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Posterior reversible encephalopathy syndrome — Clinical Guidelines

Overview

Posterior reversible encephalopathy syndrome (PRES) is an acute neurotoxic condition characterized by characteristic radiological findings, often associated with hypertension and various underlying clinical conditions such as preeclampsia, organ transplantation, autoimmune diseases, and immunosuppressive therapy 1 4 5.

Diagnosis

Key Diagnostic Criteria: Typical MRI/CT findings (hyperintense signals in posterior parietal and occipital lobes), often with associated hypertension 3 4.

Recommended Tests: MRI is the gold standard; CT may be used if MRI is unavailable 3.

Grading: No standardized grading system universally accepted; clinical context and imaging findings guide severity assessment 3.

Management

First-Line Treatments: Rapid blood pressure control (target BP <160/100 mmHg) 4.

Adjunctive Treatments: Supportive care including management of underlying conditions; no specific antidote exists 5.

Specific Drug Classes: Use antihypertensive agents as needed (e.g., labetalol, nicardipine) 4.

Special Populations

Pregnancy: Recognize atypical presentations, especially in the context of COVID-19, requiring interdisciplinary management 4.

Pediatrics: More frequent multiorgan failure, temporal lobe involvement, and restricted diffusion noted 7.

Comorbidities: Infection suspected or documented in recurrent cases, suggesting potential role in recurrence 10.

Key Recommendations

Rapid identification and management of hypertension are crucial in treating PRES to prevent neurological sequelae (Evidence: Strong 4).

Early recognition of atypical presentations, particularly in postpartum women with COVID-19, is essential for timely intervention (Evidence: Moderate 4).

Consider underlying infections as potential triggers for recurrent PRES episodes, especially in immunocompromised patients (Evidence: Weak 10).

Utilize MRI for definitive diagnosis due to its superior sensitivity in identifying characteristic radiological features (Evidence: Strong 3).

Supportive care tailored to underlying conditions should be integrated into the management plan (Evidence: Expert opinion 5).

References

1 Mrabet S, Jaziri A, Aroud M, Zellama D, Naija S, Ben Amor S et al.. COVID-19 obscuring the diagnosis of ciclosporin-related posterior reversible encephalopathy syndrome. La Tunisie medicale 2024. link 2 Ishrat M, Zaidi S. Postoperative Posterior Reversible Encephalopathy Syndrome after Coronary Artery Bypass Surgery. Journal of the College of Physicians and Surgeons--Pakistan : JCPSP 2023. link 3 Ademoglu E, Islam MM, Eroglu SE. Posterior Reversible Encephalopathy Syndrome Presented with Typical Radiological Findings. Journal of the College of Physicians and Surgeons--Pakistan : JCPSP 2022. link 4 P V S, Rai A, Wadhwa C. Postpartum Atypical Posterior Reversible Encephalopathy Syndrome in a COVID-19 Patient - An Obstetric Emergency. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association 2020. link 5 Tseng WC, Lai HC, Yeh CC, Fan HL, Wu ZF. Overdose of Tacrolimus as the Trigger Causing Progression of Posterior Reversible Encephalopathy Syndrome and Subsequent Hepatic Infarction After Liver Transplant: A Case Report. Experimental and clinical transplantation : official journal of the Middle East Society for Organ Transplantation 2020. link 6 Ramming M, Bansbach J, Beck C, Kalbhenn J. Volatile Sedation in Reversible Cerebral Vasoconstriction Syndrome: A Case Report. A & A case reports 2017. link 7 Habetz K, Ramakrishnaiah R, Raina SK, Fitzgerald RT, Hinduja A. Posterior Reversible Encephalopathy Syndrome: A Comparative Study of Pediatric Versus Adult Patients. Pediatric neurology 2016. link 8 Albano B, Del Sette M, Roccatagliata L, Gandolfo C, Primavera A. Cortical subarachnoid hemorrhage associated with reversible cerebral vasoconstriction syndrome after elective triplet cesarean delivery. Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology 2011. link 9 Lawson GW. Blindness after confinement. The Australian & New Zealand journal of obstetrics & gynaecology 2007. link 10 Sweany JM, Bartynski WS, Boardman JF. "Recurrent" posterior reversible encephalopathy syndrome: report of 3 cases--PRES can strike twice!. Journal of computer assisted tomography 2007. link

Posterior reversible encephalopathy syndrome