Atypical posterior reversible encephalopathy syndrome in a noncompliant hemodialysis patient: Case report and literature review

Abstract

Posterior reversible encephalopathy syndrome (PRES) is a reversible vasogenic brain edema in patients who present with seizure, headache, visual disturbance, and altered mental status, and a characteristic neuroimaging profile. Although PRES predominantly affects the bilateral parieto‐occipital areas, involvement of the frontal and temporal lobes, basal ganglia, brainstem, and cerebellum is not uncommon. Isolated involvement of the brainstem and cerebellum sparing the parieto‐occipital lobe is rarely reported. Here, we describe a 47‐year‐old man with end‐stage renal disease on chronic hemodialysis who presented with prominent hypertension and coma after missing three dialysis sessions. On examination, there was paucity of focal neurologic signs. Diagnosis of PRES was based on brain magnetic resonance imaging findings that were consistent with vasogenic edema of the pons and cerebellum without involvement of other areas. With antihypertensive therapy and intense ultrafiltration during hemodialysis, the patient's blood pressure and consciousness returned to normal, along with complete resolution of the abnormal imaging findings. This case stresses that noncompliance with dialysis should be considered a risk factor for PRES. This case is considered relative to the available literature on three patients with brainstem variant of PRES.

Extensive Brainstem Posterior Reversible Encephalopathy Syndrome in a Hemodialysis Non-Adherent Patient

“…She had missed three dialysis sessions which likely contributed to her presentation. Renal failure is one of the most common causes of PRES and isolated brainstem and cerebellar PRES has been reported in patients non-adherent to hemodialysis [ 1 , 5 , 7 ]. A recently published study also found that majority of patients presenting to the emergency department with PRES were hypertensive similar to the patient described in this case [ 8 ].…”

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

“…Posterior reversible encephalopathy syndrome (PRES) represents a neurological disorder with varied clinical presentation and typical imaging findings. Numerous triggering-factors are prevalent among end-stage renal disease (ESRD) population: arterial hypertension, volume-overload, uremia, transplantation, autoimmune and hematological diseases, (pre)eclampsia, infection, electrolyte disturbances, medication [immunosuppressants, chemotherapy, erythropoietin stimulating agents (ESA)] [1][2][3][4][5]. Clinical manifestations depend on the involved region(s) of the brain [1].…”