From the Research
The management of posterior reversible encephalopathy syndrome (PRES) primarily focuses on identifying and treating the underlying cause while providing supportive care, with the most recent and highest quality study 1 suggesting that prompt removal of the triggering factor and aggressive control of blood pressure are crucial. The most critical step is to promptly remove the triggering factor, which commonly includes discontinuing the offending medication (such as immunosuppressants like tacrolimus or cyclosporine), aggressively controlling blood pressure, or delivering the fetus in cases of eclampsia.
- For hypertension management, intravenous medications like labetalol (initial dose 10-20 mg, followed by 20-80 mg every 10 minutes as needed), nicardipine (5 mg/hour, titrated by 2.5 mg/hour every 5-15 minutes), or clevidipine (1-2 mg/hour, doubled every 90 seconds as needed) are preferred to achieve a controlled reduction in blood pressure, typically aiming for a 25% reduction in the first hours rather than rapid normalization, as suggested by 2.
- Seizures, if present, should be treated with benzodiazepines such as lorazepam (4 mg IV) followed by levetiracetam (loading dose 20 mg/kg) or phenytoin (loading dose 20 mg/kg at 50 mg/min) for seizure control, as seen in 1.
- Supportive care includes airway protection, maintaining adequate oxygenation, and preventing complications like aspiration. PRES is generally reversible when promptly recognized and appropriately managed, with most neurological symptoms resolving within days to weeks as the condition results from vasogenic edema rather than infarction or permanent tissue damage, as noted in 3 and 4. Some cases may require more aggressive management, such as surgical decompression, as seen in 3, but this is typically reserved for severe cases with brainstem compression or hydrocephalus. Overall, the key to successful management of PRES is prompt recognition and treatment of the underlying cause, as well as careful control of blood pressure and seizures, as highlighted by the most recent study 1.