What are the initial management steps for a patient presenting with Posterior Reversible Encephalopathy Syndrome (PRES) symptoms?

Initial Management of Posterior Reversible Encephalopathy Syndrome (PRES)

The immediate management of Posterior Reversible Encephalopathy Syndrome (PRES) requires prompt identification and removal of triggering factors, discontinuation of offending medications, and very stringent blood pressure control. 1

Step 1: Identify and Address Triggering Factors

• Discontinue potential causative medications:

  • Immunosuppressive drugs
  • Chemotherapy agents
  • Anti-angiogenic therapy 1

• Address underlying conditions:

  • For eclampsia cases: immediate delivery
  • For autoimmune disorders: appropriate disease-specific management
  • For renal impairment: optimize renal function 1

Step 2: Blood Pressure Management

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

Step 3: Seizure Management

• For active seizures:

  • Administer benzodiazepines for acute seizure control
  • For prolonged seizures (>180 seconds): additional methohexital, diazepam, or lorazepam
  • Consider prophylactic anticonvulsants in high-risk patients 1

• Monitor for at least 24 hours for late seizures (tardive seizures)

• Obtain neurology consultation for recurrent or prolonged seizures 1

Step 4: Cerebral Edema Management

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

• For evidence of cerebral edema or increased intracranial pressure:

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

Step 5: Diagnostic Imaging

• Obtain MRI (gold standard) showing:

  • T2-weighted hyperintensities indicating vasogenic edema
  • Bilateral parieto-occipital lobe involvement
  • White matter more affected than gray matter 1, 2

• Consider brain CT to rule out other causes of decreased mental status 1

Step 6: Management of Complications

• For post-ictal symptoms (headache, nausea, vomiting, confusion):

  • Provide conservative management as these typically resolve within 24 hours 1

• For delirium:

  • Implement nonpharmacologic interventions
  • Reduce or eliminate delirium-inducing medications
  • Consider oral haloperidol, risperidone, olanzapine, or quetiapine for moderate delirium 1

• For refractory intracranial hypertension:

  • Consider decompressive craniectomy in severe cases with malignant cerebral edema 1

Monitoring and Follow-up

• Perform frequent neurological evaluations to assess response to treatment 2
• Schedule follow-up MRI to assess resolution of lesions 1
• Monitor for potential complications including intracranial hemorrhage or stroke 3

Important Considerations

• Early diagnosis and management are crucial for preventing permanent neurological sequelae 1, 2
• 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, and delayed control of causative factors 1