What is the initial management of Posterior Reversible Encephalopathy Syndrome (pRES syndrome)?

Initial Management of Posterior Reversible Encephalopathy Syndrome (PRES)

The initial management of PRES requires immediate identification and removal of triggering factors, discontinuation of offending medications, and very stringent blood pressure control to prevent irreversible neurological damage. 1

Immediate Interventions

1. Identify and Remove Triggering Factors

   • Discontinue offending medications (immunosuppressants, chemotherapy agents) 1
   • Address underlying autoimmune conditions 1
   • For eclampsia cases, immediate delivery is recommended 1

2. Blood Pressure Management

   • Target: Gradual reduction to avoid cerebral hypoperfusion 1
   • For severe hypertension (systolic BP ≥220 mmHg), use IV antihypertensives 1
   • Preferred medications:
     • IV labetalol (first-line)
     • Oral nifedipine (alternative)
     • IV hydralazine (second-line) 1

3. Seizure Management

   • Administer antiepileptic treatment for active seizures 1
   • Consider prophylactic anticonvulsants in high-risk patients 1
   • For acute seizure control, use benzodiazepines followed by antiepileptic drugs (levetiracetam, phenytoin, or valproate) 1
   • Monitor for at least 24 hours for late seizures 1

Cerebral Edema Management

1. Position the Patient

   • Elevate head of bed to 30 degrees to decrease hydrostatic pressure and cerebral edema 1

2. Hyperosmolar Therapy (for patients with cerebral edema or increased intracranial pressure)

   • Options:
     • Mannitol: 0.5-1 g/kg IV initially, then 0.25-1 g/kg every 6 hours for maintenance
     • Hypertonic 3% saline: 5 ml/kg IV over 15 minutes initially, then 1 ml/kg/hour IV to target serum sodium 150-155 meq/l 1

3. For Severe Cases

   • Consider intubation for airway protection in severe encephalopathy (Grade III/IV) 1
   • For refractory intracranial hypertension, consider decompressive craniectomy 1

Monitoring and Supportive Care

1. Neurological Monitoring

   • Regular neurological assessments at least twice daily 2
   • Obtain neurology consultation if:
     • Patient develops grade 1 CRES (altered mental status) 2
     • Recurrent prolonged seizures occur 1
     • Specialized screening for papilledema is needed 2

2. Imaging

   • MRI is the gold standard diagnostic tool 1
   • Follow-up MRI to assess resolution of lesions 1

3. Management of Complications

   • For delirium: Nonpharmacologic interventions first, then consider oral haloperidol, risperidone, olanzapine, or quetiapine for moderate delirium 1
   • For post-ictal symptoms (headache, nausea, vomiting, confusion): Manage conservatively 1

Special Considerations

1. Volume Control

   • For hemodialysis patients, strict volume control may be a key element for treatment 3

2. Reintroduction of Prior Therapy

   • The decision to reintroduce prior anticancer therapy must be individualized and carefully considered in cases of chemotherapy-induced PRES 1

3. Intensive Care Monitoring

   • Early recognition is crucial for prompt control of blood pressure or removal of precipitating factors 4
   • Delay in diagnosis and treatment may result in death or irreversible neurological sequelae 4

Prognosis

• PRES is typically reversible with appropriate management within 2 weeks 1
• Poor prognostic factors include:
  • Altered sensorium
  • Extensive cerebral edema
  • Presence of hemorrhage on imaging
  • Delayed control of causative factors 1

The key to successful management of PRES is early recognition and prompt intervention to address the underlying cause, control blood pressure, and manage seizures and cerebral edema.