My PRESentation Dr Luke Williamson Mrs K Confusion

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