1. My PRESentation Dr Luke Williamson

3. Mrs K61 years old Confusion Twitching Headache Nausea Conscious collapse

4. What else would you like to know?

5. 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

6. What next?

7. Obs BP: 206/80 HR: 53 SpO2: 97% RA RR: 16 T: 35.9oC

8. GCS E:4 V:4 M:6

9. Examination CVS: NAD Resp: NAD Abdo: NAD Neuro…

10. Eyes PEARL Deviated left gaze Unable to fixate No reaction to visual confrontation

11. Upper Limbs Bilateral myoclonic jerks Power: 5/5 all muscle groups Tone: normal Reflexes: normal Sensation: grossly normal Coordination: unable to finger-nose point

12. Lower limbs Tone – hypertonic, sustained clonus bilaterally Reflexes – hyperreflexic bilaterally Plantars: downgoing

13. And then… Generalised tonic-clonic seizure – Terminated with 1mg clonazepam

14. Investigations Bloods – pending ECG: sinus bradycardia CXR: NAD CT Brain…

15. CT Brain

16. Differential Diagnosis Haemorrhage Infarction Infection Something else?

17. Who ya’ gonna call?

18. Neurology ? PRES Lower BP Give clonazepam Admit patient Needs MRI

19. ICU We’ll take the patient! – Arterial line – IV sodium nitroprusside

20. MRI

21. Outcome Posterior Reversible Encephalophathy Syndrome Symptoms resolved with control of BP Discharged once well

22. PRES Clinicoradiological entity – Combination of clinical and MRI findings – Data come from retrospective case series – Global incidence unknown – Mean age 39-47 – Females > males

23. Clinical Features Consciousness impairment (26-94%) Seizure activity (71-92%) Acute hypertension (67-80%) Headaches (26-53%) Visual abnormalities (26-53%) Nausea/vomiting (26-53%) Focal neurological signs (3-17%)

24. 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

25. Radiological Features (MRI - FLAIR) Bilateral (69-100%) Confluent (13-23%) Posterior>anterior (22-93%) Occipital (93-99%) Parietal (50-99%) CT – hypodensities in a suggestive topographic distribution can suggest PRES

26. Pathophysiology

27. Cerebral Vasogenic Oedema Leaky blood brain barrier Two conflicting theories Hyperperfusion – hypertension as feature Hypoperfusion – SPECT 99mTc-HMPAO imaging

28. Reverse The Encephalopathy Toxins – Cytotoxic agents – Anti-angiogenic agents – Immunomodulatory cytokines – Immunosuppressive agents – Miscellaneous

29. Other causes Hypertension Sepsis Preeclampsia/Eclampsia Autoimmune disease

30. Investigations Early diagnosis – clinical suspicion MRI EEG Mg2+ Consider LP Consider toxicological screen Look for PRES-associated conditions

31. 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 160/100mmHG within 6 hours

32. Correct the underlying cause

33. Summary Potentially reversible condition Combination of clinical and radiological findings Involve ICU Find and treat the underlying cause