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

Abstract

<jats:p>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.</jats:p>

Rapid intracranial pressure drop as a cause for posterior reversible encephalopathy syndrome: Two case reports

“…Twelve cases were associated with a spinal tap or epidural anesthesia. [6121315162225272931323334] Although not all of the above-mentioned reports directly described a relationship between ICP and PRES, these cases indicate a strong association between PRES and a rapid reduction in ICP. In fact, cases with a high risk of severe CSF leak, such as in epidural catheter migration,[27] continuous lumbar drainage after spinal surgery,[13] and lumbar drainage for incisional effusion after spinal surgery,[32] were reported to antedate PRES, which is similar to situation described here in Case 1.…”

“…[6121315162225272931323334] Although not all of the above-mentioned reports directly described a relationship between ICP and PRES, these cases indicate a strong association between PRES and a rapid reduction in ICP. In fact, cases with a high risk of severe CSF leak, such as in epidural catheter migration,[27] continuous lumbar drainage after spinal surgery,[13] and lumbar drainage for incisional effusion after spinal surgery,[32] were reported to antedate PRES, which is similar to situation described here in Case 1. In addition, the emergence of PRES after surgeries, such as VP shunt,[12] lumbo-peritoneal shunt,[8] and posterior fossa tumors with obstructed hydrocephalus,[211232633] have also been reported.…”

Posterior reversible encephalopathy syndrome with lumbar drainage and surgery: coincidence or correlation? A case report

“…However, an intraoperative CSF leak and the continued lumbar CSF drainage post-operatively decreased the volume of CSF, thereby decreasing CSF pressure. This phenomenon may lead to increased perfusion pressure and passive edema [18]. Increased perfusion pressure could potentially lead to over-distension of cerebral veins and arterioles causing hydrostatic extravasation of fluid [17].…”

Rituximab‐associated posterior reversible encephalopathy syndrome

“…Posterior reversible encephalopathy syndrome is associated with diverse illnesses that cause elevated blood pressure; including eclampsia and pre‐eclampsia. Other causes include malignancy, autoimmune diseases and other non‐inflammatory conditions . In a study of 113 patients with PRES, acute hypertension was present in 97 patients (86%).…”