Posterior reversible encephalopathy syndrome: A review with emphasis on neuroimaging characteristics

Tetsuka, Syuichi; Ogawa, Takumi

doi:10.1016/j.jns.2019.07.018

Cited by 98 publications

(133 citation statements)

References 44 publications

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“…All reviewed patients presented cortical and/or subcortical T2/FLAIR hyperintensities or hypodensities on CT when MRI was not performed, which was consistent with the main findings of PRES (3,4). These hyperintensities correspond to the brain edema caused by vascular dysregulation, leading to acute vasodilatation and classically vasogenic edema, with proven pathological/imaging correlation (56).…”

Section: Radiological Featuressupporting

confidence: 73%

“…Although there is currently no unified diagnostic algorithm, neuroimaging usually yields bilateral corticalsubcortical vasogenic edema according to three anatomic patterns: dominant parieto-occipital involvement, variant atypical PRES, and combination of different patterns. Variant atypical PRES gathers superior frontal sulcus, holohemispheric watershed, cerebellum, basal ganglia, brainstem, and spinal cord involvements (3,4). The atypical or combined patterns are more common than the typical PRES with isolated parieto-occipital involvement.…”

Section: Introductionmentioning

confidence: 99%

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Posterior Reversible Encephalopathy Syndrome in Clinical Toxicology: A Systematic Review of Published Case Reports

et al. 2020

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Background: Posterior reversible encephalopathy syndrome (PRES) is a rare clinical and radiological entity characterized by a typical brain edema. Although several case reports have described PRES in a context of poisoning, to our knowledge, a comprehensive assessment has not been performed. The aim of this systematic review was to raise awareness on poisoning-specific PRES features and to encourage consistent and detailed reporting of substance abuse-and drug overdose-associated PRES. Methods: Medline/PubMed, Web of Science, and PsycINFO were screened through May 31, 2019, to systematically identify case reports and case series describing PRES associated with poisoning (i.e., alcohol, drugs, illicit drugs, natural toxins, chemical substances) in accidental context, intentional overdose, and substance abuse. The methodological quality of eligible case reports/series was assessed. Patients and exposure characteristics were recorded; relevant toxicological, radiological, and clinical data were extracted. Results: Forty-one case reports and one case series reporting 42 unique cases were included. The median time to PRES onset from the start of exposure was 3 days (IQR 2-10). Acute high blood pressure, visual disturbance, and seizure were reported in 70, 55, and 50% of patients, respectively. The initial clinical presentation was alertness disorders in 64% of patients. Nine patients (21%) required mechanical ventilation. One-third of patients had at least one risk factor for PRES such as chronic hypertension (17%) or acute/chronic kidney failure (24%). The main imaging pattern (67%) was the combination of classical parieto-occipital edema with another anatomical region (e.g., frontal, basal ganglia, posterior fossa involvement). Vasogenic edema was found in 86% of patients. Intracranial hemorrhage occurred in 14% of patients. Both brain infarction and reversible cerebral vasoconstriction syndrome were diagnosed in 5% of patients. Three patients (12%, 3/25) had non-reversible lesions on follow-up magnetic resonance Largeau et al. PRES in Clinical Toxicology imaging. The median time required to hospital discharge was 14 days (IQR 7-18). Mortality and neurological recurrence rate were null. Conclusions: Comorbidities such as chronic hypertension and kidney failure were less frequent than in patients with other PRES etiologies. Imaging analysis did not highlight a specific pattern for poisoning-induced PRES. Although less described, PRES in the context of poisoning, which shares most of the clinical and radiological characteristics of other etiologies, is not to be ignored.

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Section: Radiological Featuressupporting

confidence: 73%

Section: Introductionmentioning

confidence: 99%

Posterior Reversible Encephalopathy Syndrome in Clinical Toxicology: A Systematic Review of Published Case Reports

et al. 2020

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“…In addition to the clinical features, neuroimaging, especially MRI, is essential in the evaluation and diagnosis of PRES with atypical regions (28). The lesion locations are very important in terms of the MRI features.…”

Section: Discussionmentioning

confidence: 99%

Clinical and MRI Features of Posterior Reversible Encephalopathy Syndrome With Atypical Regions: A Descriptive Study With a Large Sample Size

Yang²,

Guo

et al. 2020

Front. Neurol.

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Background: Accurate diagnosis and timely treatment for posterior reversible encephalopathy syndrome (PRES) with atypical regions are very important in clinical practice. However, until now, little has been known about the clinical and MRI manifestations of this disease. Therefore, the aim of this study is to investigate the clinical and MRI features of PRES to promote clinical management and deepen our understanding of this disease. Materials and Methods: Data from six PRES patients with atypical regions were collected from our hospital. Data from another 550 cases were obtained by searching the PubMed, EMBASE and Web of Science databases with the keywords "posterior reversible encephalopathy syndrome" "PRES" "reversible posterior leukoencephalopathy" "RPLS" "hypertensive encephalopathy" "hyperperfusion encephalopathy" or "reversible posterior cerebral edema encephalopathy." The clinical and MRI features of these 556 cases were analyzed together. Results: A total of 305 patients were female, and 248 were male, with a median age of 34 years. The information on sex and age of three patients was not available. The most common symptom was headache (282/556, 50.7%), followed by altered mental status (243/556, 43.7%), seizures (233/556, 41.9%), visual disturbances (194/556, 34.9%), nausea/vomiting (130/556, 23.4%), and focal neurological deficits (101/556, 18.2%). Hypertension (425/556, 76.4%), renal diseases (152/556, 27.3%), immunosuppressant drugs (79/556, 14.2%), and chemotherapy/chemoradiotherapy (59/556, 10.6%) were the major predisposing factors. The atypical regions of the lesions were the cerebellum (331/556, 59.5%), basal ganglia (135/556, 24.3%), periventricular/deep white matter (125/556, 22.5%), pons (124/556, 22.3%), brainstem (115/556, 20.7%), thalamus (114/556, 20.5%), midbrain (48/556, 8.6%), spinal cord (33/556, 5.9%), and medulla (29/556, 5.2%). Additionally, the following typical regions were observed: occipital (278/556, 50.0%), parietal (234/556, 42.1%), frontal (150/556, 27.0%), and temporal (124/556, 22.3%) lobes. The major treatments were antihypertensives (358/515, 69.5%), antiepileptics/sedation (126/515, 24.5%), discontinuation/switching agents (67/515, Li et al. PRES With Atypical Regions 13.0%), and steroids (54/515, 10.5%). The median time of the clinical state improved and abnormal neuroimaging resolved is 2-3 weeks after appropriate treatment. Conclusion: The common symptoms of PRES with atypical regions include headaches, altered mental status, seizures, visual disturbances, nausea or vomiting, and focal neurological deficits. The frequent predisposing factors include hypertension, renal diseases, immunosuppressant drugs and chemotherapy/chemoradiotherapy. MRI features are mainly characterized by vasogenic edema in central zones always accompanied by typical regions. Most cases can be reversed in 2-3 weeks when promptly recognized and properly treated.

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“…The vasogenic theory proposes that sudden, severe hypertension (i.e., exceeding the capacity of cerebral blood flow autoregulation) leads to endothelial injury, breakdown of the blood-brain barrier (BBB), and subsequent vasogenic edema [2,10]. On the other hand, vasospasm and resultant cerebral ischemia may develop neurological symptoms [6,11]. The cytotoxic theory proposes that the endothelial dysfunction of PRES is due to exogenic toxins, such as drugs for chemotherapy or immunosuppression, or endogenic toxins, such as those generated during sepsis or eclampsia [2,6,12,13].…”

Section: Pathophysiological Theoriesmentioning

confidence: 99%

“…On the other hand, vasospasm and resultant cerebral ischemia may develop neurological symptoms [6,11]. The cytotoxic theory proposes that the endothelial dysfunction of PRES is due to exogenic toxins, such as drugs for chemotherapy or immunosuppression, or endogenic toxins, such as those generated during sepsis or eclampsia [2,6,12,13]. The immunogenic theory proposes that endotheliopathy, mediated by T-cell activation and the release of cytokines such as tumor necrosis factor-α (TNF) and interleukin-1 (IL-1), increases endothelial permeability and subsequent vasogenic edema [3,4,10,14].…”

Section: Pathophysiological Theoriesmentioning

confidence: 99%

Clinical Spectrum of Posterior Reversible Encephalopathy Syndrome in Children

Hwang

Lee

et al. 2020

Ann Child Neurol

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Posterior reversible encephalopathy syndrome (PRES) is a complex neurological condition characterized by the acute onset of neurological symptoms, such as seizures and potentially reversible vasogenic edema with preferential involvement of the parieto-occipital region in brain magnetic resonance imaging. Although PRES can present with a wide spectrum of clinical manifestations, the most common are seizures, visual disturbances, headaches, and altered mental states. PRES has been recognized in a wide variety of clinical settings including hypertension, immunosuppressants following organ transplantation, chemotherapy, renal diseases, sepsis, and autoimmune disorders. It has been increasingly reported even in children, but many aspects of this syndrome are incompletely understood and validated diagnostic criteria is still lacking. In this review, we will cover putative pathophysiological mechanisms, etiologic categories, clinico-radiological manifestations, and outcomes from previous studies.

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Posterior reversible encephalopathy syndrome: A review with emphasis on neuroimaging characteristics

Cited by 98 publications

References 44 publications

Posterior Reversible Encephalopathy Syndrome in Clinical Toxicology: A Systematic Review of Published Case Reports

Posterior Reversible Encephalopathy Syndrome in Clinical Toxicology: A Systematic Review of Published Case Reports

Clinical and MRI Features of Posterior Reversible Encephalopathy Syndrome With Atypical Regions: A Descriptive Study With a Large Sample Size

Clinical Spectrum of Posterior Reversible Encephalopathy Syndrome in Children

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