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Posterior Reversible Encephalopathy Syndrome (PRES) in the Emergency Department

PRES is a clinical and radiological syndrome characterized by seizure, headache, altered mental status and visual impairment with radiographic findings of vasogenic edema within the posterior occipital and parietal lobes of the brain. PRES is commonly associated with acute hypertension; however, the exact pathophysiology of PRES remains unknown and controversial. The three leading hypotheses include cerebral vasoconstriction causing cerebral infarcts, failure of cerebral autoregulation resulting in cerebral vessel damage and lastly, systemic inflammation resulting in endothelial damage within the blood-brain barrier causing disruption and fluid transduction. Clinically, the symptoms of…

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 Posterior Reversible Encephalopathy Syndrome (PRES)

Cerebral arterioles typically vasoconstrict with systemic high blood pressure to avoid hyperemia: however, this mechanism can fail with extreme elevations in blood pressure. This ultimately promotes fluid extravasation and tissue edema.

 PRES

Posterior reversible encephalopathy syndrome (PRES) is a syndrome of ‘cephalgia, convulsions, confusion, and vision loss’ (CCCV) typically in the context of severe hypertension.

 What is PRES?

Although described in various case reports, PRES was not defined as a syndrome until a 1996 New England Journal of Medicine case series defined it as “a reversible syndrome of headache, altered mental functioning, seizures, and loss of vision associated with findings indicating predominantly posterior leukoencephalopathy on imaging studies”. This is not really all that helpful, especially because the syndrome is not always reversible, and because it is often not confined to either the white matter or the posterior regions of the brain. It is essentially a vasogenic edema that causes neurological problems.

Articles of Interest

Posterior Reversible Encephalopathy Syndrome (PRES)

PRES is a clinicoradiologic diagnosis that was not discovered until the widespread application of brain imaging modalities such as CT and MRI. No single diagnostic test proves PRES (although MRI may be strongly suggestive). PRES refers to reversible, vasogenic edema which occurs predominantly in the posterior brain. PRES is less commonly known as “reversible posterior leukoencephalopathy syndrome” (RPLS). However, both terms may be misleading, because: Brain injury is not always reversible. Involvement is not always localized to the posterior regions of the brain, nor to the white matter... The exact incidence of PRES is unclear... High-quality evidence on the pathogenesis of PRES is lacking.

A broad spectrum of posterior reversible encephalopathy syndrome - a case series with clinical and paraclinical characterisation, and histopathological findings

Our case series demonstrates that PRES was not reversible in 42 % of the studied patients. Delay in diagnosis seems to contribute to limited reversibility and poor outcome.

Posterior reversible encephalopathy syndrome (PRES) on the second postpartum day: learning experience from a case report and literature review

Posterior reversible encephalopathy syndrome (PRES) is an uncommon neurological disorder which is characterised by variable symptoms. The transient clinical condition may be underestimated and misdiagnosed as other conditions, especially, among pregnant women with severe preeclampsia, eclampsia, and HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome in the puerperium.

Posterior reversible encephalopathy syndrome (PRES): presentation, diagnosis and treatment

Posterior reversible encephalopathy syndrome (PRES) is a neurological disorder which is characterised by variable symptoms, which include visual disturbances, headache, vomiting, seizures and altered consciousness. The exact pathophysiology of PRES has not been completely explained, but hypertension and endothelial injury seem to be almost always present.

Posterior reversible encephalopathy syndrome(PRES)

Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiological syndrome characterized by a headache, seizures, altered mental status and visual loss and characterized by white matter vasogenic edema affecting the posterior occipital and parietal lobes of the brain predominantly. This clinical syndrome is increasingly recognized due to improvement and availability of brain imaging specifically magnetic resonance imaging

Posterior Reversible Encephalopathy Syndrome: Clinical Features and Outcome

Posterior reversible encephalopathy syndrome (PRES) is an acute neurotoxic syndrome that is characterized by a spectrum neurological and radiological feature from various risk factors. Common neurological symptoms includes headache, impairment in level of consciousness, seizures, visual disturbances, and focal neurological deficits. Common triggering factors include blood pressure fluctuations, renal failure, eclampsia, exposure to immunosuppressive or cytotoxic agents and autoimmune disorders.

Posterior Reversible Leukoencephalopathy Syndrome (PRES)

PRES is a diagnosis of exclusion... R/o stroke, ICH, malignancy, eclampsia, meningoencephalitis, metabolic encephalopathy.

Resources

Radiopaedia

Posterior reversible encephalopathy syndrome (PRES), also known as reversible posterior leukoencephalopathy syndrome (RPLS), is a neurotoxic state that occurs secondary to the inability of the posterior circulation to autoregulate in response to acute changes in blood pressure. Hyperperfusion with resultant disruption of the blood-brain barrier results in vasogenic edema, usually without infarction, most commonly in the parieto-occipital regions.

StatPearls

Posterior reversible encephalopathy syndrome (PRES) is a neurologic disorder that can present with multiple different symptoms such as visual disturbances, seizures, headaches, and altered mentation. It is classically diagnosed based on its imaging characteristics on MRI imaging of the brain that is most commonly seen in the parieto-occipital lobes. To avoid potential pitfalls of this treatable condition, prompt recognition and diagnosis are paramount in improving patient outcomes.