Posterior reversible encephalopathy syndrome coexists with acute cerebral infarction: challenges of blood pressure management

Abstract

Hypertension is the most common cause of posterior reversible encephalopathy syndrome (PRES) and acute cerebral infarction. Due to the lack of randomized controlled clinical trials (RCTs), early antihypertensive methods are diverse, even contradictory. So far, there is no consensus on the method of blood pressure (BP) management when the 2 diseases coexist. Generally, antihypertensive therapy should be initiated quickly in the acute phase of PRES, as most patients have elevated BP. However, various factors must be considered before the administration of early antihypertensive therapy in acute cerebral infarction.The coexistence of PRES and acute cerebral infarction is uncommon clinically, and more complicated subsequent BP management. This article reports a case of PRES coexisting with acute lacunar cerebral infarction, which was caused by hypertension. We have analyzed and summarized the antihypertensive principles in PRES and different phases of acute cerebral ischemic injury. We assert that when PRES and acute cerebral infarction coexist, the antihypertensive treatment should be individualized, and careful consideration should be given to the various influencing factors.

Simultaneous Presentation of Brainstem and Cerebellar Posterior Reversible Encephalopathy Syndrome With Acute Cerebral Infarction

“…The combination of cerebral infarction and PRES is rare, and Table 1 summarizes the few reported cases [2,[14][15][16]. Only one prior case of cerebral infarction combined with brainstem and cerebellar PRES has been published, and the PRES lesion, in that case, was confined to the infratentorial region, as in our patient [14].…”

“…Although both cerebral infarction and posterior reversible encephalopathy syndrome (PRES) are caused by poorly controlled hypertension, the two conditions are completely different and rarely occur together. If both develop in the same patient, management becomes challenging [2]. Here, we present a successfully treated case of the brainstem and cerebellar PRES coexisting with cerebral infarction.…”

A case study of posterior reversible encephalopathy syndrome: Not always reversible with detrimental consequences

“…Although a variety of conditions may result in the development of PRES, hypertension is the most common in adults (Liu & Zhang, 2020). Those who are at particular risk include those with recent discontinuation of antihypertensive medications, current subarachnoid hemorrhage, the recent initiation of chemotherapy, and a disease that predisposes them to hypertension (Ando et al, 2022).…”

“…Computed tomography of the head may show a white matter abnormality (Anderson et al, 2020). Vasogenic edema will be noted posteriorly and bilaterally, more often in the parietal and occipital lobes (Liu & Zhang, 2020). Posterior reversible encephalopathy syndrome affects the white matter of the brain, rarely involving the spinal cord, and 10-25% will have an intracranial hemorrhage (Triplett et al, 2022).…”

“…Immunosuppressive agents, especially tacrolimus and cyclosporine, have been implicated in causing the syndrome (Gewirtz et al, 2021). Sepsis and renal insufficiency or failure are also commonly associated conditions (Liu & Zhang, 2020) with half of the patients with PRES also having associated renal failure (Ando et al, 2022). Transplant patients, including both organ and bone marrow, have an increased risk (Triplett et al, 2022).…”