Transcript Posterior Reversible Encephalopathy Syndrome (PRES)

Tacrolimus-associated posterior reversible
encephalopathy syndrome (PRES) in a
bone marrow transplant recipient.
G. Ntetskas, E. Spanou, V. Papastergiou, M.
Stampori, E. Asonitis, E. Anastasiou, F. Alourda,F.
Lambrianou, A. Kotis, S. Karatapanis
First Department of Internal Medicine, General Hospital
of Rhodes,
Posterior Reversible Encephalopathy
Syndrome (PRES)
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Clinicoradiological entity
Described by Hinchey et al in 1996
Reversible ischemia of the posterior cerebral
vasculature
Vasogenic edema (parietal-occipital region)
Posterior Reversible Encephalopathy
Syndrome (PRES)
Neurologic features (consciousness impairment,
seizures, headaches, visual abnormalities, nausea/vomit,
focal neurological signs)
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Cerebral imaging abnormalities (often
symmetric and predominate in the posterior white
matter)
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Posterior Reversible Encephalopathy
Syndrome (PRES)
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Unknown incidence (rare)
Most commonly occur in middle-aged adults (39-47
years)
Female predominance
Associated comorbidities: Hypertension, bone marrow
or solid organ transplantation, chronic renal failure,
medications, eclampsia.
Usually reversible once the cause is removed
Need for mechanical ventilation in 35-40%
Permanent neurological impairment or death (up to
15%) may occur in a minority of patients
Posterior Reversible Encephalopathy
Syndrome (PRES)
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Pathogenesis is unknown
Hypertensive PRES: failure of cerebrovascular
autoregulation
Non-hypertensive PRES: autoimmune or
immune response to various stimuli
There are no consensual guidelines to validate
diagnosis of PRES
Case presentation
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Female
55 years old
History of acute myeloid leukemia treated with
bone marrow transplantation 12 months ago
Since the last 3 months the patient was under
Tacrolimus to prevent graft-vs-host disease.
Case presentation
Presentation to the ER
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Altered mental status
Confused
Disoriented
GCS score was 10 (eye response to verbal
command, incomprehensive speech, purposeful
movements to painful stimulus)
Case presentation
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History obtained from the patient’s husband revealed
no recent infection, fever, weight loss or trauma.
She was moving her extremities equally, bilaterally.
Reflexes were brisk throughout with equivocal plantar
response
Rest of the neurological exam was limited as the patient
was not following commands consistently.
Case presentations
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blood pressure was 220/110 mmHg
Blood count, routine biochemical tests and
ABG were normal
No ECG abnormalities
Chest X-Ray was normal
D.D.
 Cerebrovascular
accident
 Seizures
 Complicated
 PRES
migraine
MRI BRAIN
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Bilateral regions of edema (hyperintensities in
FLAIR and T2-weighted sequences) located in
the white matter and predominating in the
posterior part of the parietal and occipital lobes.
Management
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Supportive care
Discontinuation of Tacrolimus
Nicardipine/labetolol to control BP (rapid BP
reduction may aggravate cerebral perfusion and
promote ischemia!!!)
Outcome
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Gradual resolution of PRES symptoms
Follow-up MRI, 1 mo after discharge,
demonstrated normal findings
Conclusions
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PRES should be considered in the differential diagnosis
of patients with a
history of bone marrow transplantation
and/or under tacrolimus-based immunosuppresion.
Toxic agents in association with PRES
Legriel S et al., Annual Update in Intensive Care and Emergency Medicine, 2011
Thank
you!!!