My PRESentation Dr Luke Williamson
Feb 23, 2016
My PRESentation
Dr Luke Williamson
Mrs K 61 years old
• Confusion
• Twitching
• Headache
• Nausea
• Conscious collapse
What else would you like to know?
History
• No further Hx from patient• No collateral Hx• Patient notes– Medical admission 10/7 ago– Confusion, headache, nausea, generally unwell– ? Aseptic meningo-encephalitis– Acute Kidney Injury– Sent home on oral antibiotics
What next?
Obs
• BP: 206/80
• HR: 53
• SpO2: 97% RA
• RR: 16
• T: 35.9oC
GCS
• E:4
• V:4
• M:6
Examination
• CVS: NAD
• Resp: NAD
• Abdo: NAD
• Neuro…
Eyes
• PEARL
• Deviated left gaze
• Unable to fixate
• No reaction to visual confrontation
Upper Limbs
• Bilateral myoclonic jerks• Power: 5/5 all muscle groups• Tone: normal• Reflexes: normal• Sensation: grossly normal• Coordination: unable to finger-nose point
Lower limbs
• Tone – hypertonic, sustained clonus bilaterally
• Reflexes – hyperreflexic bilaterally
• Plantars: downgoing
And then…
• Generalised tonic-clonic seizure– Terminated with 1mg clonazepam
Investigations
• Bloods – pending• ECG: sinus bradycardia• CXR: NAD• CT Brain…
CT Brain
Differential Diagnosis
• Haemorrhage
• Infarction
• Infection
• Something else?
Who ya’ gonna call?
Neurology
• ? PRES
• Lower BP
• Give clonazepam
• Admit patient
• Needs MRI
ICU
• We’ll take the patient!– Arterial line– IV sodium nitroprusside
MRI
Outcome
• Posterior Reversible Encephalophathy Syndrome
• Symptoms resolved with control of BP
• Discharged once well
PRES
• Clinicoradiological entity
– Combination of clinical and MRI findings
– Data come from retrospective case series
– Global incidence unknown
– Mean age 39-47
– Females > males
Clinical Features
• Consciousness impairment (26-94%)
• Seizure activity (71-92%)
• Acute hypertension (67-80%)
• Headaches (26-53%)
• Visual abnormalities (26-53%)
• Nausea/vomiting (26-53%)
• Focal neurological signs (3-17%)
Acute Hypertension
• N.B. Acute hypertension is associated with PRES
• However, it is not associated with the intensity of clinico-radiological manifestations nor severity of PRES
Radiological Features (MRI - FLAIR)
• Bilateral (69-100%)• Confluent (13-23%)• Posterior>anterior (22-93%)• Occipital (93-99%)• Parietal (50-99%)
• CT – hypodensities in a suggestive topographic distribution can suggest PRES
Pathophysiology
Pathophysiology
• Cerebral Vasogenic Oedema• Leaky blood brain barrier
• Two conflicting theories• Hyperperfusion – hypertension as feature• Hypoperfusion – SPECT 99mTc-HMPAO imaging
Reverse The Encephalopathy
• Toxins– Cytotoxic agents– Anti-angiogenic agents– Immunomodulatory cytokines– Immunosuppressive agents– Miscellaneous
Other causes
• Hypertension
• Sepsis
• Preeclampsia/Eclampsia
• Autoimmune disease
Investigations
• Early diagnosis – clinical suspicion• MRI• EEG• Mg2+• Consider LP• Consider toxicological screen• Look for PRES-associated conditions
Management
• Involve ICU
• Antiepileptic treatment as required
• Blood pressure control as required– Decrease MAP by 20-25% in 1st 2 hours– Aim for BP 160/100mmHG within 6 hours
Correct the underlying cause
Summary
• Potentially reversible condition
• Combination of clinical and radiological findings
• Involve ICU
• Find and treat the underlying cause