Treatment of Posterior Reversible Encephalopathy Syndrome (PRES)
The cornerstone of PRES management is immediate identification and removal of the triggering factor, coupled with aggressive blood pressure control to prevent further brain injury. 1
Step 1: Identify and Address Underlying Causes
- Immediately discontinue any potential offending agents such as anticancer therapy, immunosuppressants (particularly cyclosporine), or other medications that may have triggered PRES 1
- Common triggers include pre-existing hypertension, renal impairment, autoimmune diseases, high-dose antineoplastic therapy, stem-cell transplantation, solid organ transplantation, and immunosuppression 1
- Pregnancy-related conditions like pre-eclampsia/eclampsia are significant triggers that require prompt management 2
Step 2: Blood Pressure Management
- Implement stringent blood pressure control as the primary therapeutic intervention, with gradual reduction to avoid cerebral hypoperfusion 1, 3
- When BP is markedly elevated and cerebral autoregulation fails, cerebral edema develops, especially in posterior brain areas where sympathetic innervation is less pronounced 3, 4
- Monitor blood pressure frequently during the acute phase to ensure it remains within safe ranges 1
- In hemodialysis patients, strict volume control may be a key element for successful treatment 5
Step 3: Seizure Management
- Administer antiepileptic treatment for patients who develop seizures during PRES 1, 6
- Consider prophylactic anticonvulsants in high-risk patients with significant neurological deficits 1
- Benzodiazepines may be used for acute seizure management, with careful monitoring for adverse effects 1
Step 4: Supportive Care
- Correct electrolyte imbalances if present, particularly in patients with renal dysfunction 1
- Monitor renal function closely, especially in patients with pre-existing renal impairment 1
- Implement aspiration precautions and intravenous hydration for patients with altered consciousness 3
- Avoid medications that cause CNS depression in patients with encephalopathy 3
Imaging and Monitoring
- MRI is the gold standard for diagnosis, showing increased signal intensity on T2-weighted or fluid-attenuated inversion recovery (FLAIR) imaging in posterior brain regions 3, 2
- CT scan can be useful to exclude intracranial hemorrhage when MRI is not feasible 3, 4
- Consider repeat neuroimaging to monitor resolution of brain edema 7
Special Considerations
- For PRES associated with immunotherapy, follow specific guidelines for immune-related adverse events 1
- In cases with persistent symptoms, consider alternative diagnoses or complications and consult with relevant specialists 1
- For patients with PRES during extracorporeal membrane oxygenation (ECMO), neurological consultation is recommended 1
Prognosis and Follow-up
- Complete spontaneous remission occurs in most cases without sequelae when treated promptly 1, 8
- Early detection and management are key factors for rapid recovery and good outcomes 1
- PRES is not always reversible and may be associated with considerable morbidity and even mortality if not treated promptly 8, 7
Common Pitfalls to Avoid
- Failure to identify and discontinue the triggering agent can lead to prolonged illness and increased risk of complications 1
- Missing concomitant conditions that may complicate management, such as sepsis or metabolic disturbances 1
- Delaying diagnosis and treatment may result in death or irreversible neurological sequelae 6