A Case of Posterior Reversible Encephalopathy Syndrome Mimicking Stroke

INTRODUCTION

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological entity characterized by headache, altered mental status, seizures, and visual disturbances and is associated with characteristic reversible lesions on neuroimaging in a severe arterial hypertension setting.¹ This condition is usually seen in patients who had received immunosuppressive therapy, eclampsia, hypertension, and autoimmune diseases.² Typically, PRES involves parieto-occipital lobes and can also involve other cerebral areas, such as brain stem and cerebellum.³ Early recognition and treatment are important to prevent neurologic sequelae. PRES is reversible once the underlying precipitating cause is treated. Here, we present a case of cisplatin induced PRES mimicking stroke with atypical magnetic resonance imaging (MRI) features.

CASE DESCRIPTION

A 46-year-old female patient admitted with complaints of repeated vomiting, aphasia, and right upper limb weakness since 12 hours. Patient was operated case of Ca colon 5 months back. She was on chemotherapy and received eighth cycle of cisplatin 8 days back.

DISCUSSION

The mechanism by which immunosuppressive and cytotoxic agents cause PRES is the alteration in blood–brain barrier due to direct impairment of endothelium results in extravasation of fluid leading to vasogenic edema.^4–6 Many conditions may resemble PRES including ictal or post-ictal state (with or without status epilepticus), infectious encephalitis, vasculitis, cerebral venous sinus thrombosis, and ischemic stroke.⁷

Chemotherapy agents that can cause PRES are cisplatin, gemcitabine, oxaliplatin, carboplatin, cytarabine, methotrexate, vincristine, bevacizumab, sunitinib, rituximab, and infliximab.^7–10 Condition that can cause PRES eclampsia, preeclampsia, autoimmune diseases, and hypertensive crisis.

MRI brain is the first investigation of choice for the diagnosis of PRES. Nonconvulsive status epilepticus should be ruled out by electroencephalogram.

Treatment includes correction of underlying cause of PRES, control of blood pressure, antiedema measure, and antiepileptic drugs. Patient may require withdrawal of chemotherapy or immunosuppressive drugs, cesarean section in case of eclampsia, and other interventions. Risk of ischemia and bleeding can be reduced by treating the underlying precipitating cause.

CONCLUSION

Although the clinical presentation of PRES is nonspecific, most patients have variable symptoms. High index of suspicion should be kept for patients of PRES having new onset of seizures, altered sensorium, and new onset of neuro deficit with normal CT brain on presentation and presence of strong predisposing factors such as recent chemotherapy, PIH, and uncontrolled hypertension.

MRI is crucial for diagnosing PRES, monitoring the course, and assessing the treatment effectiveness. Repeated cerebral imaging helps to support the diagnosis. Risk of ischemia, bleeding, and death can be prevented by early diagnosis and treatment of underlying cause of PRES.

Our case is important as patient presented with symptoms mimicking of left-sided stroke with initial CT brain normal on presentation and MRI suggestive of atypical findings. MRI should be the first investigation of choice for diagnosing PRES. Early recognition and resolution of the underlying cause lead to complete recovery.

CONSENT OF PATIENT

The authors certify that they have done all appropriate patient consent formalities. Patient has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names, and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

REFERENCES

1. Hinchey J, Chaves C, Appignani B, Breen J, Pao L, Wang A, et al. A reversible posterior leukoencephalopathy syndrome. N Engl J Med 1996;334(8):494–500. DOI: 10.1056/NEJM199602223340803.

2. Lee VH, Wijdicks EF, Manno EM, Rabinstein AA. Clinical spectrum of reversible posterior leuko encephalopathy syndrome. Arch Neurol 2008;65:205–210.

3. Ahn KJ, You WJ, Jeong SL, Lee JW, Kim BS, Lee JH, et al. Atypical manifestations of reversible posterior leuko encephalopathy syndrome: findings on diffusion imaging and ADC mapping. Neuroradiology 2004;46(12):978–983. DOI: 10.1007/s00234-004-1276-1.

4. Pande AR, Ando K, Ishikura R, Nagami Y, Takada Y, Wada A, et al. Clinicoradiological factors influencing the reversibility of posterior reversible encephalopathy syndrome: a multicenter study. Radiat Med 2006;24(10):659–668. DOI: 10.1007/s11604-006-0086-2.

5. De Seze J, Mastain B, Stojkovic T, Ferriby D, Pruvo JP, Destee A, et al. Unusual MR findings of the brain in arterial hypertension. Am J Neuroradiol 2000;21(2):391–394.

6. Kitaguchi H, Tomimoto H, Miki Y, Yamamoto A, Terada K, Satoi H, et al. A brainstem variant of reversible posterior leukoencephalopathy syndrome. Neuroradiology 2005;47(9):652–656. DOI: 10.1007/s00234-005-1399-z.

7. Trikha A, Sharma A, Kumar R. Posterior reversible encephalopathy syndrome. J Obstet Anaesth Crit Care 2014;4(Issue 2):59–63. DOI: 10.4103/2249-4472.143873.

8. Zahir MN, Masood N, Shabbir-Moosajee M. Cisplatin-induced posterior reversible encephalopathy syndrome and successful re-treatment in a patient with non-seminomatous germ cell tumor: a case report. J Med Case Rep 2012;6(1):409. DOI: 10.1186/1752-1947-6-409.

9. Mirzamoradi M, Hosseini M-S, Saleh M, Esmaeili S. Posterior reversible encephalopathy syndrome (PRES) associated with eclampsia: a case study. Int J Med Res Health Sci 2017;6(3):41–47.

10. Abraham J, Truong QV, Nagaiah G, Newton M, Veltri L. Gemcitabine associated with Posterior reversible encephalopathy syndrome (PRES): a case report and review of the literature. Clin Adv Hematol Oncol 2012;10(9).