Posterior reversible encephalopathy syndrome

AKA reversible posterior leukoencephalopathy syndrome (RPLS). A group of encephalopathies with a characteristic pattern of widespread vasogenic brain edema seen on CT or MRI with some predominance in the parietal and occipital regions 1).

The most common PRES pattern involves watershed zones with involvement of the cortex, subcortical and deep white matter to a variable extent 2).

A small number of patients with PRES will go on to infarction.

Patients may present with headaches, seizures, mental status changes, and focal neurologic deficits.

Intracerebral hemorrhage (ICH) and SAH may occur in up to 15% 3).

Posterior reversible encephalopathy syndrome (PRES) is a constellation of neurologic symptoms-seizures, headaches, altered mental status, and visual changes-associated with characteristic brain magnetic resonance imaging findings seen on T2 and fluid-attenuated inversion recovery sequences.

The etiology of this entity includes a sudden increase in blood pressure, renal failure, immunosuppressive drugs, infections, and intravenous immunoglobulin (IVIG).

The development of PRES after surgical resection of posterior fossa tumors has mostly been linked to the pediatric neurosurgical practice.

Patients may present with headache, seizures, mental status changes and focal neurologic deficit. Intracerebral hemorrhage (ICH) and SAH may occur in up to 15% 4).

Classically, magnetic resonance imaging (MRI) findings show a symmetric reversible vasogenic edema in the parietooccipital lobes. PRES can involve the brainstem and cerebellum and sometimes can leave irreversible lesions but it can also recur, which is a very rare presentation.

Two cases of patients with SCI who developed PRES from AD. Each patient was correctly diagnosed, leading to appropriate treatment of the factors leading to their AD and subsequent resolution of their PRES symptoms. Conclusions/Clinical Relevance: In SCI patients who present with new seizures, visual deficits, or other neurologic signs, PRES should be considered as a part of the differential diagnosis as a good outcome relies on rapid recognition and treatment of AD 5).

Hage et al., from the Saint George Hospital University Medical Center, Beirut, Lebanon report a case of recurrent PRES with cerebellar involvement associated with noncommunicating hydrocephalus in a 2-year-old child with renal failure on peritoneal dialysis after receiving Etoposide for macrophage activation syndrome 6).


Quarante et al report 2 new pediatric cases of posterior reversible encephalopathy syndrome (PRES) that developed after surgical resection of a posterior fossa tumor. Appropriate management includes supportive measures, antihypertensive agents, and antiepileptic drugs, if needed. Full recovery is the most likely outcome in line with previous articles 7).


Sorour et al. report the first case of PRES after resection of a giant vestibular schwannoma in an adult patient. This 57-year-old female patient underwent a retrosigmoid approach for total resection of her left-sided giant tumor. On the second postoperative day, she developed the classic clinical and radiologic characteristics of PRES. She was treated aggressively with antihypertensive and anticonvulsant medications and showed complete recovery without sequelae. Conclusion PRES is a potential yet rare complication of surgeries to posterior fossa tumors that are compressing the brainstem. Rapid diagnosis and aggressive management are essential for achieving the best outcome 8).

1) , 2) , 3) , 4)
Bartynski WS. Posterior reversible encephalopathy syndrome, part 1: fundamental imaging and clinical features. AJNR Am J Neuroradiol. 2008; 29:1036–1042
Hubbard ME, Phillips AA, Charbonneau R, Squair JW, Parr AM, Krassioukov A. PRES secondary to autonomic dysreflexia: A case series and review of the literature. J Spinal Cord Med. 2019 May 29:1-7. doi: 10.1080/10790268.2019.1616146. [Epub ahead of print] PubMed PMID: 31140946.
Hage P, Kseib C, Hmaimess G, Jaoude PA, Noun P. Recurrent posterior reversible encephalopathy syndrome with cerebellar involvement leading to acute hydrocephalus. Clin Neurol Neurosurg. 2018 Jul 5;172:120-123. doi: 10.1016/j.clineuro.2018.07.005. [Epub ahead of print] PubMed PMID: 29990959.
Quarante LH, Mena-Bernal JH, Martín BP, Carrasco MR, Casado MJ, de Aragón AM, de Las Heras RS. Posterior reversible encephalopathy syndrome (PRES): a rare condition after resection of posterior fossa tumors: two new cases and review of the literature. Childs Nerv Syst. 2016 May;32(5):857-63. doi: 10.1007/s00381-015-2954-5. Epub 2015 Nov 19. Erratum in: Childs Nerv Syst. 2016 Apr;32(4):763. PubMed PMID: 26584552.
Sorour M, Sayama C, Couldwell WT. Posterior Reversible Encephalopathy Syndrome after Surgical Resection of a Giant Vestibular Schwannoma: Case Report and Literature Review. J Neurol Surg A Cent Eur Neurosurg. 2015 Jun 19. [Epub ahead of print] PubMed PMID: 26091111.
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