ingestion of ondansetron following bariatric surgery

Summary

Introduction

Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiographic syndrome formally recognized in 1996, which describes specific changes noted on neuroimaging thought to be related to impaired cerebral blood flow autoregulation and endothelial dysfunction. PRES appears to be related to impaired cerebral blood flow autoregulation, as well endothelial dysfunction (Hinchey et al 1996; Stott et al 2005). Endothelial dysfunction has been implicated, in PRES associated with pre-eclampsia, immunosuppressive and cytotoxic therapies (Hinchey et al 1996; Stott et al 2005; Staykov and Schwab 2012). Treatment of PRES remains supportive with control of blood pressure in hypertensive patients and removal of offending agents where identified

Results

Discussion

Conclusion