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My PRESentation

My PRESentation. Dr Luke Williamson. Mrs K 61 years old. Confusion Twitching Headache Nausea Conscious collapse. What else would you like to know?. History. No further Hx from patient No collateral Hx Patient notes Medical admission 10/7 ago

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My PRESentation

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  1. My PRESentation Dr Luke Williamson

  2. Mrs K 61 years old • Confusion • Twitching • Headache • Nausea • Conscious collapse

  3. What else would you like to know?

  4. 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

  5. What next?

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

  7. GCS • E:4 • V:4 • M:6

  8. Examination • CVS: NAD • Resp: NAD • Abdo: NAD • Neuro…

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

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

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

  12. And then… • Generalised tonic-clonic seizure • Terminated with 1mg clonazepam

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

  14. CT Brain

  15. Differential Diagnosis • Haemorrhage • Infarction • Infection • Something else?

  16. Who ya’ gonna call?

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

  18. ICU • We’ll take the patient! • Arterial line • IV sodium nitroprusside

  19. MRI

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

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

  22. 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%)

  23. 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

  24. 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

  25. Pathophysiology

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

  27. Reverse The Encephalopathy • Toxins • Cytotoxic agents • Anti-angiogenic agents • Immunomodulatory cytokines • Immunosuppressive agents • Miscellaneous

  28. Other causes • Hypertension • Sepsis • Preeclampsia/Eclampsia • Autoimmune disease

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

  30. Management • Involve ICU • Antiepileptic treatment as required • Blood pressure control as required • Decrease MAP by 20-25% in 1st 2 hours • Aim for BP 160/100mmHG within 6 hours

  31. Correct the underlying cause

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

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