|
1
|
Uppal V, Russell R, Sondekoppam RV, Ansari J, Baber Z, Chen Y, DelPizzo K, Dirzu DS, Kalagara H, Kissoon NR, Kranz PG, Leffert L, Lim G, Lobo C, Lucas DN, Moka E, Rodriguez SE, Sehmbi H, Vallejo MC, Volk T, Narouze S. Evidence-based clinical practice guidelines on postdural puncture headache: a consensus report from a multisociety international working group. Reg Anesth Pain Med 2024; 49:471-501. [PMID: 37582578 DOI: 10.1136/rapm-2023-104817] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 07/25/2023] [Indexed: 08/17/2023]
Abstract
INTRODUCTION Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis or management of this condition is, however, currently lacking. This multisociety guidance aims to fill this void and provide practitioners with comprehensive information and patient-centric recommendations to prevent, diagnose and manage patients with PDPH. METHODS Based on input from committee members and stakeholders, the committee cochairs developed 10 review questions deemed important for the prevention, diagnosis and management of PDPH. A literature search for each question was performed in MEDLINE (Ovid) on 2 March 2022. The results from each search were imported into separate Covidence projects for deduplication and screening, followed by data extraction. Additional relevant clinical trials, systematic reviews and research studies published through March 2022 were also considered for the development of guidelines and shared with contributors. Each group submitted a structured narrative review along with recommendations graded according to the US Preventative Services Task Force grading of evidence. The interim draft was shared electronically, with each collaborator requested to vote anonymously on each recommendation using two rounds of a modified Delphi approach. RESULTS Based on contemporary evidence and consensus, the multidisciplinary panel generated 50 recommendations to provide guidance regarding risk factors, prevention, diagnosis and management of PDPH, along with their strength and certainty of evidence. After two rounds of voting, we achieved a high level of consensus for all statements and recommendations. Several recommendations had moderate-to-low certainty of evidence. CONCLUSIONS These clinical practice guidelines for PDPH provide a framework to improve identification, evaluation and delivery of evidence-based care by physicians performing neuraxial procedures to improve the quality of care and align with patients' interests. Uncertainty remains regarding best practice for the majority of management approaches for PDPH due to the paucity of evidence. Additionally, opportunities for future research are identified.
Collapse
Affiliation(s)
- Vishal Uppal
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Robin Russell
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rakesh V Sondekoppam
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Jessica Ansari
- Anesthesia Department, Stanford Health Care, Stanford, California, USA
| | - Zafeer Baber
- Department of Anesthesiology and Perioperative Medicine, Newton-Wellesley Hospital, Newton, Massachusetts, USA
| | - Yian Chen
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California, USA
| | - Kathryn DelPizzo
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Dan Sebastian Dirzu
- Anesthesia and Intensive Care, Emergency County Hospital Cluj-Napoca, Cluj-Napoca, Romania
| | - Hari Kalagara
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Narayan R Kissoon
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter G Kranz
- Depatement of Radiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Lisa Leffert
- Department of Anesthesiology, Yale New Haven Health System; Yale University School of Medicine, New Haven, Connecticut, USA
| | - Grace Lim
- Department of Anesthesiology & Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Obstetrics & Gynecology, Magee Womens Hospital of UPMC, Pittsburgh, Pennsylvania, USA
| | - Clara Lobo
- Anesthesiology Institute, Interventional Pain Medicine Department, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Dominique Nuala Lucas
- Department of Anaesthesia, London North West Healthcare NHS Trust, Harrow, London, UK
| | - Eleni Moka
- Department of Anaesthesiology, Creta Interclinic Hospital - Hellenic Healthcare Group (HHG), Heraklion, Crete, Greece
| | - Stephen E Rodriguez
- Department of Anesthesia, Walter Reed Army Medical Center, Bethesda, Maryland, USA
| | - Herman Sehmbi
- Department of Anesthesia, Western University, London, Ontario, Canada
| | - Manuel C Vallejo
- Departments of Medical Education, Anesthesiology, Obstetrics & Gynecology, West Virginia University, Morgantown, West Virginia, USA
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Samer Narouze
- Northeast Ohio Medical University, Rootstown, Ohio, USA
- Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, OH, USA
| |
Collapse
|
|
2
|
Gallop L, McNeillis N. Posterior reversible encephalopathy syndrome in a child, following splenectomy under combined general and spinal anaesthesia. Anaesth Rep 2023; 11:e12245. [PMID: 37767368 PMCID: PMC10520240 DOI: 10.1002/anr3.12245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
Posterior reversible encephalopathy syndrome is a rare and serious condition that presents with acute neurological symptoms with characteristic changes on imaging. It can lead to substantial morbidity and mortality, but can be reversible if recognised and treated. Here, we report a case of posterior reversible encephalopathy syndrome in a child post-splenectomy under general anaesthesia with spinal anaesthesia. As far as we are aware, this condition has not previously been described in relation to spinal anaesthesia in the paediatric population. This case demonstrates the importance of recognising blood pressure changes in children, which can be challenging due to age-, sex- and height-related centiles for blood pressure measurements. Posterior reversible encephalopathy syndrome should be considered as a differential diagnosis for headache in a patient that has had a spinal anaesthesia.
Collapse
Affiliation(s)
- L. Gallop
- Department of AnaesthesiaConquest HospitalHastingsUK
| | - N. McNeillis
- Department of AnaesthesiaConquest HospitalHastingsUK
| |
Collapse
|
|
3
|
Wang Y, Zhang Q. Postpartum posterior reversible encephalopathy syndrome secondary to preeclampsia and cerebrospinal fluid leakage: A case report and literature review. World J Clin Cases 2022; 10:10332-10338. [PMID: 36246802 PMCID: PMC9561592 DOI: 10.12998/wjcc.v10.i28.10332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/28/2022] [Accepted: 08/25/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Postpartum posterior reversible encephalopathy syndrome (PRES) is not uncommon. Its mechanisms and risk factors are not clear.
CASE SUMMARY A 28-year-old woman underwent cesarean section but had inadvertent dural puncture during epidural anesthesia. To manage the symptoms of intracranial hypotension, crystalloid fluid was infused. However, the patient developed postpartum preeclampsia and PRES. The patient was treated with diazepam and dehydration therapy. The signs of cerebral lesions on magnetic resonance imaging disappeared on postpartum day 7.
CONCLUSION Postpartum preeclampsia and PRES can develop concomitantly. Treating postdural puncture headaches with infusion of crystalloid fluid may precipitate the development of PRES.
Collapse
Affiliation(s)
- Yu Wang
- Department of Anesthesiology, Zhabei Central Hospital, Shanghai 200071, China
| | - Qing Zhang
- Department of Anesthesiology, Zhabei Central Hospital, Shanghai 200071, China
| |
Collapse
|
|
4
|
Abstract
PURPOSE To provide updated evidence-based recommendations for the evaluation and treatment of primary and secondary headaches in pregnancy and postpartum. TARGET POPULATION Pregnant and postpartum patients with a history of or experiencing primary or new secondary headaches. METHODS This guideline was developed using an a priori protocol in conjunction with a writing team consisting of two specialists in obstetrics and gynecology appointed by the ACOG Committee on Clinical Practice Guidelines-Obstetrics and one external subject matter expert. ACOG medical librarians completed a comprehensive literature search for primary literature within Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements. RECOMMENDATIONS This Clinical Practice Guideline includes recommendations on interventions to prevent primary headache in individuals who are pregnant or attempting to become pregnant, postpartum, or breastfeeding; evaluation for symptomatic patients presenting with primary and secondary headaches during pregnancy; and treatment options for primary and secondary headaches during pregnancy and lactation. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence.
Collapse
|
|
5
|
Sagir A, Ahuja S, Soliman LM, Farag E. Co-presentation of Posterior Reversible Encephalopathy Syndrome in a patient with Post Dural Puncture Headache. PAIN MEDICINE 2021; 23:1029-1031. [PMID: 34260726 DOI: 10.1093/pm/pnab216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Post Dural Puncture Headache (PDPH) is a well-known complication of neuraxial anesthesia, however the occurrence of seizures and vision loss within few days after dural puncture could be alarming. Posterior Reversible Encephalopathy Syndrome (PRES) is associated with reversible edema and leukoencephalopathy in the posterior parieto-occipital cortex. We report the co-presentation of PRES and PDPH after labor epidural analgesia. CASE PRESENTATION 25-year-old multiparous African-American woman was admitted for evaluation of new onset seizures and headache in the postpartum period. She had a recent history of multiple needle insertion attempts and inadvertent dural puncture during epidural analgesia for delivery. Soon after delivery, she was diagnosed with PDPH and was treated with epidural blood patch, with no relief of symptoms. Six days later, she developed sudden onset transient blindness, seizures and altered sensorium and magnetic resonance imaging (MRI) of the brain revealed white matter changes suggestive of PRES. CONCLUSION PRES is an uncommon complication of cerebrospinal fluid (CSF) leak and intracranial hypotension. We report the occurrence of PRES in a patient with no known risk factors, except a traumatic dural tap. Is it important to expand the differentials for headache after dural puncture to encompass PRES as a possibility, especially in patients with a delayed presentation of seizures and cortical blindness.
Collapse
Affiliation(s)
- Afrin Sagir
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
| | - Sanchit Ahuja
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH.,Department of Anesthesiology, Pain Management & Perioperative Medicine, Henry Ford Health Systems, Detroit, MI
| | - Loran M Soliman
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
| | - Ehab Farag
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH.,Department of Outcomes Research, Cleveland Clinic, Cleveland, OH
| |
Collapse
|
|
6
|
Turetti M, Barbagallo M, Scoditti U, Genovese A, Angeli L, Fieni S, Frusca T, Bignami EG. A case of postpartum headache post dural puncture. Post Dural Puncture Headache or Reversible Cerebral Vasoconstriction Syndrome - Posterior Reversible Encephalopathy Syndrome? ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021119. [PMID: 33944816 PMCID: PMC8142776 DOI: 10.23750/abm.v92is1.10960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 11/18/2020] [Indexed: 11/23/2022]
Abstract
Background and aim: Reversible Cerebral Vasoconstriction Syndrome (RCVS) and Posterior Reversible Encephalopathy Syndrome (PRES) are two rare neurological conditions, clinically characterized by headache. In our case a diagnosis of PDPH was made though imaging showed signs of RCVS-PRES. Methods: We present a case of RCVS-PRES in a postpartum woman who presented headache as first symptom and only later experienced seizures. Dural puncture worked as a confounding factor in the clinical postpartum evaluation. Results-Conclusions: We want to focus the attention on changes of clinical characteristics of headache as an important factor to be analysed, in order to have a prompt diagnosis. We therefore propose a diagnostic algorithm. Moreover, we evaluate possible triggers of RCVS and PRES; in our case dural puncture is probably not the trigger, in fact there were no liquoral hypotension signs on imaging.
Collapse
Affiliation(s)
- Melania Turetti
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Maria Barbagallo
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | | | | | - Laura Angeli
- Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy.
| | - Stefania Fieni
- Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy .
| | - Tiziana Frusca
- Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy.
| | - Elena Giovanna Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy.
| |
Collapse
|
|
7
|
Zheng YY, Weng XP, Fu FW, Cao YG, Li Y, Zheng GQ, Chen W. Cerebrospinal Fluid Hypovolemia and Posterior Reversible Encephalopathy Syndrome. Front Neurol 2020; 11:591. [PMID: 32655488 PMCID: PMC7324723 DOI: 10.3389/fneur.2020.00591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 05/22/2020] [Indexed: 12/23/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a reversible neuroradiological syndrome characterized by reversible vasogenic edema. The pathophysiological mechanism is still unclear, but PRES may be triggered by various etiologies. To date, only a few PRES cases linked to cerebrospinal fluid (CSF) hypovolemia were reported. The association between PRES and CSF hypovolemia needs to be explored. We presented a case of PRES with CSF hypovolemia as a result of an inadvertent dural puncture and reviewed the literature to identify the clinical characterization and pathophysiological mechanism of PRES following CSF hypovolemia. A total of 31 cases of PRES-CSF hypovolemia was included for analysis. The median age was 33 years, with a notable female predominance (87.1%). Fifteen patients (48.4%) didn't have either a history of hypertension nor an episode of hypertension. The most common cause of CSF hypovolemia was epidural or lumbar puncture (n = 21), followed by CSF shunt (n = 6). The median interval between the procedure leading to CSF hypovolemia and PRES was 4 days. Seizure, altered mental state, and headache were the most frequent presenting symptom. The parietooccipital pattern was most frequent (71.0%). Conservative management remains the mainstay of treatment with excellent outcomes. Three patients had a second episode of PRES. CSF hypovolemia is a plausible cause of PRES via a unique pathophysiologic mechanism including arterial hyperperfusion and venous dysfunction. Patients with CSF hypovolemia is more susceptible to PRES, which is potentially life-threatening. Given that CSF hypovolemia is a common complication of anesthetic, neurological, and neurosurgical procedures, PRES should be early considered for prompt diagnosis and appropriate management.
Collapse
Affiliation(s)
- Yuan-Yuan Zheng
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiong-Peng Weng
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Fang-Wang Fu
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yun-Gang Cao
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yan Li
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Guo-Qing Zheng
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Wei Chen
- Department of Radiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| |
Collapse
|
|
8
|
Chondrogiorgi M, Zikou AK, Konitsiotis S, Markoula S. Postpartum intracranial hypotension complicated by posterior reversible encephalopathy syndrome: a case report. Int J Neurosci 2020; 130:1174-1177. [PMID: 32070168 DOI: 10.1080/00207454.2020.1730365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Purpose: To present an unusual case of posterior encephalopathy syndrome (PRES) preceded by intracranial hypotension.Materials and Methods: We present a case of a 27-year-old parturient with an uneventful pregnancy that shortly after labor developed a persistent headache with characteristics compatible with intracranial hypotension. The patient had undergone epidural anesthesia for caesarian section. Results: The symptomatology of intracranial hypotension was attributed to inadvertent dural puncture during epidural anesthesia. The MRI revealed multiple white matter lesions located in frontal, temporal and parietal regions of both hemispheres. The type of lesions was suggestive of PRES. Pachymeningeal enhancement was also observed. The patient was managed conservatively. The symptoms improved gradually and the imaging findings resolved completely. Conclusions: This case demonstrates the need for clinical alertness for PRES in patients with prolonged and possibly atypical symptoms of intracranial hypotension. As probable causal relationship between these disorders we propose a sympathetic over-activation as a result of cerebrospinal fluid leakage leading to vasospasm and manifestation of PRES.
Collapse
Affiliation(s)
| | - Anastasia K Zikou
- Department of Radiology, University Hospital of Ioannina, Ioannina, Greece
| | | | - Sofia Markoula
- Department of Neurology, University Hospital of Ioannina, Ioannina, Greece
| |
Collapse
|
|
9
|
Oxford BG, Khattar NK, Adams SW, Schaber AS, Williams BJ. Posterior reversible encephalopathy syndrome with lumbar drainage and surgery: coincidence or correlation? A case report. BMC Neurol 2019; 19:214. [PMID: 31470816 PMCID: PMC6716908 DOI: 10.1186/s12883-019-1438-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 08/21/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a rare neurological disorder usually associated with specific medical conditions that cause a disturbance of the CNS homeostasis. It has seldom been reported to be a consequence of an iatrogenic intervention causing intracranial hypotension. CASE PRESENTATION We report the case of an individual 69-year-old male presenting with headache and blurred vision following cerebrospinal fluid (CSF) leak from resection of a sellar mass. The patient developed the condition following removal of the lumbar drain post-operatively. Magnetic Resonance Imaging showed bilateral occipital, parieto-occipital, and cerebellar T2 FLAIR hyper-intensities, suggesting a radiological diagnosis of posterior reversible encephalopathy syndrome (PRES). The patient's symptoms started to improve shortly afterwards and had completely resolved at 3 months follow-up. CONCLUSIONS The absence of severe hypertension and presence of an intraoperative CSF leak requiring placement of the lumbar drain suggests that decreased CSF volume and associated reactive hyperemia could have a role in the pathophysiology of the disease.
Collapse
Affiliation(s)
- Brent G Oxford
- Department of Neurological Surgery, University of Louisville School of Medicine, 220 Abraham Flexner Way, 15th Floor, Louisville, KY, 40202, USA
| | - Nicolas K Khattar
- Department of Neurological Surgery, University of Louisville School of Medicine, 220 Abraham Flexner Way, 15th Floor, Louisville, KY, 40202, USA
| | - Shawn W Adams
- Department of Neurological Surgery, University of Louisville School of Medicine, 220 Abraham Flexner Way, 15th Floor, Louisville, KY, 40202, USA
| | - Alexandra S Schaber
- Department of Neurological Surgery, University of Louisville School of Medicine, 220 Abraham Flexner Way, 15th Floor, Louisville, KY, 40202, USA
| | - Brian J Williams
- Department of Neurological Surgery, University of Louisville School of Medicine, 220 Abraham Flexner Way, 15th Floor, Louisville, KY, 40202, USA.
| |
Collapse
|
|
10
|
Postpartum Posterior Reversible Encephalopathy Syndrome (PRES): Three Case Reports and Literature Review. Case Rep Obstet Gynecol 2019; 2019:9527632. [PMID: 30809401 PMCID: PMC6369475 DOI: 10.1155/2019/9527632] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 12/23/2018] [Accepted: 12/26/2018] [Indexed: 11/17/2022] Open
Abstract
Posterior reversible encephalopathy syndrome is a rare complication generally associated with headache and acute changes in blood pressure. Delay in the diagnosis and treatment may result in death or in irreversible neurological sequelae. We present three cases of PRES occurring in young women during puerperium. We report a literature review ranged from January 1990 to June 2015 describing clinical features, diagnostic and medical approach, and maternal outcome.
Collapse
|
|
11
|
Katsevman GA, Turner RC, Cheyuo C, Rosen CL, Smith MS. Post-partum posterior reversible encephalopathy syndrome requiring decompressive craniectomy: case report and review of the literature. Acta Neurochir (Wien) 2019; 161:217-224. [PMID: 30659351 DOI: 10.1007/s00701-019-03798-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 01/04/2019] [Indexed: 10/27/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is an uncommon but potentially devastating syndrome if not recognized and treated appropriately. As the name implies, recognition of the condition and proper management may reverse the clinical and radiological findings. However, diagnosis is not always straightforward. We present the case of a 24-year-old female who was 4 days post-partum and presented with headache, neck pain, and new-onset seizures. She had undergone epidural anesthesia during labor, and initial imaging was suggestive of intracranial hypotension versus pachymeningitis. Despite initial conservative therapy including anti-epileptic drugs, magnesium therapy, empiric antibiotics, and Trendelenburg positioning, the patient continued to deteriorate. Follow-up imaging was suggestive of PRES with signs of intracranial hypertension. The patient underwent a decompressive suboccipital craniectomy for refractory and severe PRES and later fully recovered. This case highlights the sometimes difficult diagnosis of PRES, possible association with pregnancy, eclampsia/preeclampsia and/or cerebrospinal fluid drainage, and the rare but life-saving need for decompression in severe cases.
Collapse
|
|
12
|
Niwa R, Oya S, Nakamura T, Hana T, Matsui T. Rapid intracranial pressure drop as a cause for posterior reversible encephalopathy syndrome: Two case reports. Surg Neurol Int 2017; 8:103. [PMID: 28695050 PMCID: PMC5473084 DOI: 10.4103/sni.sni_55_17] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Accepted: 02/23/2017] [Indexed: 01/12/2023] Open
Abstract
Background: Posterior reversible encephalopathy syndrome (PRES) is characterized by reversible edematous lesions on radiological examinations as well as symptoms of altered consciousness and seizures. To date, the underlying mechanism remains largely unknown. Case Descriptions: Case 1 is a 72-year-old man with a history of hypertension presented with a subarachnoid hemorrhage. Fourteen days after the successful clipping of a ruptured aneurysm; he experienced inadvertent overdrainage via the intraventricular drain. Nine hours later, he started to have seizures followed by disturbances in consciousness. An emergency magnetic resonance imaging showed multiple high-intensity lesions in the frontal, temporal, parietal, and occipital lobes, basal ganglia, brainstem, and cerebellar hemispheres bilaterally, which are compatible with typical magnetic resonance findings in PRES patients. He was treated conservatively and recovered well. Case 2 is a 68-year-old woman with a mild history of hypertension and a ventriculo-peritoneal shunt for obstructive hydrocephalus, who underwent a cysto-peritoneal shunt placement because of an enlarging symptomatic arachnoid cyst. Immediately following surgery, she experienced disturbances in consciousness and developed status epilepticus. Radiological examinations revealed remarkable shrinkage of the arachnoid cyst and multiple edematous lesions, which led us to strongly suspect PRES. With conservative treatment, her symptoms and the radiological abnormalities disappeared. Conclusion: Based on the previous literature and our cases, we believe that the association between rapid reduction of intracranial pressure (ICP) and the development of PRES should be recognized because most neurosurgical procedures such as craniotomy or cerebrospinal fluid diversion present a potential risk of rapid reduction of ICP.
Collapse
Affiliation(s)
- Ryoko Niwa
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Soichi Oya
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Takumi Nakamura
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Taijun Hana
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Toru Matsui
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| |
Collapse
|
|
13
|
Karakis I, Nuccio AH, Amadio JP, Fountain AJ. The Monro-Kellie Doctrine in Action: Posterior Reversible Leukoencephalopathy Syndrome Caused by Intracranial Hypotension from Lumboperitoneal Shunt Placement. World Neurosurg 2017; 98:868.e11-868.e15. [DOI: 10.1016/j.wneu.2016.12.046] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 12/11/2016] [Accepted: 12/14/2016] [Indexed: 10/20/2022]
|
|
14
|
Shields LBE, Johnson JR, Shields CB. Posterior reversible encephalopathy syndrome following a thoracic discectomy–induced dural leak: case report. J Neurosurg Spine 2016; 25:586-590. [DOI: 10.3171/2016.4.spine1623] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological syndrome characterized by headaches, altered mental status, seizures, and visual disturbances. Classic MRI findings include white matter changes of the parieto-occipital regions. This syndrome has been encountered in myriad medical illnesses, including hypertension, preeclampsia/eclampsia, and immunosuppressive conditions. While the pathogenesis of the disorder is unclear, vasoconstriction and hypoperfusion leading to brain ischemia and vasogenic edema have been implicated as potential mechanisms. The authors present, to the best of their knowledge, the first case of PRES following a thoracic spinal surgery–induced dural leak noted on resection of the fifth rib during a thoracotomy for a T4–5 discectomy. Brain MRI revealed large areas of increased FLAIR and T2 hyperintensity in the superior posterior frontal lobes, superior and medial parietal lobes, and bilateral occipital lobes. Following repair of the CSF leak, the patient's symptoms resolved. Spinal surgeons should be alert to the potentially life-threatening condition of PRES, especially in a hypertensive patient who experiences surgery-induced dural leakage. The development of a severe positional headache with neurological signs is a red flag that suggests the presence of PRES. Prompt attention to the diagnosis and treatment of this condition by repairing the dural leak via surgery or expeditious blood patch increases the likelihood of a favorable outcome.
Collapse
Affiliation(s)
| | | | - Christopher B. Shields
- 1Norton Neuroscience Institute,
- 2Norton Healthcare; and
- 3Department of Anatomical Science and Neurobiology, University of Louisville, School of Medicine, Louisville, Kentucky
| |
Collapse
|
|
15
|
Therapy and differential diagnosis of posterior reversible encephalopathy syndrome (PRES) during pregnancy and postpartum. Arch Gynecol Obstet 2015; 292:1217-23. [PMID: 26122264 DOI: 10.1007/s00404-015-3800-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 06/17/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Posterior reversible encephalopathy syndrome (PRES) is an usually reversible neuro-radiological clinical entity characterized by headache, confusion, visual disturbances or blindness and seizures. It rarely occurs without seizures. METHODS We conducted a literature review in MEDLINE about PRES during post partum and pregnancy, focusing on differential diagnosis and therapy. We reviewed 28 articles (case reports, original articles and reviews) describing PRES as well as a case of a severe, immediate postpartum HELLP syndrome (haemolysis, elevated liver enzyme levels, low platelet count) with PRES without generalized seizure. RESULTS The development of PRES after delivery is unusual. Magnetic resonance imaging represents the gold standard for the diagnosis of this condition. White matter oedema in the posterior cerebral hemispheres is typical on neuroimaging. PRES is reversible when early diagnosis is established and appropriate treatment is started without delay. The pathogenesis of PRES is discussed and the importance of a prompt diagnosis is emphasized, as the crucial role of rapid blood press reduction. CONCLUSION MRI is the diagnostic gold standard and it may be useful in the differential diagnosis. The goal of the therapy is to control elevated blood pressure and to prevent seizures or promptly manage it.
Collapse
|
|
16
|
Posterior Reversible Encephalopathy Syndrome Secondary to CSF Leak and Intracranial Hypotension: A Case Report and Literature Review. Case Rep Neurol Med 2015; 2015:538523. [PMID: 26106495 PMCID: PMC4461750 DOI: 10.1155/2015/538523] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 05/18/2015] [Indexed: 11/17/2022] Open
Abstract
Posterior Reversible Encephalopathy Syndrome (PRES) is a clinical neuroradiological condition characterized by insidious onset of neurological symptoms associated with radiological findings indicating posterior leukoencephalopathy. PRES secondary to cerebrospinal fluid (CSF) leak leading to intracranial hypotension is not well recognized etiology of this condition. Herein, we report a case of PRES that occurred in the setting of CSF leak due to inadvertent dural puncture. Patient underwent suturing of the dural defect. Subsequently, his symptoms resolved and a repeated brain MRI showed resolution of brain lesions. The pathophysiology and mechanistic model for developing PRES in the setting of intracranial hypotension were discussed. We further highlighted the importance of tight blood pressure control in patients with CSF leak and suspected intracranial hypotension because they are more vulnerable to develop PRES with normal or slightly elevated bleed pressure values.
Collapse
|
|
17
|
Grelat M, Debaux JB, Sautreaux JL. Posterior reversible encephalopathy syndrome after depletive lumbar puncture: a case report. J Med Case Rep 2014; 8:261. [PMID: 25063365 PMCID: PMC4138940 DOI: 10.1186/1752-1947-8-261] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Accepted: 05/28/2014] [Indexed: 11/15/2022] Open
Abstract
Introduction Posterior reversible encephalopathy syndrome is a rare entity. Its pathophysiology is still poorly understood. Case presentation We report the case of a 69-year-old White European woman who presented complete and proportional right hemiplegia, confusion, deviation of her head and eyes to the right, cortical blindness, and generalized tonic-clonic seizure 12 hours following a depletive lumbar puncture. Emergency cerebral magnetic resonance imaging showed bioccipital and left-side basal ganglia hyperintensities in the fluid attenuated inversion recovery and the diffusion-weighted images suggesting a radiological diagnosis of posterior reversible encephalopathy syndrome. Conclusions The diagnosis is established on clinical and radiological signs. This is the first report of this kind in the literature. We present a case of posterior reversible encephalopathy syndrome after depletive lumbar puncture and we discuss the pathophysiology.
Collapse
Affiliation(s)
- Michael Grelat
- Department of Neurosurgery, Bocage Central, University Hospital of Dijon, 14 rue Paul Gaffarel, Dijon 21000, France.
| | | | | |
Collapse
|
|
18
|
Doherty H, Hameed S, Ahmed I, Russell IF. Post-dural puncture headache and posterior reversible encephalopathy syndrome: a misdiagnosis or co-presentation? Int J Obstet Anesth 2014; 23:279-82. [PMID: 24768557 DOI: 10.1016/j.ijoa.2014.02.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Revised: 01/05/2014] [Accepted: 02/09/2014] [Indexed: 10/25/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a rare neurological condition associated with a variety of underlying conditions, including preeclampsia. The headache associated with PRES may be indistinguishable from post-dural puncture headache, which may result in diagnostic delay. We report a case of PRES that was initially diagnosed as post-dural puncture headache. The case was unique because there were no features of preeclampsia, initial presentation was typical of post-dural puncture headache, and there was a five-day interval between the onset of headache and the development of seizures and cortical blindness, pathognomonic of PRES. It remains unclear whether this was an atypical presentation of PRES, initially misdiagnosed as post-dural puncture headache, or whether delayed treatment of headache triggered PRES.
Collapse
Affiliation(s)
- H Doherty
- Department of Anaesthesia, Hull Royal Infirmary, Hull, UK.
| | - S Hameed
- Department of Anaesthesia, Hull Royal Infirmary, Hull, UK
| | - I Ahmed
- Department of Anaesthesia, Hull Royal Infirmary, Hull, UK
| | - I F Russell
- Department of Anaesthesia, Hull Royal Infirmary, Hull, UK
| |
Collapse
|
|
19
|
Yi JH, Ha SH, Kim YK, Choi EM. Posterior reversible encephalopathy syndrome in an untreated hypertensive patient after spinal surgery under general anesthesia -A case report-. Korean J Anesthesiol 2011; 60:369-72. [PMID: 21716568 PMCID: PMC3110298 DOI: 10.4097/kjae.2011.60.5.369] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2010] [Revised: 11/30/2010] [Accepted: 12/02/2010] [Indexed: 12/17/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is an unfamiliar term to anesthesiologists, and this is characterized by neurologic symptoms that include mental change, headache, seizure and visual disturbance and also abnormal neuroimaging finding. A 71-year-old female patient was operated on for posterior decompression and total laminectomy under general anesthesia for the spinal stenosis. After the operation, she developed generalized tonic-clonic seizure and a stuporous mentality in the recovery room. The magnetic resonance imaging (MRI) revealed swelling and increased signal intensity at the deep gray nuclei, cerebral cortex and cerebellum. After one week, she returned to an alert mentality and then she was diagnosed with PRES. She was discharged without any neurologic deficit on postoperative day 20. This report describes our experience with PRES after spinal surgery was performed under general anesthesia on a suspected untreated hypertensive patient.
Collapse
Affiliation(s)
- Ji Hwan Yi
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | | | | | | |
Collapse
|
|
20
|
Abstract
Posterior reversible encephalopathy syndrome (PRES) is characterized by headache, altered mental status, visual disturbances, and seizures. Radiological features typically include edema of the posterior cerebral regions, especially of the parietooccipital lobes. Atypical imaging features, such as involvement of anterior cerebral regions, deep white matter, and the brain stem are also frequently seen. Vasoconstriction is common in vascular imaging. Different conditions have been associated with PRES, but toxemia of pregnancy, solid organ or bone marrow transplantation, immunosuppressive treatment, cancer chemotherapy, autoimmune diseases, and hypertension are most commonly described. The pathophysiology of PRES is unclear and different hypotheses are being discussed. Posterior reversible encephalopathy syndrome is best managed by monitoring and treatment in the setting of a neurointensive care unit. The prognosis is usually benign with complete reversal of clinical symptoms within several days, when adequate treatment is immediately initiated. Treatment of severe hypertension, seizures, and withdrawal of causative agents represent the hallmarks of specific therapy in PRES. Delay in diagnosis and treatment may lead to permanent neurological sequelae. Therefore, awareness of PRES is of crucial importance for the intensivist.
Collapse
Affiliation(s)
- Dimitre Staykov
- Neurology Department, University of Erlangen-Nuremberg, Germany.
| | | |
Collapse
|
|
21
|
Nerve injuries after neuraxial anaesthesia and their medicolegal implications. Best Pract Res Clin Obstet Gynaecol 2010; 24:367-81. [PMID: 20053587 DOI: 10.1016/j.bpobgyn.2009.11.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2009] [Accepted: 11/25/2009] [Indexed: 11/21/2022]
|
|
22
|
|
|
23
|
Pradhan A, Jairam A, Kumar R, Srivastava A, Srivastava A, Sreevastava D, Dutta A, Arora S, Bairaria A, Bhargava A. Posterior Reversible Encephalopathy Syndrome Posttransplantation: A Case Report of Possible Association With Cerebrospinal Fluid Leak After Epidural Catheterization. Transplant Proc 2009; 41:1957-60. [DOI: 10.1016/j.transproceed.2008.12.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2008] [Revised: 07/27/2008] [Accepted: 12/02/2008] [Indexed: 11/15/2022]
|
|
24
|
Muñoz H, López-Tafall M, Blanco IF, Barez E. [Postpartum blindness following postdural puncture headache]. ACTA ACUST UNITED AC 2009; 56:122-3. [PMID: 19334665 DOI: 10.1016/s0034-9356(09)70346-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
|
25
|
Eran A, Barak M. Posterior reversible encephalopathy syndrome after combined general and spinal anesthesia with intrathecal morphine. Anesth Analg 2009; 108:609-12. [PMID: 19151296 DOI: 10.1213/ane.0b013e31818f635e] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
We describe a patient who was in a stupor for several days after combined general-spinal anesthesia. Both clinical manifestations and magnetic resonance imaging findings were consistent with posterior reversible encephalopathy syndrome and resolved after the patient recovered spontaneously.
Collapse
Affiliation(s)
- Ayelet Eran
- Department of Radiology, Rambam Health Care Campus and the Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | | |
Collapse
|
|
26
|
|
|
27
|
Servillo G, Apicella E, Striano P. Posterior reversible encephalopathy syndrome (PRES) in the parturient with preeclampsia after inadvertent dural puncture. Int J Obstet Anesth 2008; 17:88-9. [PMID: 17881219 DOI: 10.1016/j.ijoa.2007.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|