Heterogeneity of Radiological Spectrum in Tacrolimus-Associated Encephalopathy after Lung Transplantation

Abstract

Background. Tacrolimus-associated encephalopathy (TAC-E) is usually described under the term of posterior reversible encephalopathy syndrome (PRES). However, a large amount of data has suggested that TAC-E is not a homogenous entity: indeed, TAC-E which is often presented with atypical and potentially misleading imaging characteristics does not always correspond to PRES. Objective. We aimed to identify the spectrum of brain MR imaging of TAC-E and discuss the underlying pathophysiological features. Methods. From September 2008 to October 2010, the neurological statuses of 45 patients, who underwent lung transplantation with TAC as posttransplantation immunosuppressive therapy, were regularly assessed in a prospective study. MRI was repeatedly performed, until recovery, in patients who developed central neurological symptoms. Results. Symptoms suggestive of encephalopathy occurred in five out of 45 patients (11.1%). According to our MRI study, two patients presented with reversible bilateral and relatively symmetric subcortical white matter edema with proximal vasospasms on MRA; however, three other patients were characterized by coexistence of two different lesions including laminar cortical infarcts with hemorrhagic transformation not typically found in PRES and reversible deep white matter edema, associated with distal vasospasms on MRA. Conclusions. It is considered that the mechanism of TAC-E would be more heterogenous than commonly perceived.

Tacrolimus induced optic neuropathy in post-lung transplant patients: A series of 3 patients

“…Isolated cases of brain stem involvement have also been reported. 13 , 14 In one study, 2/5 patients with tacrolimus toxicity had no reversal of white matter abnormalities upon discontinuation, even in the context of clinical improvement. 15 This appears similar to case 1 in which white matter lesions persisted after medication discontinuation.…”

Posterior Reversible Encephalopathy Syndrome (PRES) in the peripartum period

“…In as many as 28% of the cases these involvement might be unilateral only. 23,24 On CT brain, the affected areas are depicted as diffuse hypo-dense lesions, but MRI is far superior in delineating the lesions 24 -which appears as iso-dense or low signal intensity on T1 weighted images and high signal intensity on T2 weighted images and FLAIR (Fluid Attenuated Inversion Recovery).…”

Pearls & Oy-sters: Tacrolimus neurotoxicity presenting as an isolated brainstem lesion

“…Brain PET scan revealed no abnormalities of FDG-PET uptake. Based on few reports in the literature of tacrolimus-induced neurotoxicity, [1][2][3][4][5] we hypothesized that this was the potential culprit and changed to cyclosporine. Tacrolimus levels were therapeutic throughout his hospitalization (6.3-9.0 ng/mL).…”

“…[1][2][3][4][5] Tacrolimus is an immunosuppressive agent that inhibits calcineurin phosphatase activity and T lymphocyte activation. 7 Neurologic adverse effects range from tremors and headaches to cortical blindness and status epilepticus.…”

“…In a prospective study of 14 patients with tacrolimus neurotoxicity, 5 had white matter abnormalities on brain MRI, one had putaminal hemorrhage, and 8 were normal. 10 We found only 5 prior reports describing tacrolimus neurotoxicity presenting as a pontine predominant lesion with hyperintense signal on T2-weighted MRI, [1][2][3][4][5] and in these cases, the clinical presentations varied widely.…”