How do I treat Posterior Reversible Encephalopathy Syndrome (PRES) with significant vasogenic edema?

From the Guidelines

Treatment of Posterior Reversible Encephalopathy Syndrome (PRES) with significant vasogenic edema should primarily involve removing the underlying cause, controlling blood pressure, and providing supportive care, with hyperosmolar therapy using mannitol or hypertonic saline considered for severe cases with increased intracranial pressure. The management approach is crucial in preventing further brain injury and improving outcomes. Controlling blood pressure is essential, and this can be achieved with intravenous antihypertensive medications such as nicardipine, labetalol, or clevidipine, aiming for a gradual reduction in blood pressure to avoid cerebral hypoperfusion 1.

For patients with significant vasogenic edema, hyperosmolar therapy is a critical consideration. According to the 2022 guideline for the management of patients with spontaneous intracerebral hemorrhage, hyperosmolar therapy is the principal medical strategy in the treatment of cerebral edema, with mannitol or hypertonic saline being effective options 1. The choice between mannitol and hypertonic saline may depend on individual patient factors, including the severity of edema and the presence of other comorbidities.

Key considerations in the management of PRES with significant vasogenic edema include:

• Removing the underlying cause of PRES
• Controlling blood pressure with intravenous antihypertensive medications
• Providing supportive care, including seizure management with antiepileptic drugs if necessary
• Considering hyperosmolar therapy with mannitol or hypertonic saline for severe cases with increased intracranial pressure
• Monitoring patients in an ICU setting with frequent neurological assessments to promptly address any changes in condition.

The use of hyperosmolar therapy, such as mannitol, has been shown to be effective in reducing intracranial pressure in patients with cerebral edema, with the optimal dose dependent on factors such as hemorrhage location, hematoma volume, and pretreated ICP measurement 1. However, the duration of transient effects from hyperosmolar therapy and its impact on preventing poor outcomes require further study.

From the Research

Treatment of PRES with Significant Vasogenic Edema

• The treatment of Posterior Reversible Encephalopathy Syndrome (PRES) with significant vasogenic edema is a complex process, and the available evidence does not provide a clear consensus on the best approach 2.
• However, it is known that corticosteroid therapy is sometimes used to treat PRES, although its effectiveness in reducing the severity of vasogenic edema is not well established 2.
• In terms of managing acute hypertension, which is often associated with PRES, clevidipine and nicardipine are two intravenous antihypertensives that have been compared in several studies 3, 4, 5.
• These studies suggest that both clevidipine and nicardipine are effective in reducing blood pressure, but they may have different profiles in terms of onset of action, duration of effect, and potential side effects 3, 4, 5.
• For example, one study found that clevidipine had a faster onset of action and a shorter duration of effect compared to nicardipine, but it also had a higher cost 5.
• Another study found that nicardipine was associated with less rebound hypertension and bradycardia compared to clevidipine, but it had a higher total volume of infusion 4.

Management of Hypertension in PRES

• The management of hypertension in PRES is critical, as uncontrolled blood pressure can exacerbate the condition and lead to further brain injury 2.
• The use of intravenous antihypertensives such as clevidipine and nicardipine may be necessary to rapidly reduce blood pressure and prevent further complications 3, 4, 5.
• However, the choice of antihypertensive agent and the target blood pressure range should be individualized based on the patient's specific clinical circumstances and comorbidities 2.

Monitoring and Adjunctive Therapy

• In addition to managing hypertension, patients with PRES may require monitoring and adjunctive therapy to manage other symptoms and prevent further complications 2.
• For example, patients may require antiseizure medications to prevent seizures, and they may also require close monitoring of their neurological status and vital signs 6.
• The use of other therapies such as corticosteroids and immunosuppressants may also be necessary in some cases, although their effectiveness in treating PRES is not well established 2.