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Life in the Fast Lane • LITFL • Medical Blog

Emergency medicine and critical care medical education blog

Critical Care Compendium | Posterior reversible encephalopathy syndrome (PRES)

Posterior reversible encephalopathy syndrome (PRES)

by Chris Nickson, Last updated December 13, 2017

Reviewed and revised [last-modified]

OVERVIEW

Posterior reversible encephalopathy syndrome (PRES) is a syndrome of ‘cephalgia, convulsions, confusion, and vision loss’ (CCCV) typically in the context of severe hypertension

PATHOPHYSIOLOGY

The pathophysiology of PRES is poorly understood

  • classically affects the posterior circulation of the brain
  • combination of endothelial damage, impaired auto-regulation and increased cerebral perfusion pressure
  • leads to hyperperfusion with resultant disruption of the blood brain barrier causing vasogenic oedema

CLINICAL MANIFESTATIONS

  • headache
  • seizures
  • confusion
  • vision loss
  • hypertension
  • risk factors

RISK FACTORS

  • severe hypertension
  • eclampsia
  • renal failure
  • immunosuppressive medications such as tacrolimus and cyclosporine
  • hypomagnesemia
  • post-transplant

INVESTIGATIONS

  • MRI brain
    • classically bilateral hyperintense densities in the parieto-occipital regions on T2 weighted images
  • analogous finds may be seen on a CT head

MANAGEMENT

Specfic therapy

  • Control hypertension
  • Treat seizures
  • Treat underlying cause
    • e.g. IV magnesium and emergent delivery if pregnant
  • Stop precipitating medications (e.g tacrolimus, cyclosporin)

PROGNOSIS

  • partial to complete recovery is usual with appropriate treatment
  • residual neurological and visual deficits may persist

References and Links

Journal articles

  • Moratalla MB. Posterior Reversible Encephalopathy Syndrome. Emerg Med J. 2010 Jul;27(7):547 [pubmed]

FOAM and web resources

  • Radiopaedia — Posterior Reversible Encephalopathy Syndrome (PRES)

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About Chris Nickson

FCICM FACEM BSc(Hons) BHB MBChB MClinEpid(ClinTox) DipPaeds DTM&H GCertClinSim

Chris is an Intensivist at the Alfred ICU in Melbourne and is an Adjunct Clinical Associate Professor at Monash University. He is also the Innovation Lead for the Australian Centre for Health Innovation and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He has a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia's Northern Territory, Perth and Melbourne. He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education. He coordinates the Alfred ICU's education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the 'Critically Ill Airway' course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of Lifeinthefastlane.com, the RAGE podcast, the Resuscitology course, and the SMACC conference. His one great achievement is being the father of two amazing children. On Twitter, he is @precordialthump.

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