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

Treatment of Posterior Reversible Encephalopathy Syndrome (PRES)

The cornerstone of PRES management is prompt 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 immunosuppressants, anticancer therapy, or other medications that may trigger PRES 1
• Common triggers include hypertension, renal impairment, autoimmune diseases, high-dose antineoplastic therapy, stem-cell transplantation, solid organ transplantation, and immunosuppression (particularly cyclosporine) 1
• Evaluate for other conditions that may complicate management, such as sepsis or metabolic disturbances 1

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 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
• For patients with altered consciousness and seizures, avoid medications that cause CNS depression 3, 1

Step 4: Supportive Care

• Implement aspiration precautions and intravenous hydration for patients with altered consciousness 1
• Withhold oral intake of food, medicines, and fluids if swallowing is impaired 3
• Substitute oral medications with intravenous forms when necessary 3
• Correct any electrolyte imbalances and monitor renal function 1

Step 5: Neuroimaging and Monitoring

• MRI is the gold standard for diagnosis, showing increased signal intensity on T2-weighted or FLAIR imaging in posterior brain regions 1, 4
• CT scan can be useful to exclude intracranial hemorrhage when MRI is not feasible 1
• Monitor neurological status closely for any changes that may indicate worsening of condition 1, 5

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 1
• For severe cases (Grade III-IV encephalopathy), consider intubation for airway protection 2
• For patients on ECMO with PRES, obtain neurological consultation for acute neurological changes 1

Prognosis

• Complete spontaneous remission occurs in most cases without sequelae when treated promptly 1, 5
• Early detection and management are key factors for rapid recovery and good outcomes 1, 5
• While typically reversible, PRES can be associated with morbidity and mortality if not properly managed 4

Common Pitfalls to Avoid

• Failure to identify and discontinue the triggering agent can lead to prolonged illness and increased complications 1
• Overly rapid correction of blood pressure may cause cerebral hypoperfusion 1
• Delay in diagnosis and treatment can lead to permanent neurological damage 4, 5
• Missing concomitant conditions that may complicate management 1