Treatment for Posterior Reversible Encephalopathy Syndrome (PRES)
The best treatment for PRES is immediate and stringent control of blood pressure, discontinuation of the triggering agent (if identified), and symptomatic management of seizures.1
Pathophysiology and Clinical Presentation
PRES is characterized by:
- Disruption of the blood-brain barrier due to endothelial injury from abrupt blood pressure changes
- Vasogenic edema predominantly affecting parietal-occipital lobes
- Typical symptoms include:
- Altered consciousness
- Visual disturbances (including blindness)
- Headaches
- Seizures
Treatment Algorithm
Step 1: Immediate Blood Pressure Management
- Very stringent control of blood pressure is crucial 1
- Target: Gradual reduction of blood pressure to avoid cerebral hypoperfusion
- Intravenous antihypertensive agents are preferred for rapid titration
Step 2: Identify and Remove Triggering Factors
- Discontinue potential causative agents 1
- Immunosuppressants (especially cyclosporin)
- Chemotherapeutic agents
- Ifosfamide
- Anti-angiogenic therapy
Step 3: Seizure Management
- Administer antiepileptic treatment if seizures occur 1
- Benzodiazepines may be used for symptomatic treatment 1
Step 4: Supportive Care
- Correct electrolyte imbalances if present 1
- Monitor neurological status closely
- Consider neurological consultation for patients with acute neurological changes 1
Diagnostic Evaluation
- MRI with T2-weighted or FLAIR imaging showing hyperintensities in posterior regions 1
- CT scan to exclude intracranial hemorrhage 1
- Laboratory analysis to identify potential causes and assess organ function
Special Considerations
Risk Factors to Identify
- Pre-existing hypertension
- Renal impairment
- Autoimmune diseases
- High-dose antineoplastic therapy
- Allogenic stem-cell transplantation
- Solid organ transplantation
- Immunosuppression (particularly cyclosporin) 1
Prognosis
- PRES is usually reversible with appropriate supportive management within 2 weeks 1
- Full remission without sequelae occurs in most cases when treated promptly 1
Common Pitfalls and Caveats
- Delayed recognition: PRES may be misdiagnosed as stroke, encephalitis, or other neurological disorders. Prompt recognition is essential for reversibility.
- Inadequate blood pressure control: Failure to control hypertension aggressively can lead to permanent neurological damage.
- Reintroduction of triggering agents: Decisions about reintroducing potential causative agents should be made on an individual basis and with caution 1.
- Atypical presentations: While posterior regions are typically affected, PRES can present with atypical imaging features involving other brain regions 2, 3.
- Recurrence risk: PRES can recur, especially in patients with persistent risk factors like end-stage renal disease 4.
Early recognition and aggressive management of PRES are essential to prevent permanent neurological sequelae and ensure complete recovery.