Reversible posterior (leuko)encephalopathy syndrome (PRES)

Posted by e-Medical PPT Monday, September 5, 2011
Medical conditions associated with Reversible posterior (leuko)encephalopathy syndrome (PRES)
HYPERTENSIVE ENCEPHALOPATHY
Eclampsia / preeclampsia
Immunosuppressants (cyclosporin A, tacrolimus, vincristine, cisplatin)
Acute or chronic renal disease
Vasculitis (SLE, PAN)
TTP/HUS
Blood transfusions
Contrast media exposure
Cocaine/amphetamine use

Pathogenesis
Disordered cerebral autoregulation: high pressures overwhelm autoregulatory system > brain hyperperfusion > breakdown of blood brain barrier > vasogenic edema
Cerebral ischemia caused by reactive vasoconstriction > local hypoperfusion
Endothelial dysfunction: implicated especially in cases associated with preeclampsia and cytotoxic therapy
Clinical Manifestations
Headaches
Altered consciousness
Visual disturbances
Seizures (generalized or focal)
Elevated blood pressure

Diagnosis
No specific diagnositic criteria for PRES
Brain MRI with diffusion weighed images, along with clinical picture, suggests the diagnosis
MRI shows edema involving the white matter (and sometimes gray matter) in the posterior portion of the cerebral hemispheres, especially bilaterally in the parieto-occipital regions

Treatment
Often improve dramatically with blood pressure control (nitroprusside, labetolol, hydralazine).  In hypertensive emergency, lower MAP by 20% or diastolic to 100 within first hour
Anticonvulsants
Removal or reduction in dosage of offending drug

Prognosis
In many cases, fully reversible within a period of days to weeks after removal of inciting factor and control of blood pressure
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