Type of edema in PRES depends on serum albumin

1. Type of edema in PRES depends on serum albumin Agnes Pirker Dpt. of Neurology Medical University of Vienna, Austria

2. PRES • cytotoxic edema? • immunosuppresion, renal diseases, sepsis, malignancies… • other localizations? • Cerebral vasogenic edema • Excessive hypertension overvhelms cerebral autoregulatory mechanisms • posterior circulation Hinchey et al. NEJM 1996, Paulson et al. Cerebraovasc Brain metab Rev 1990, Sheth et al. Eur Neurol 1996, Müller-Mang et al. Neurorad 2009, Bartynski et al AJNR 2006

3. What determines type of edema in PRES? • Serum albumin? • 75% of Plasma-Protein • 75% of COP • COP acts against perfusion pressure • scavanges ROS • prevents endothel from damage • low in many conditions prone to PRES (elevated turnover or damage through ROS) Quinlan et al, Hepatology 2005

4. Study • 28 patients • albumin, routine chemistry, RBC, WBC • Type of edema: cytotoxic vs. vasogenic • FLAIR, DWI, ADC-maps vasogenic edema cytotoxic edema ADC FLAIR FLAIR DWI ADC

5. albumin (mg/dl) cytotoxic vasogenic Results I • 21 female, 7 male • mean age 43± 18,6 • etiology: • pregnancy (8), hypertension (11), immunosuppressive drugs (11), sepsis (1) • edema: • 22 vasogenic, 6 cytotoxic • albumin lower in vasogenic than in cytotoxic edema, • 29,3mg/dl ±4,2 vs 38,4mg/dl ±6,7, p<0,01

6. Results II

7. Decreased albumin involved in Pathogenesis of PRES COP – perfusion pressure reduced Interaction with ECM reduced ROS – scavanging endothelial damage increased vascular permeability fluid extravasation vasogenic edema

8. f, 40a, 180/90 – vasogenic edema FLAIR DWI ADC Albumin 21 mg/dl

9. f, 68a, 190/110 – cytotoxic edema FLAIR DWI ADC Albumin 38,6 mg/dl

10. f, 30a, pulmoTx, CyA – cytotoxic edema DWI ADC Albumin 41,2 mg/dl

11. f, 22a, SLE, CyA – vasogenic edema FLAIR DWI ADC Albumin 24,7 mg/dl

12. Thank you for your attention.