MRI SPECTRUM OF POSTERIOR REVERSIBLE ENCEPHALOPATHY SYNDROME(PRES)

Dr Nirav Kadvani Dr Chandresh Karnavat Dr Ritu Kashikar Dr Shrinivas Desai JASLOK HOSPITAL AND RESEARCH CENTRE

AIM

To study the spectrum of PRES(Posterior Reversible Encephalopathy Syndrome)

DEFINITION

Acute change in Blood Pressure. 

Inability of posterior circulation  to autoregulate

Neurotoxicity menifiested as PRES

Hyperperfusion

Disruption of the  blood brain barrier 

Vasogenic oedema, but not infarction, commonly in the parieto-occipital regions

MATERIALS & METHODSStudy Area: Radiology department, JHRCAge: All Age group Sex: 11 male 8 female Machine:3T SIEMENS MAGNETOM, Sequences:T1,T2, FLAIR,DWI,ADC Images

were obtainedDuration: August 2014 to January 2016

CASE-1 PREGNANCY WITH HYPERTENSION & HEADACHE

WATERSHED AREA LESION

CASE-2 POST LSCS, HYPERTENSION & SEIZURES, RIGHT UPPER LIMB

WEAKNESS

FRONTAL LOBE LESION

CASE-3 POST RENAL TRANSPLANT, VISUAL SYMPTOMS

OCCIPITAL LOBE LESION

CASE-5 UNCONTROLLED HYPERTENSION & HEADACHE

WITH MICROBLEED

CASE-6 POST BONE MARROW TRANSPLANT, HEADACHE & APHASIA

SPLENIAL LESION

CASE -7 POST RENAL TRANSPLANT, ALTERED MENTATION

BASAL GANGLIA LESION

CASE-8 POST TRANSPLANT, UNCONTROLLED HYPERTENSION & ATAXIA

CEREBELLAR LESION

CASE-9 POST TRANSPLANT H/O SEIZURES

UNILATRRAL LESION

LOCATIONS OF BRAIN LESIONS

Location % PatientsOccipital/parietal 98

Frontal lobe 68

Inferior temporal/occipital 40

Cerebellum 32

Brain stem 13

Basal ganglia 14

Deep white matter 18

Splenium corpus callosum 10

RESULTS

DISCUSSION PRES is also known as acute  hypertensive

encephalopathy or reversible posterior leukoencephalopathy.

Presents with headache, seizures, encephalopathy and/or visual disturbance.

Two main theories High blood pressure: leads to loss of self-regulation, Endothelial dysfunction: leads to vasoconstriction and

hypoperfusion

ETIOLOGYSevere hypertension

◦ post partum◦ eclampsia/preeclampsia◦ acute glomerulonephritis

Haemolytic uraemic syndrome (HUS)

Thrombocytopaenic thromboic purpura (TTP)

Systemic lupus erythematosus (SLE)

Drug toxicity◦ cisplatin◦ interferon◦ erythropoietin◦ tacrolimus◦ cyclosporin◦ azathioprine◦ use of L-asparginase ◦ bone marrow or stem cell

or organ transplantationSepsisHyperammonemia

MRI FEATURES T1: hypo intense in affected regions

T1 C+ (Gd): patchy variable enhancement. It can be seen in ~35% of

patients, whether leptomeningeal or cortical pattern.

T2: hyperintense in affected regions

DWI: usually normal

ADC: signal increased in affected regions due to increased diffusion

GRE: may show hypointense signal in cases of haemorrhage

SWI: may show microhemorrhages in up to 50%

DIFFERENTIALSProgressive multifocal leukoencephalopathy (PML):

immunocompromised, commonly affect subcortical u-fibre

Severe hypoglycaemia:diabetic and insulinoma, typically bilateral,spares cerebellum brainstem and thalami in adults

Posterior circulation strokeGliomatosis cerebri: Diffusely infiltrative glial

tumour that involves at least three lobes by definitionSagital sinus thrombosisHypoxic-ischaemic encephalopathy: Primarily affects

gray matter structure.

DIFFERENTIALSProgressive multifocal leukoencephalopathy

(PML)Severe hypoglycaemia Posterior circulation strokeGliomatosis cerebriSagital sinus thrombosisHypoxic-ischaemic encephalopathy

TYPICAL PATTERNS

Dominant Parietal-Occipital Pattern

Superior Frontal Sulcus Pattern

Holohemispheric watershed pattern

TAKE HOME MESSAGE

Syndrome can involve or extend beyond the posterior cerebrum, Like Frontal and temporal lobes Cerebellum Brain stem Basal ganglia Deep white matter Splenium

Some patients can progress to develop permanent cerebral injury

Can be unilateral May have associated microbleed

PRES CAN BE MISNOMER

REFERENCESPosterior Reversible Encephalopathy Syndrome,Part 1:

Fundamental Imaging and ClinicalFeatures ,W.S. Bartynski,Am J Neuroradiol 29:1036–42

Posterior reversible encephalopathy syndrome: clinical and radiological manifestations, pathophysiology, and outstanding questions Jennifer E Fugate Prof and Alejandro A Rabinstein ProfLancet Neurology, The, 2015-09-01, Volume 14, Issue 9.

The many faces of posterior reversible encephalopathy syndrome C J Stevens, MD and M K S Heran, MD, FRCPC,Br J Radiol.2012 Dec

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