Download - My PRESentation
![Page 1: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/1.jpg)
My PRESentation
Dr Luke Williamson
![Page 2: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/2.jpg)
![Page 3: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/3.jpg)
Mrs K 61 years old
• Confusion
• Twitching
• Headache
• Nausea
• Conscious collapse
![Page 4: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/4.jpg)
What else would you like to know?
![Page 5: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/5.jpg)
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
![Page 6: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/6.jpg)
What next?
![Page 7: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/7.jpg)
Obs
• BP: 206/80
• HR: 53
• SpO2: 97% RA
• RR: 16
• T: 35.9oC
![Page 8: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/8.jpg)
GCS
• E:4
• V:4
• M:6
![Page 9: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/9.jpg)
Examination
• CVS: NAD
• Resp: NAD
• Abdo: NAD
• Neuro…
![Page 10: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/10.jpg)
Eyes
• PEARL
• Deviated left gaze
• Unable to fixate
• No reaction to visual confrontation
![Page 11: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/11.jpg)
Upper Limbs
• Bilateral myoclonic jerks• Power: 5/5 all muscle groups• Tone: normal• Reflexes: normal• Sensation: grossly normal• Coordination: unable to finger-nose point
![Page 12: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/12.jpg)
Lower limbs
• Tone – hypertonic, sustained clonus bilaterally
• Reflexes – hyperreflexic bilaterally
• Plantars: downgoing
![Page 13: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/13.jpg)
And then…
• Generalised tonic-clonic seizure– Terminated with 1mg clonazepam
![Page 14: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/14.jpg)
Investigations
• Bloods – pending• ECG: sinus bradycardia• CXR: NAD• CT Brain…
![Page 15: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/15.jpg)
CT Brain
![Page 16: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/16.jpg)
Differential Diagnosis
• Haemorrhage
• Infarction
• Infection
• Something else?
![Page 17: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/17.jpg)
Who ya’ gonna call?
![Page 18: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/18.jpg)
Neurology
• ? PRES
• Lower BP
• Give clonazepam
• Admit patient
• Needs MRI
![Page 19: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/19.jpg)
ICU
• We’ll take the patient!– Arterial line– IV sodium nitroprusside
![Page 20: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/20.jpg)
MRI
![Page 21: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/21.jpg)
Outcome
• Posterior Reversible Encephalophathy Syndrome
• Symptoms resolved with control of BP
• Discharged once well
![Page 22: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/22.jpg)
PRES
• Clinicoradiological entity
– Combination of clinical and MRI findings
– Data come from retrospective case series
– Global incidence unknown
– Mean age 39-47
– Females > males
![Page 23: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/23.jpg)
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%)
![Page 24: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/24.jpg)
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
![Page 25: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/25.jpg)
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
![Page 26: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/26.jpg)
Pathophysiology
![Page 27: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/27.jpg)
Pathophysiology
• Cerebral Vasogenic Oedema• Leaky blood brain barrier
• Two conflicting theories• Hyperperfusion – hypertension as feature• Hypoperfusion – SPECT 99mTc-HMPAO imaging
![Page 28: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/28.jpg)
Reverse The Encephalopathy
• Toxins– Cytotoxic agents– Anti-angiogenic agents– Immunomodulatory cytokines– Immunosuppressive agents– Miscellaneous
![Page 29: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/29.jpg)
Other causes
• Hypertension
• Sepsis
• Preeclampsia/Eclampsia
• Autoimmune disease
![Page 30: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/30.jpg)
Investigations
• Early diagnosis – clinical suspicion• MRI• EEG• Mg2+• Consider LP• Consider toxicological screen• Look for PRES-associated conditions
![Page 31: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/31.jpg)
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
![Page 32: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/32.jpg)
Correct the underlying cause
![Page 33: My PRESentation](https://reader035.vdocument.in/reader035/viewer/2022070422/5681643b550346895dd605f3/html5/thumbnails/33.jpg)
Summary
• Potentially reversible condition
• Combination of clinical and radiological findings
• Involve ICU
• Find and treat the underlying cause