Posterior Reversible Encephalopathy Syndrome after Intravenous Caffeine for Post–Lumbar Puncture Headaches: Fig 1.

Johnson

2016

SPI

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological syndrome characterized by headaches, altered mental status, seizures, and visual disturbances. Classic MRI findings include white matter changes of the parieto-occipital regions. This syndrome has been encountered in myriad medical illnesses, including hypertension, preeclampsia/eclampsia, and immunosuppressive conditions. While the pathogenesis of the disorder is unclear, vasoconstriction and hypoperfusion leading to brain ischemia and vasogenic edema have been implicated as potential mechanisms. The authors present, to the best of their knowledge, the first case of PRES following a thoracic spinal surgery–induced dural leak noted on resection of the fifth rib during a thoracotomy for a T4–5 discectomy. Brain MRI revealed large areas of increased FLAIR and T2 hyperintensity in the superior posterior frontal lobes, superior and medial parietal lobes, and bilateral occipital lobes. Following repair of the CSF leak, the patient's symptoms resolved. Spinal surgeons should be alert to the potentially life-threatening condition of PRES, especially in a hypertensive patient who experiences surgery-induced dural leakage. The development of a severe positional headache with neurological signs is a red flag that suggests the presence of PRES. Prompt attention to the diagnosis and treatment of this condition by repairing the dural leak via surgery or expeditious blood patch increases the likelihood of a favorable outcome.

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Posterior reversible encephalopathy syndrome following a thoracic discectomy–induced dural leak: case report

Johnson

2016

SPI

“…Cerebrospinal fluid analysis , 66, pages 738-742 . ..................................................................................................................................................................................................................... and electroencephalography do not play a role in diagnosis of the condition, with lumbar puncture being implicated in the aetiology of PRES in one case report [9]. Despite its name, the condition is not always limited to posterior white matter regions and it is not always reversible [10].…”

Section: Discussionmentioning

confidence: 99%

Influenza A‐induced rhabdomyolysis and acute kidney injury complicated by posterior reversible encephalopathy syndrome

Fearnley

Lines²,

Lewington

et al. 2011

Anaesthesia

SummaryWe report a case of Influenza A‐induced rhabdomyolysis causing acute kidney injury in a young adult female who required invasive ventilation and renal replacement therapy. This case was further complicated by posterior reversible encephalopathy syndrome. Although this represents an extremely rare neurological complication of Influenza A infection, an appreciation of the condition and its management is important, given the high numbers of critically ill patients recently affected by H1N1 Influenza A in intensive care units in the UK.

“…Although our initial management involved caffeine, our patient only consumed minimal amounts by mouth. 10 Thus, we believe it is possible that PRES was due to autoregulatory dysfunction from a combination of hyperperfusion, venous pooling, and overdistension of the vasculature in an attempt to compensate for lost CSF.…”

Section: Oy-stersmentioning

confidence: 99%

Pearls & Oy-sters: Spontaneous intracranial hypotension and posterior reversible encephalopathy syndrome

2016

Pearls & Oy-sters: Spontaneous intracranial hypotension and posterior reversible encephalopathy syndrome PEARLS• Although rare, cases of posterior reversible encephalopathy syndrome (PRES) secondary to CSF leak and intracranial hypotension have been documented in the literature.• The pathogenesis of PRES in these settings has been associated with both arterial and venous cerebrovascular dysfunction. OY-STERS• PRES should be suspected in patients with CSF leak who continue to experience headache, visual changes, and altered mentation despite conservative management.• The mainstay of treatment involves resolution of the CSF leak, typically with an autologous epidural blood patch.CASE REPORT A 65-year-old woman with no significant medical history was brought to the emergency room after experiencing 2 weeks of band-like occipital headaches and 2 days of progressive mental status changes. Her neurologic examination was significant for decreased alertness, disorientation to time, confabulation, loss of recent and remote memory, diffuse hyperreflexia, and a left Hoffmann sign. MRI of the brain with contrast showed bilateral subdural hygromas, diffuse enhancement of the dura mater, with mild sagging of the brainstem suggestive of intracranial hypotension (figure 1, A and B). MRI of the spine showed a large collection of CSF in the lumbar epidural space ( figure 2A); however, the tear site was not identified. EEG also revealed generalized slowing with no evidence of seizure activity. Her mental status continued to deteriorate despite conservative measures such as aggressive hydration, caffeine intake, and bedrest in the Trendelenburg position. A head CT was ordered for worsening mental status and revealed symmetric hypoattenuation of the bilateral parasagittal occipital cortices consistent with PRES ( figure 2B), a finding that was not present on the initial MRI. She then received an emergent lumbar epidural blood patch, resulting in dramatic improvement in mental status several hours later. She was discharged without any focal neurologic deficits. An MRI performed 10 days later revealed no evidence of PRES in the occipital region. An MRI of the lumbar spine performed 5 weeks later showed resolution of the fluid collection (figure 3).DISCUSSION Spontaneous intracranial hypotension (SIH) is a known neurologic condition characterized by occipital headaches, neck stiffness, and altered mentation that results from leakage of CSF through a structural break in the meninges. Distinct abnormalities on MRI support the diagnosis, including diffuse meningeal enhancement, subdural fluid collections, engorgement of the dural sinuses, and downward displacement of the brain that can result in compression of vital structures (figure 1, A and B). Stupor and coma, for example, have been linked to compression of the diencephalon. 1 While our patient's altered mental status was initially attributed to brain sagging, her clinical deterioration was complicated by a transient occipital hypodensity concerning for PRES (figure 2B). Although rare...