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My PRESentation Dr Luke Williamson. Mrs K61 years old Confusion Twitching Headache Nausea Conscious collapse.

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Presentation on theme: "My PRESentation Dr Luke Williamson. Mrs K61 years old Confusion Twitching Headache Nausea Conscious collapse."— Presentation transcript:

1 My PRESentation Dr Luke Williamson

2

3 Mrs K61 years old Confusion Twitching Headache Nausea Conscious collapse

4 What else would you like to know?

5 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

6 What next?

7 Obs BP: 206/80 HR: 53 SpO2: 97% RA RR: 16 T: 35.9oC

8 GCS E:4 V:4 M:6

9 Examination CVS: NAD Resp: NAD Abdo: NAD Neuro…

10 Eyes PEARL Deviated left gaze Unable to fixate No reaction to visual confrontation

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

12 Lower limbs Tone – hypertonic, sustained clonus bilaterally Reflexes – hyperreflexic bilaterally Plantars: downgoing

13 And then… Generalised tonic-clonic seizure – Terminated with 1mg clonazepam

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

15 CT Brain

16 Differential Diagnosis Haemorrhage Infarction Infection Something else?

17 Who ya’ gonna call?

18 Neurology ? PRES Lower BP Give clonazepam Admit patient Needs MRI

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

20 MRI

21 Outcome Posterior Reversible Encephalophathy Syndrome Symptoms resolved with control of BP Discharged once well

22 PRES Clinicoradiological entity – Combination of clinical and MRI findings – Data come from retrospective case series – Global incidence unknown – Mean age – Females > males

23 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%)

24 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

25 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

26 Pathophysiology

27 Cerebral Vasogenic Oedema Leaky blood brain barrier Two conflicting theories Hyperperfusion – hypertension as feature Hypoperfusion – SPECT 99mTc-HMPAO imaging

28 Reverse The Encephalopathy Toxins – Cytotoxic agents – Anti-angiogenic agents – Immunomodulatory cytokines – Immunosuppressive agents – Miscellaneous

29 Other causes Hypertension Sepsis Preeclampsia/Eclampsia Autoimmune disease

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

31 Management Involve ICU Antiepileptic treatment as required Blood pressure control as required – Decrease MAP by 20-25% in 1 st 2 hours – Aim for BP 160/100mmHG within 6 hours

32 Correct the underlying cause

33 Summary Potentially reversible condition Combination of clinical and radiological findings Involve ICU Find and treat the underlying cause


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