Management of Posterior Reversible Encephalopathy Syndrome (PRES)
The cornerstone of PRES management is immediate identification and removal of the triggering factor, along with stringent 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 trigger 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
- Obtain diagnostic neuroimaging (MRI is gold standard) showing characteristic T2-weighted hyperintensities in bilateral parietal-occipital lobes, predominantly affecting white matter 1
Step 2: Blood Pressure Management
- Implement gradual but stringent blood pressure control to prevent cerebral hypoperfusion while reducing vasogenic edema 1
- Monitor blood pressure frequently during the acute phase to ensure it remains within a safe range 1
- Position patient with head elevated at 30 degrees to help reduce intracranial pressure 2
Step 3: Seizure Management
- Administer antiepileptic treatment for patients who develop seizures 1
- Consider prophylactic anticonvulsants in high-risk patients with significant neurological deficits 1
- For acute seizures, benzodiazepines may be used with careful monitoring 1
Step 4: Supportive Care
- Implement aspiration precautions and intravenous hydration for patients with altered consciousness 1
- Avoid medications that cause CNS depression in patients with encephalopathy 1
- For patients with declining level of consciousness, obtain urgent ICU assessment for airway protection and ventilatory support 2
- Monitor and correct electrolyte imbalances, particularly in patients with pre-existing renal impairment 1
Step 5: Monitoring and Follow-up
- Perform frequent neurological evaluations to assess response to treatment 3
- Obtain follow-up neuroimaging to confirm resolution of radiographic findings 3
- Consult with neurological specialists for ongoing management, especially in cases with persistent symptoms 1
Special Considerations
- For PRES associated with immunotherapy, follow the Society for Immunotherapy of Cancer guidelines for immune-related adverse events 1
- In cases with persistent symptoms, consider alternative diagnoses or complications 1
- For severe cases ("malignant PRES"), more aggressive management in an ICU setting may be required, including intubation, hyperosmolar therapy, or even decompressive surgery in extreme cases 4
Prognosis
- With early diagnosis and prompt treatment, PRES is usually fully reversible without sequelae 5
- Complete spontaneous remission occurs in most cases, but early detection and management are key factors for rapid recovery 1
- A minority of patients may develop residual neurologic sequelae, particularly in cases with associated structural injury such as intracranial hemorrhage or stroke 4
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
- Delayed diagnosis can lead to permanent neurological deficits, emphasizing the importance of prompt recognition and treatment 6
- Recurrent PRES can occur, particularly if underlying causes are not adequately addressed 5