My PRESentation Dr Luke Williamson

Mrs K61 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 – 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

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 1 st 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