Case Of Posterior Reversible Encephalopathy Syndrome Research Articles

Should Calcineurin Inhibitors/Sirolimus Be Ceased Completely In Posterior Reversible Encephalopathy Syndrome?

To investigate the relationship between immunosuppressive treatments and posterior reversible encephalopathy syndrome (PRES) in transplant patients. We presented a retrospective study of 4 cases of PRES in transplant patients. Patient records were reviewed to identify potential risk factors, clinical presentations, radiological findings, and immunosuppressive treatments used. Our analysis revealed a potential association between immunosuppressive treatments and the development of PRES in transplant patients. Specifically, we found that adjusting or switching immunosuppressive treatments can improve outcomes and prevent the recurrence of PRES. Our findings highlight the importance of recognizing PRES as a potential complication of immunosuppressive treatments in transplant patients. Early detection and management, including a review of immunosuppressive treatments, may improve patient outcomes and prevent further complications.

Demographic Disparities in the Incidence, Clinical Characteristics, and Outcome of Posterior Reversible Encephalopathy Syndrome in the United States.

To estimate age-specific, sex-specific, and race-specific incidence of posterior reversible encephalopathy syndrome (PRES) in the United States. We conducted a retrospective cohort study using the State Inpatient Database of Florida (2016-2019), Maryland (2016-2019), and New York (2016-2018). All new cases of PRES in adults (18 years or older) were combined with Census data to compute incidence. We evaluated the generalizability of incident estimates to the entire country using the 2016-2019 National Readmissions Database (NRD). Across the study period, there were 3,716 incident hospitalizations for PRES in the selected states. The age-standardized and sex-standardized incidence of PRES was 2.7 (95% CI 2.5-2.8) cases/100,000/y. Incidence in female patients was >2 times that of male patients (3.7 vs 1.6 cases/100,000/y, p < 0.001). Incidence increased with age in both sexes (p-trend <0.001). Similar demographic distribution of first hospitalization for PRES was also noted in the entire country using the NRD. Age-standardized and sex-standardized PRES incidence in Black patients (4.2/100,000/y) was significantly greater than in Non-Hispanic White (2.7/100,000/y) and Hispanic patients (1.2/100,000/y) (p < 0.001 for pairwise comparisons). The incidence of PRES in the United States is approximately 3/100,000/y, but incidence in female patients is >2 times that of male patients. PRES incidence is higher in Black compared with non-Hispanic White and Hispanic patients.

Late Postpartum Posterior Reversible Encephalopathy Syndrome: Case Series and Literature Review

Abstract Posterior reversible encephalopathy syndrome (PRES) is a reversible neurological entity characterized by seizures, headache, visual symptoms and other focal neurological findings. It is caused by wide variety of causes ultimately leading to vasogenic cerebral edema of occipital and parietal lobes of the brain. Prompt and early diagnosis of PRES is key in reducing the risk of permanent neurological sequelae. Occurrence of PRES during pregnancy or early postpartum period is well known. However, occurrence of PRES between 48 hours and one month postpartum in women who had normal pregnancy and delivery and no signs of preeclampsia is rare. In this case series we present three cases of PRES that occurred in young women during late postpartum period. All these three patients were normotensive during antenatal and early puerperal period but developed hypertension and vision loss in late puerperium. The prompt diagnosis and management of symptoms resulted in complete reversal of the symptoms with no permanent neurological deficit. Posterior reversible encephalopathy syndrome (PRES) is a reversible neurological entity characterized by the presence of white matter edema affecting the occipital and parietal lobes. The predominantly affected area of the cerebral cortex determines presentation in the patient. The reversibility of these symptoms is one of the hallmarks of the disease. Diffusion-weighted MRI is the gold standard in diagnosis of PRES as it helps to distinguish between vasogenic edema from cytotoxic edema. Prompt diagnosis and initiation of early treatment may lead to complete recovery with no residual neurological deficit.

Posterior reversible encephalopathy syndrome in malignancy: Hypercalcemic storm?

e17559 Background: Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiological entity characterized by seizures, headaches, altered mental status and visual anomalies associated with vasogenic edema affecting the parietal-occipital lobes on brain magnetic resonance imaging. PRES is rarely described in hypercalcemia of malignancy although multiple mechanisms have been postulated in various case reports. Hence, we conducted this study to evaluate whether there is an increased risk of PRES with hypercalcemia of malignancy. Methods: We analyzed the 2016-2020 National Inpatient Sample (NIS) and extracted patient data with a diagnosis of ovarian cancer, lung cancer, multiple myeloma (MM), breast cancer, diffuse large B-cell lymphoma (DLBCL), and secondary bone cancer. Cases with a history of primary hyperparathyroidism, vitamin D intoxication and familial hypocalciuric hypercalcemia were excluded. The presence of hypercalcemia and PRES were estimated (per 10,000 cases), and their respective adjusted odds ratios (aOR) were calculated via multivariate regression analysis. Results: We identified 1,775 PRES cases in 3,781,899 cancer patients studied. Patients with breast cancers (26 per 10,000 hypercalcemia cases vs. 4 per 10,000 cases with no hypercalcemia, aOR 4.523, 95% CI 3.418-5.984, p &lt; 0.01), ovarian cancers (41 per 10,000 hypercalcemia cases vs. 8 per 10,000 cases with no hypercalcemia, aOR 5.224, 95% CI 3.075-8.875, p &lt; 0.010), and secondary bone neoplasms (14 per 10,000 hypercalcemia cases vs. 5 per 10,000 cases with no hypercalcemia, aOR 2.160, 95% CI 1.671-2.793, p &lt; 0.01) exhibited a statistically significant increased outcome of PRES in association with hypercalcemia. The presence of hypercalcemia among lung cancer patients (aOR 0.755, 95% CI 0.451-1.263, p = 0.284), MM (aOR 1.005, 95% CI 0.751-1.346, p = 0.973), and DLBCL (aOR 1.393, 95% CI 0.806-2.408, p = 0.236) did not show a valid odds ratio for PRES. Conclusions: Our study found a higher association of PRES among hypercalcemia patients with ovarian cancer, breast cancer and secondary bone neoplasms. Prompt recognition of PRES and hypercalcemia-directed treatment can allay the morbidity related to PRES. While our study was limited in quantifying the cut-off values of hypercalcemia causing PRES, designated protocols entitled solely to determining serum calcium thresholds in these cancers warranting rigorous treatments are needed. PRES’s association with hypercalcemia in female-dominant cancers also paves way for further studies looking into the influences of sex hormones and hormonal therapies on the development of PRES with hypercalcemia.

A systematic review of posterior reversible encephalopathy syndrome in pregnant women with severe preeclampsia and eclampsia

Background The association of posterior reversible encephalopathy syndrome (PRES) and severe preeclampsia/eclampsia has been established but the frequency is uncertain. Objectives To determine the frequency of PRES in severe preeclampsia or eclampsia. Methods We searched published articles in PubMed, Cochrane library, Embase, and CINAHL from 1990 to 2020. We included articles that reported on six or more cases of PRES with eclampsia or severe preeclampsia who underwent neuroimaging during pregnancy or up to 6 weeks postpartum. Results We identified 29 studies presenting data on 1519 women with eclampsia or severe preeclampsia. Among 342 women with eclampsia who had neuroimaging, 176 (51.4%) were diagnosed with PRES. Of 121 women with severe preeclampsia, 24 (19.8%) had PRES. The pooled maternal death rate was 5.3% (21/395). Conclusion PRES is commonly reported on neuroimaging of women with eclampsia/ severe preeclampsia. The role of neuroimaging in eclampsia and especially in women with severe preeclampsia requires re-evaluation as further management is often dictated by this finding.

A Reversible Event Leading to Lifestyle Reversion: About a Case of PRES

The posterior reversible encephalopathy syndrome (PRES) is a heterogeneous clinical-radiological characterized by a combination of encephalopathy, altered mental status, epileptic seizures, visual disturbances, headache, and focal neurologic signs. Other neurologic deficits, such as ataxia, may occur. PRES can be found in a nonposterior distribution, mainly in watershed areas, including the frontal, inferior temporal, cerebellar, and brainstem regions. We present the case of a middle age male presenting with headache, dizziness, ataxia, and hypertensive emergency. PRES was suspected, and the diagnosis was confirmed by brain magnetic resonance imaging. Computerized tomography showed bilateral hypodensities of the cerebellar white matter with associated narrowing of the cortical sulci and basal cisterns. This case represents a rare presentation of PRES with unusual clinical and topographical involvement, such as brainstem and cerebellum.

P15.01: Posterior Reversible Encephalopathy Syndrome in Transplant Patients: Diagnosis and Management

Introduction: Posterior reversible encephalopathy syndrome (PRES) is a rare neurotoxic status composed of own brain imaging patterns. Depending on the location of the lesion, is characterized by a wide scale of neurologic symptoms. Although, the main cause of PRES is not fully enlightened, it is shown that, especially in solid organ transplant patients due to calcineurin inhibitors (CNI) toxicity, severe hypertension and any kind of infections are strongly related with PRES. The current therapy accepted is only supportive care. In this study we aim to evaluate diagnosis and management of PRES in our transplant patients. Method: From 3 November 1975 to 31 December 2021, we performed 3288 kidney transplant, 701 liver transplant and 142 heart transplants. Among these transplants 381 patient in kidney,334 patient in liver and 70 patients in heart were pediatric. 785 pediatric transplant patients were examined, and PRES was observed in 12 pediatric patients with median age 12 years (5 month - 18 year). 6 (50%) of these patients were male and median BMI is 18,5 (12,4 - 28,9). The radiology report database was analyzed for patients which PRES was cited in brain MR imaging text reports. Cases of PRES were included and searched for demographic values, laboratory values, clinical presentation, immunosuppressive they use, management we made and results. Results: Among PRES cases, 6 (50%) patients were liver transplant, 4 (33%) were kidney transplant and 2 (17%) were heart transplant patients. %66,5 (n:8) of the patients were using Tacrolimus as immunosuppressant. Causes of PRES were toxicity of Tacrolimus in 3 (25%) patients, hypertension in 4 (33%) patients, sepsis in 2 (16%) patients, hypomagnesemia in 1(8,5%) patient, hyponatremia in 1 (8,5%) patient and cyclosporine toxicity in 1(8,5%) patient. Symptoms of PRES were Seizure in 8 (66,5%) patients, vision change in 3 (25%) patients, status epilepticus in 1 (8,5%) patient and nausea/ vomiting in 1 (8,5%) patient. The average time between transplant and the diagnosis of PRES was 23 days (2 - 27 days). In brain MRI edema (n:5), hemorrhagic lesions (n:4), ischemia (n:1) and brain infarction (n:1) were observed. As medical treatment all patients consulted with pediatric neurology. Patients having hypertension (n:4) are treated with antihypertensives ACEİ combined with calcium canal blockers. Seizure is controlled with hydantoin at early period and levetiracetam (36.9 mg/kg/day) as maintenance treatment. Patients having hypertension are taken to hemodialysis. Also, patients related with tacrolimus toxicity (n:3) were switched to cyclosporine and the patient who had cyclosporine toxicity was switched to tacrolimus. End of the treatment period all patients were discharged successfully. Conclusion: PRES is a rare diagnosis which is having an unknown etiology and due to that doesn’t have a proven management strategy. When the patient is suspected of PRES, MRI should be performed immediately, in order to avoid complications, achieve a better recovery and treat PRES successfully.

A Critical Review of Posterior Reversible Encephalopathy Syndrome Cases in a Peritoneal Dialysis Population: Case Series and Review of Literature

Introduction: Posterior reversible encephalopathy syndrome (PRES) represents a neurological disorder with varied clinical presentation and typical imaging findings. End-stage-renal-disease patients have a combination of riskfactors for PRES: hypertension, volume-overload, erythropoietin stimulating agents, immunosuppressants, hyponatremia, uremia. Methods: We explored the presentation and outcome of PRES in a chronic peritoneal-dialysis (PD) population over a 2-year period. We also reviewed the literature on PRES in PD. Result: 3 patients had PRES over a 2-year period. They were young, had uncontrolled hypertension and most presented shortly after PD-induction. Fluid/salt non-compliance, faster decline of urine-output after graft-failure, maintenance immunosuppression/ESA was possible triggers. Conclusion: PRES is a serious complication associated with a higher risk for dialytic modality transition since subclinical hypervolemia is a prevalent and probable risk factor. The complication is hardly predictable, with inconsistent correlation of clinical presentation, blood-pressure and weight-gain profiles after PD-induction.

Neuroimaging findings of posterior reversible encephalopathy syndrome (PRES) following haematopoietic stem cell transplantation in paediatric recipients

BackgroundHaematopoietic stem cell transplantation (HSCT) is used worldwide in various malignant and nonmalignant childhood diseases, including haematologic, genetic, autoimmune and metabolic disorders, and is the only curative treatment for many of these illnesses. The survival rates of many childhood diseases have been increased due to HSCT treatment. However, associated complications are still important for management. Central nervous system (CNS) complications in paediatric HSCT recipients can be associated with high morbidity and significantly contribute to mortality. Posterior reversible encephalopathy syndrome (PRES) is one of the most common CNS complications in patients with neurological symptoms following HSCT. Magnetic resonance imaging (MRI) is the modality of choice and shows typical bilateral vasogenic oedema at the posterior parts of the cerebral hemispheres; however, various atypical imaging manifestations can also occur. In this study, we retrospectively examined CNS complications in our paediatric HSCT recipients with a focus on the typical and atypical neuroimaging manifestations of PRES following HSCT.MethodsWe retrospectively reviewed the medical records of 300 consecutive paediatric HSCT recipients from January 2014 to November 2018. A total of 130 paediatric HSCT recipients who experienced neurological signs and symptoms and were evaluated with neuroimaging studies following HSCT were enrolled in the study. The timing of CNS complications was defined according to immune status, including the pre-engraftment period (< 30 days after HSCT), the early postengraftment period (30–100 days after HSCT), and the late postengraftment period (> 100 days after HSCT), which were defined as phases 1, 2 and 3, respectively.ResultsOverall, 130 paediatric HSCT recipients experienced neurological signs and symptoms and therefore underwent neuroimaging examinations. Among these 130 patients, CNS complications were present in 23 patients (17.6%, 23/130), including 13 (56.5%) females and 10 (43.5%) males with a median age of 8.0 years (range, 8 months to 18.0 years). Among these 23 patients, 14 cases of PRES (60.9%), 5 (21.7%) cases of leukoencephalopathy, 3 cases of acute subdural haemorrhage (ASDH) (13%) and 1 (4.3%) case of fungal CNS infection were identified by neuroimaging. On MRI, typical parietooccipital vasogenic oedema was present in 78.5% of the PRES cases (11/14). The following atypical neuroimaging manifestations were observed: isolated involvement of the bilateral frontal lobes in 1 case, isolated cerebellar vermis involvement in 1 case, and isolated basal ganglia involvement in 1 case. Restricted diffusion associated with cytotoxic damage was demonstrated in 2 of 14 cases, one of which also showed subacute cytotoxic injury with ADC pseudonormalization.ConclusionPaediatric HSCT recipients presenting with CNS signs and symptoms should be evaluated by neuroimaging studies for timely diagnosis and early management. PRES is the most common CNS complication and may present with atypical MRI manifestations, which should not dissuade a PRES diagnosis in appropriate clinical settings.

Posterior Reversible Encephalopathy Syndrome Following Intracranial Hypotension Due to Cerebrospinal Fluid (CSF) Leakage: A Report of Two Cases

Posterior reversible encephalopathy syndrome (PRES) in cases of intracranial hypotension is a life-threatening condition. Early suspicion, appropriate treatment, and tight control of possible contributing factors that may facilitate PRES in cerebrospinal fluid (CSF) leak patients may bring a more favorable outcome, lowering the morbidity and mortality rate.Two cases of PRES with features of intracranial hypotension are presented.We also discussed the possible pathogenesis of PRES in patients with intracranial hypotension. We emphasize the importance of the early diagnosis and treatment of ICH by repairing the leakage and further prompt attention to tight blood pressure control in those patients to avoid PRES development.

Management of posterior reversible encephalopathy syndrome in a pediatric patient with a rare adrenocortical tumor after computed tomography-guided biopsy

The posterior reversible encephalopathy syndrome (PRES) in pediatric patients is rare but a treatable reversible condition. In the pediatric age group, most cases had been reported among patients with leukemia undergoing chemotherapy and rarely in patients with solid tumors. We report a 2-year-old male child with a large retroperitoneal mass arising from the right adrenal gland. The patient had a significant rise in blood pressure followed by seizures and altered sensorium after a computed tomography-guided biopsy from the tumour mass. The patient was managed meticulously considering it as a case of PRES by a multidisciplinary team of the intensive care unit. Later, the adrenal mass was evaluated and confirmed to be a pediatric adrenocortical tumor on biopsy report which is also a rare occurrence in the pediatrics age group.

Persistent visual dysfunction following posterior reversible encephalopathy syndrome due to COVID-19: Case series and literature review.

Background and purposeThe full spectrum of neurological sequelae in COVID‐19 is beginning to emerge. SARS‐CoV‐2 has the potential to cause both direct and indirect brain vascular endothelial damage through infection and inflammation that may result in long‐term neurological signs and symptoms. We sought to illuminate persistent neuro‐ophthalmological deficits that may be seen following posterior reversible encephalopathy syndrome (PRES) due to COVID‐19.MethodsWe identified three individuals with PRES due to COVID‐19 in our hospital system. One patient was identified on presentation to our neuro‐ophthalmology clinic. The other patients were identified through internal records search. These cases were compared to published reports of PRES in COVID‐19 identified through systematic literature search of PubMed/LitCOVID.ResultsAll three patients were hospitalized with severe COVID‐19 and developed altered mental status with new onset seizures that led to the recognition of PRES through diagnostic imaging. During recovery, two patients had persistent visual dysfunction including visual field deficits. One patient also experienced hallucinatory palinopsia and visual hallucinations. Literature search identified 32 other cases of PRES in the context of COVID‐19. Visual disturbances were described in 14 cases (40%), with only seven cases (50%) reporting full recovery by the time of publication.ConclusionsAs we learn about enduring neurological complications of COVID‐19, it is possible that complications may be underrecognized and underreported. Understanding the range of complications can help in postcare evaluation and management changes in the critical care setting to potentially allow intervention before persistent deficits occur due to COVID‐19.

Abstract P578: A Comparison of Clinical Features Between Posterior Reversible Encephalopathy Syndrome and Reversible Cerebral Vasoconstriction Syndrome

Introduction: Posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS) might represent a pathophysiological spectrum. They are commonly diagnosed separately, based on prominent clinical features. We aimed to compare clinical and radiographic findings of PRES and RCVS. Methods: We performed a retrospective study of adult patients admitted to a tertiary medical center from February 2008 until February 2018 and were diagnosed with PRES or RCVS. Patient demographics, risk factors, clinical features, imaging, and outcomes were compared. Appropriate statistical tests were used to compare the variables and significant findings are reported. Results: There were 281 PRES and 98 RCVS cases meeting diagnostic criteria. Seizures, encephalopathy, and hypertension were more common with PRES, whereas headache was more common with RCVS (p &lt;0.001). Hypertension and transplant recipient or immunocompromised status were associated with PRES (p &lt;0.001), as did diabetes mellitus (p &lt;0.05). Marijuana use, smoking, and obesity were associated with RCVS (p &lt;0.05). ). Intraparenchymal or subarachnoid hemorrhage was found in 51 PRES cases and 34 RCVS cases. Arterial stenosis was present in 19 % of PRES cases. Brain FLAIR MRI hyperintensity that was reversible on follow-up was present in 26% of RCVS cases. Conclusion: PRES and RCVS share common clinical characteristics and might represent a pathophysiological spectrum, though distinct clinical features were noted in our retrospective analysis.

Abstract P460: Comparison of Hemorrhagic Posterior Reversible Encephalopathy Syndrome and Hemorrhagic Reversible Cerebral Vasoconstriction Syndrome

Introduction: Posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS) are diagnoses that have a clinical and radiographic overlap. One particular overlap includes the presence of hemorrhage, which we studied in each population to determine its effect on outcomes. Objective: To compare characteristics and outcomes of hemorrhagic PRES and hemorrhagic RCVS populations. Methods: We conducted a review of the electronic health record at a single tertiary center from January 2008 to December 2018. Inclusion criteria were 18 years or older with clinical and radiographic evidence of PRES or RCVS. Patient demographics, presenting symptoms, imaging findings, and outcomes were compared between PRES and RCVS groups. Poor outcome was defined as discharge to skilled nursing facility or death. Analysis was performed using Pearson’s Chi-Square test. Results: Among 281 PRES and 98 RCVS cases, intracranial hemorrhage was seen on imaging in 51 PRES cases (18%) and 34 RCVS cases (35%). Headache was present in all patients with hemorrhagic RCVS but only seen in 40% of hemorrhagic PRES. Use of antidepressants or drugs of abuse was more frequent with hemorrhagic RCVS (53%) as compared to hemorrhagic PRES (7%, p &lt;0.05). Among hemorrhagic PRES, presence of intraparenchymal hemorrhage but not subarachnoid hemorrhage was associated with vasoconstriction on arterial imaging (p&lt;0.05). Length of stay was longer for both hemorrhagic PRES and hemorrhagic RCVS (p&lt;0.001) compared those without hemorrhage. Presence of focal neurological deficits, motor and sensory, was associated with poor outcomes in hemorrhagic RCVS patients (p&lt;0.05). Discharge to a rehabilitation facility was associated with hemorrhagic PRES (p&lt;0.05), no association in those without hemorrhage. There is no evidence that discharge location is significantly different between RCVS hemorrhage and non-hemorrhage groups. Conclusion: Hemorrhage in PRES and RCVS is associated with more clinical deficits at presentation and longer hospital stays. Underlying vasoconstriction is frequent and associated with hemorrhagic PRES.

Posterior Reversible Encephalopathy Syndrome in a Patient With SARS-CoV-2 Infection Treated With Tocilizumab

As the world has struggled to adapt to the coronavirus disease (COVID-19) pandemic, new evidence has emerged suggesting that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may manifest with a wide variety of neurologic symptoms. We present the case of a 70-year-old patient hospitalized for COVID-19 related pneumonia who was treated with off-label interleukin (IL)-6 inhibitor tocilizumab and eventually developed prolonged delirium. MRI findings were consistent with posterior reversible encephalopathy syndrome (PRES). PRES was felt to be from SARS-CoV-2 infection, tocilizumab, or a combination. The patient received symptomatic treatment without success. These findings are consistent with few other recent reports, which have chronicled PRES findings in patients with SARS-CoV-2 infections. However, this is only the second example of PRES in a COVID-19 patient treated with tocilizumab. While cases of PRES have been noted to occur with other infectious diseases, clinicians should be aware of the association with SARS-CoV-2 infection and tocilizumab therapy, particularly when considering tocilizumab treatment outside its approved indication. Future research efforts are needed to establish evidence-based guidelines for the management of these patients.

Posterior reversible encephalopathy syndrome case report in an untreated, normotensive, ovarian cancer patient in the presence of paraneoplastic antibodies

BackgroundPosterior reversible encephalopathy syndrome (PRES) is a rare neurological condition with many associated risk factors. The presentation varies and consists of seizures, impaired visual acuity or visual field deficits, disorders of consciousness, headaches, confusion and focal neurological deficits. The diagnosis relies on clinical presentation and MRI findings. Treatment and prognosis are related to the underlying etiology.Case presentationWe present a 58-year-old woman with ovarian cancer who developed symptoms and radiologic signs of PRES with no apparent trigger other than a sudden increase in blood pressure for the first time in her life and before any treatment has begun. Antibodies to collapsin response-mediator protein-5 (CRMP-5), a malignancy related paraneoplastic protein, were identified in her CSF.ConclusionsWe present a novel and intriguing association between PRES and antibodies against CRMP-5 which may highlight a new etiology for this condition.

A Case Report: Isolated Pontine Lesion in Hypertensive of a Pregnant Patient with Idiopathic Thrombocytopenia

Posterior reversible encephalopathy syndrome (PRES) is a neuroradiologic diagnosis characterised by headache, seizures, altered mental status, and a spectrum of visual deficits ranging from visual neglect to cortical blindness. PRES manifestation is a situation of medical emergency; however, it is a fully reversible condition, especially when diagnosed and treated immediately. The main problem lies in the impairment of cerebral blood flow autoregulation which, in turn, leads to endothelial dysfunction and vasogenic brain oedema. MRI indicates cerebral oedema in the occipital, temporal, and parietal lobes. Brainstem involvement is very rare in the literature. Idiopathic thrombocytopenia-related PRES is also rare in the literature. In this article, a case of PRES with only pons involvement in MRI after hypertensive attack in a pregnant patient with idiopathic thrombocytopenia is presented. PRES may present only brainstem involvement, as seen in this present case. Whether or not mild hypertension and mild thrombocytopenia found in this case are associated with limited disease should be evaluated. Prolonged spreading depression may have a role in the pathophysiology of PRES.

A case of uterine sarcoma with pazopanib-induced reversible posterior leukoencephalopathy syndrome

Backgrounds: Posterior reversible encephalopathy syndrome (PRES), clinically manifested as convulsions and impaired consciousness, is characterised by oedematous changes centring around the white matter of the occipital lobe and is a reversible condition. Pazopanib (PAZ) was approved for malignant soft tissue tumours in Japan in September 2012. We herein report our experience of a patient who was administered PAZ for uterine sarcoma and developed PRES. Case: A 64-year-old woman was administered PAZ for uterine sarcoma. On the fourth day of treatment, she was taken to the emergency department with a chief complaint of impaired consciousness (GCS: E4V2M5). Right conjugate deviation without new structural disorder was found in CT. A brain MRI performed on disease day 2 revealed a high-intensity region in the white matter of the left occipital lobe in FLAIR images. Vasogenic brain oedema was indicated and considering her clinical symptoms, PRES was suspected. On disease day 8, PRES was diagnosed as the disappearance of abnormal signals as confirmed by a second MRI. The clinical symptoms and imaging findings were improved, and the patient was discharged from the hospital on disease day 9. Discussion: Only a few cases of PAZ-induced PRES have been reported, of which only one has been reported from Japan. While these cases report the development of PRES within 9 days to 2 months after initiation of PAZ, in our patient, it was developed within three days of PAZ treatment. In general, most cases of PRES are considered reversible and have a good prognosis. However, there are some reports of irreversible PES because of delayed treatment and other factors. Based on the above reasons, we believe that we need to take PRES into account and promptly start treatment if characteristic symptoms are observed after the start of PAZ treatment.

Posterior reversible encephalopathy syndrome at term pregnancy with eclampsia

The incidence of eclampsia in developed countries is 1 in 3000 and the incidence of posterior reversible encephalopathy syndrome (PRES) is 1 in 400 eclampsia patients. Not many cases of PRES have been reported from Tamil Nadu. This can be an eye opener for ophthalmologists if a patient comes with a sudden loss of vision. PRES is also known as reversible posterior leukoencephalopathy syndrome. It is a cliniconeuroradiological syndrome associated with various clinical conditions presenting with headache, seizures, and cortical visual disturbance. Imaging predominantly shows parieto-occipital white matter changes with vasogenic edema being the most accepted pathophysiology. We report a 25-year-old primigravida who presented in term pregnancy with pregnancy-induced hypertension, seizures, and blindness. Magnetic resonance imaging showed subcortical signal abnormalities in the occipital lobes, which is a sign of PRES. She was managed by controlling her blood pressure levels, and emergency cesarean section was done. Clinical improvement with complete resolution of visual disturbances was observed with supportive treatment.

Posterior Reversible Encephalopathy Syndrome Associated with Bevacizumab

Posterior Reversible Encephalopathy Syndrome (PRES) is characterized by neurologic symptoms with hyperintense lesions on magnetic resonance imaging and it presents signs including a sudden onset headache, hypertension, and fever. The pathophysiology underlying PRES have been postulated to be severe hypertension leading to failed cerebral vascular auto-regulation and endothelial injury/vasogenic edema, vasoconstriction leading to brain ischemic and subsequent vasogenic edema. PRES may be associated with recent chemotherapy agents, in particular, bevacizumab which is a recombinant, humanized, monoclonal IgG1 antibody that binds and inhibits vascular endothelial growth factor. We experienced the case of PRES associated with Reversible Cerebral Vasoconstriction Syndrome (RCVS) 15 months later after a variety of combined chemotherapies containing bevacizumab for metastatic colon cancer. PRES and RCVS are frequently associated like this case and have overlapping or similar pathophysiological mechanism. We speculated that bevacizumab may have induced vasospasm coupled with hypertension and/or endothelial dysfunction due to bevacizumab has been shown able to affect the regulation of the cerebral arterial tone and trigger vasoconstriction with subsequent hypoperfusion, breakdown of the blood-brain barrier, and vasogenic edema, and which led to PRES. It is important to come to mind PRES early in the clinical course when the patient treated with bevacizumab shows the sign and symptoms resembling the cerebrovasucular disease.