What is the treatment for Posterior Reversible Encephalopathy Syndrome (PRES)?

Treatment of Posterior Reversible Encephalopathy Syndrome (PRES)

The cornerstone of PRES management is immediate identification and removal of the triggering factor, combined with aggressive blood pressure control to prevent further brain injury.

Step 1: Identify and Address Underlying Causes

• Immediately discontinue any offending agents such as immunosuppressants (particularly cyclosporine), anticancer therapies, 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
• Early identification of triggers is critical for preventing progression and ensuring reversibility of symptoms 2

Step 2: Blood Pressure Management

• Implement stringent blood pressure control with gradual reduction to avoid cerebral hypoperfusion 1
• Monitor blood pressure frequently during the acute phase to ensure it remains within safe ranges 1
• Hypertension management is particularly important as it can lead to failure of cerebral autoregulation, especially in posterior brain regions where sympathetic innervation is less pronounced 3

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
• Benzodiazepines may be used for acute seizure management but should be carefully monitored 1

Step 4: Supportive Care

• Position patients with head elevated at 30 degrees to help reduce intracranial pressure 4
• For patients with declining consciousness, obtain urgent ICU assessment for airway protection and ventilatory support 4
• Implement aspiration precautions and provide intravenous hydration for patients with altered consciousness 1
• Avoid medications that cause CNS depression in patients with encephalopathy 1

Step 5: Electrolyte and Metabolic Management

• Correct electrolyte imbalances if present 1
• Monitor renal function, especially in patients with pre-existing renal impairment 1
• Follow glucose, potassium, magnesium, and phosphate levels closely 4

Special Considerations for Severe Cases

• For malignant PRES (severe cases with GCS <8 and clinical decline despite standard management):
  • Consider neurosurgical interventions such as craniectomy, hematoma evacuation, or external ventricular drain placement if there is significant mass effect or hemorrhage 5
  • Hyperosmolar therapy may be beneficial in cases with significant edema 5

Diagnostic Confirmation and Monitoring

• MRI is the gold standard for diagnosis, showing increased signal intensity on T2-weighted or FLAIR imaging in posterior brain regions 1
• CT scan can be useful to exclude intracranial hemorrhage when MRI is not feasible 1
• Perform frequent neurological evaluations to monitor response to treatment 2

Prognosis

• Complete spontaneous remission occurs in most cases without sequelae when promptly recognized and managed 1, 2
• Early detection and management are key factors for rapid recovery and good outcomes 2

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 recognition and treatment can result in severe and long-term neurological disability 6