My PRESentation

Dr Luke Williamson

Mrs K 61 years old

• Confusion

• Twitching

• Headache

• Nausea

• Conscious collapse

What else would you like to know?

History

• No further Hx from patient• No collateral Hx• Patient notes– Medical admission 10/7 ago– Confusion, headache, nausea, generally unwell– ? Aseptic meningo-encephalitis– Acute Kidney Injury– Sent home on oral antibiotics

What next?

Obs

• BP: 206/80

• HR: 53

• SpO2: 97% RA

• RR: 16

• T: 35.9oC

GCS

• E:4

• V:4

• M:6

Examination

• CVS: NAD

• Resp: NAD

• Abdo: NAD

• Neuro…

Eyes

• PEARL

• Deviated left gaze

• Unable to fixate

• No reaction to visual confrontation

Upper Limbs

• Bilateral myoclonic jerks• Power: 5/5 all muscle groups• Tone: normal• Reflexes: normal• Sensation: grossly normal• Coordination: unable to finger-nose point

Lower limbs

• Tone – hypertonic, sustained clonus bilaterally

• Reflexes – hyperreflexic bilaterally

• Plantars: downgoing

And then…

• Generalised tonic-clonic seizure– Terminated with 1mg clonazepam

Investigations

• Bloods – pending• ECG: sinus bradycardia• CXR: NAD• CT Brain…

CT Brain

Differential Diagnosis

• Haemorrhage

• Infarction

• Infection

• Something else?

Who ya’ gonna call?

Neurology

• ? PRES

• Lower BP

• Give clonazepam

• Admit patient

• Needs MRI

ICU

• We’ll take the patient!– Arterial line– IV sodium nitroprusside

MRI

Outcome

• Posterior Reversible Encephalophathy Syndrome

• Symptoms resolved with control of BP

• Discharged once well

PRES

• Clinicoradiological entity

– Combination of clinical and MRI findings

– Data come from retrospective case series

– Global incidence unknown

– Mean age 39-47

– Females > males

Clinical Features

• Consciousness impairment (26-94%)

• Seizure activity (71-92%)

• Acute hypertension (67-80%)

• Headaches (26-53%)

• Visual abnormalities (26-53%)

• Nausea/vomiting (26-53%)

• Focal neurological signs (3-17%)

Acute Hypertension

• N.B. Acute hypertension is associated with PRES

• However, it is not associated with the intensity of clinico-radiological manifestations nor severity of PRES

Radiological Features (MRI - FLAIR)

• Bilateral (69-100%)• Confluent (13-23%)• Posterior>anterior (22-93%)• Occipital (93-99%)• Parietal (50-99%)

• CT – hypodensities in a suggestive topographic distribution can suggest PRES

Pathophysiology

Pathophysiology

• Cerebral Vasogenic Oedema• Leaky blood brain barrier

• Two conflicting theories• Hyperperfusion – hypertension as feature• Hypoperfusion – SPECT 99mTc-HMPAO imaging

Reverse The Encephalopathy

• Toxins– Cytotoxic agents– Anti-angiogenic agents– Immunomodulatory cytokines– Immunosuppressive agents– Miscellaneous

Other causes

• Hypertension

• Sepsis

• Preeclampsia/Eclampsia

• Autoimmune disease

Investigations

• Early diagnosis – clinical suspicion• MRI• EEG• Mg2+• Consider LP• Consider toxicological screen• Look for PRES-associated conditions

Management

• Involve ICU

• Antiepileptic treatment as required

• Blood pressure control as required– Decrease MAP by 20-25% in 1st 2 hours– Aim for BP 160/100mmHG within 6 hours

Correct the underlying cause

Summary

• Potentially reversible condition

• Combination of clinical and radiological findings

• Involve ICU

• Find and treat the underlying cause