Management of Posterior Reversible Encephalopathy Syndrome (PRES)
The management of posterior reversible encephalopathy syndrome (PRES) requires immediate blood pressure control, discontinuation of triggering agents, and supportive care to prevent permanent neurological damage.
Clinical Presentation and Diagnosis
PRES typically presents with:
- Acute neurological deficits including altered consciousness
- Visual disturbances or blindness
- Headaches
- Seizures
Diagnosis is confirmed by:
- T2-weighted MRI showing hyperintensities in bilateral parietal-occipital lobes
- Predominance in white matter over gray matter
- CT scan to rule out other causes of neurological symptoms (less sensitive than MRI)
Management Algorithm
1. Immediate Interventions
- Very stringent blood pressure control is crucial when PRES is present 1
- Elevate head of bed to 30 degrees to reduce intracranial pressure
- Discontinue suspected triggering agents, especially anticancer therapies, immunosuppressants (e.g., ciclosporin) 1
- Correct electrolyte imbalances if present 1
2. Seizure Management
- Administer antiepileptic treatment for seizures 1
- Consider benzodiazepines for acute seizure control 1
- For refractory seizures, levetiracetam (10 mg/kg up to 500 mg per dose every 12 hours) may be used 1
3. Blood Pressure Management
- Target gradual reduction of blood pressure to avoid cerebral hypoperfusion
- Avoid rapid drops in blood pressure which may worsen cerebral ischemia
- In hypertensive emergencies with PRES, careful titration of antihypertensive medications is required 1
4. Supportive Care
- Monitor neurological status frequently
- Avoid sedation if possible to allow for neurological assessment
- Provide symptomatic treatment for headache and other symptoms
5. Monitoring and Follow-up
- Regular neurological assessments to track improvement
- Repeat MRI after clinical improvement to confirm resolution of edema
- Follow-up typically within 2 weeks, as PRES usually resolves with appropriate supportive management within this timeframe 1
Special Considerations
Risk Factors to Address
Several risk factors should be identified and managed:
- Pre-existing arterial hypertension
- Renal impairment
- Autoimmune diseases
- High-dose antineoplastic therapy
- Allogenic stem-cell transplantation
- Solid organ transplantation
- Immunosuppression (especially ciclosporin) 1
Potential Complications
- While most cases resolve completely, some patients may develop:
- Ischemic infarction (cytotoxic edema)
- Permanent neurological damage if not treated promptly 2
- Cerebral hemorrhage in severe cases
Prognosis
With appropriate management, PRES is typically reversible within 2 weeks 1. The decision to reintroduce prior anticancer therapy or other potentially causative medications should be made on an individual basis after complete resolution of symptoms and radiological findings.
Common Pitfalls to Avoid
- Delayed diagnosis: PRES may be mistaken for stroke, encephalitis, or other neurological disorders
- Inadequate blood pressure control: Failure to control hypertension can lead to progression of vasogenic edema
- Reintroduction of causative agents too early: Wait for complete clinical and radiological resolution
- Overlooking non-hypertensive causes: PRES can occur in normotensive patients with other risk factors
- Discontinuing monitoring too soon: Patients should be monitored until complete resolution of symptoms and imaging abnormalities
By following this management approach, most patients with PRES will experience complete clinical and radiological recovery without long-term neurological sequelae.