From the Guidelines
Posterior Reversible Encephalopathy Syndrome (PRES) is best managed by immediately addressing the underlying cause, with a focus on blood pressure control and discontinuation of offending medications, to prevent permanent neurological damage and improve quality of life. The imaging findings of PRES typically include vasogenic edema in the parieto-occipital regions, which can be visualized using MRI with T2-weighted and FLAIR sequences, as these are most sensitive and show hyperintense signal changes 1. CT scans may also be used but are less sensitive.
Key Management Strategies
- Immediate blood pressure control is crucial in hypertensive cases, typically using IV medications like nicardipine, labetalol, or clevidipine to lower blood pressure by 20-25% within the first hours 1.
- Discontinuation of offending medications, such as immunosuppressants or chemotherapy, is essential in non-hypertensive cases 2.
- Supportive care, including seizure control with benzodiazepines or levetiracetam, is also critical.
Prognosis and Follow-Up
The prognosis for PRES is generally favorable, with most patients experiencing complete clinical and radiological resolution within days to weeks 2. However, delayed treatment can lead to permanent neurological damage or death in approximately 5-15% of cases.
- Follow-up imaging in 1-2 weeks is recommended to confirm resolution of radiological findings.
- Patients should be monitored for potential recurrence, especially if the underlying cause persists. In terms of specific interventions, discontinuation of the offending medication and correction of electrolyte imbalances, along with symptomatic treatment, can lead to spontaneous full remission in almost all cases 2.
From the Research
Imaging Findings
- Posterior reversible encephalopathy syndrome (PRES) is characterized by neuroimaging findings of reversible vasogenic subcortical edema without infarction 3
- Symmetrical white matter abnormalities suggestive of edema are seen in computer tomography (CT) and magnetic resonance imaging (MRI) scans, commonly but not exclusively in the posterior parieto-occipital regions of the cerebral hemispheres 4
- Bilateral regions of subcortical vasogenic edema that resolve within days or weeks are characteristic radiographic findings 5
- The presence of hemorrhage, restricted diffusion, contrast enhancement, and vasoconstriction are all compatible with a diagnosis of PRES 5
Management
- The management of PRES is chiefly concerned with stabilization of the patient, adequate and prompt control of blood pressure, prevention of seizures, and timely caesarean section in obstetric cases with pre-eclampsia/eclampsia 4
- Early detection of the disease is key for a rapid recovery and good prognosis 6
- Prompt control of blood pressure and/or discontinuing the offending drug is crucial for the reversibility of the clinical and radiologic abnormalities 3
Prognosis
- If treated early and adequately, PRES has a favorable prognosis, but neurological residual symptoms and even mortality can occur, particularly in patients with complications such as intracranial hemorrhage 7
- Most cases of PRES resolve successfully and carry a favorable prognosis, but patients with inadequate therapeutic support or delay in treatment may not project a positive outcome 4
- In most cases, PRES resolves spontaneously and patients show both clinical and radiological improvements 5
- However, in severe forms, PRES might cause substantial morbidity and even mortality, most often as a result of acute hemorrhage or massive posterior fossa edema causing obstructive hydrocephalus or brainstem compression 5