My PRESentation Dr Luke Williamson Mrs K Confusion

































- Slides: 33

My PRESentation Dr Luke Williamson


Mrs K • Confusion • Twitching • Headache • Nausea • Conscious collapse 61 years old

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 • Sp. O 2: 97% RA • RR: 16 • T: 35. 9 o. C


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 1 mg 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 Seizure activity Acute hypertension Headaches Visual abnormalities Nausea/vomiting Focal neurological signs (26 -94%) (71 -92%) (67 -80%) (26 -53%) (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 Confluent Posterior>anterior Occipital Parietal (69 -100%) (13 -23%) (22 -93%) (93 -99%) (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 99 m. Tc-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 Mg 2+ 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 1 st 2 hours – Aim for BP 160/100 mm. HG 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
Confusion Damage Confusion Damages Confusion as an element
Ethical Confusion and Confusion of Ethics Unpacking the
PRESENTATION PRESENTATION PRESENTATION PRESENTATION PRESENTATION PRESENTATION PRESENTATION PRESENTATION
Mrs Anderson Mrs Damron Mrs Ficor Mrs Shifflett
Mrs Ackerman and Mrs Slavick MRS ACKERMAN Masters
Mrs Hearne Mrs Efstratiou Mrs Efstratiou Math and
Mr Armstrong Mrs Cason Mrs Fulsom Mrs Leal
Third Grade Team Mrs Adams Mrs Behner Mrs