Can posterior reversible encephalopathy syndrome (PRES) be caused by trauma?

Can Posterior Reversible Encephalopathy Syndrome (PRES) Be Caused by Trauma?

Yes, trauma can be a potential trigger for Posterior Reversible Encephalopathy Syndrome (PRES), particularly when it leads to significant blood pressure fluctuations, endothelial injury, or disruption of the blood-brain barrier. 1

Pathophysiology of PRES Related to Trauma

• The pathophysiology of PRES involves disruption of the blood-brain barrier due to endothelial injury, which can occur following abrupt blood pressure changes or direct trauma 1
• Trauma, especially to the head or spine, can cause significant blood pressure fluctuations that may exceed cerebral autoregulation limits, potentially triggering PRES 2
• Post-traumatic PRES may develop through mechanisms similar to other causes - vasogenic edema resulting from endothelial dysfunction and blood-brain barrier disruption 3

Documented Cases of Trauma-Associated PRES

• PRES has been reported following surgical procedures, including spinal surgeries where cerebrospinal fluid leaks may contribute to its development 4
• Cases have been documented after neurosurgical interventions, such as resection of posterior fossa tumors, suggesting mechanical disruption of brainstem structures may play a role 5
• PRES has been observed following postpartum hemorrhage and related interventions, indicating that acute blood loss and subsequent blood pressure instability can trigger the syndrome 6

Clinical Presentation of Post-Traumatic PRES

• Patients typically present with headache, altered consciousness, visual disturbances, and seizures, which may be confused with direct traumatic brain injury symptoms 1
• Diagnosis is confirmed by characteristic MRI findings showing hyperintensities in bilateral parieto-occipital lobes, predominantly affecting white matter 1
• The onset of symptoms can be rapid, sometimes occurring within hours of the traumatic event or related intervention 6

Management Considerations for Trauma-Associated PRES

• The cornerstone of management is stringent blood pressure control with gradual reduction to avoid cerebral hypoperfusion 1
• Antiepileptic treatment should be administered for patients who develop seizures, with consideration of prophylactic anticonvulsants in high-risk patients 1
• Correction of any electrolyte imbalances and monitoring of renal function are essential, particularly in patients with trauma-related complications 1

Special Considerations in Traumatic Cases

• In cases of PRES following spinal surgery, unrecognized cerebrospinal fluid leaks may be a contributing factor and should be evaluated 4
• When PRES develops after neurosurgical procedures, careful monitoring of blood pressure and prompt treatment of hypertension are crucial 5
• Differentiating post-traumatic PRES from other trauma-related neurological conditions (such as diffuse axonal injury or traumatic subarachnoid hemorrhage) requires careful clinical and radiological assessment 2

Prognosis

• Most cases of PRES, including those associated with trauma, show complete spontaneous remission without sequelae if recognized and treated promptly 1
• Early detection and management are key factors for rapid recovery and good outcomes 1
• Delayed diagnosis or inadequate treatment may lead to permanent neurological damage or other complications 3

Common Pitfalls to Avoid

• Failure to consider PRES in the differential diagnosis of neurological deterioration following trauma or surgical interventions 1
• Missing concomitant conditions that may complicate management, such as sepsis or metabolic disturbances 1
• Confusing PRES with other post-traumatic neurological conditions, potentially leading to inappropriate treatment 2