CASE BASED APPROACH FOR SPECTRUM OF PRESS

1. 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

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

3. 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

4. MATERIALS & METHODS
 Study Area: Radiology department, JHRC
 Age: All Age group
 Sex: 11 male 8 female
 Machine:3T SIEMENS MAGNETOM,
 Sequences:T1,T2, FLAIR,DWI,ADC Images
were obtained
 Duration: August 2014 to January 2016

5. CASE-1 PREGNANCY WITH
HYPERTENSION & HEADACHE
WATERSHED
AREA LESION

6. CASE-2 POST LSCS, HYPERTENSION &
SEIZURES, RIGHT UPPER LIMB
WEAKNESS
FRONTAL
LOBE LESION

7. CASE-3 POST RENAL TRANSPLANT,
VISUAL SYMPTOMS
OCCIPITAL
LOBE LESION

8. CASE-5 UNCONTROLLED
HYPERTENSION & HEADACHE
WITH
MICROBLEED

9. CASE-6 POST BONE MARROW
TRANSPLANT, HEADACHE &
APHASIA
SPLENIAL
LESION

10. CASE -7 POST RENAL TRANSPLANT,
ALTERED MENTATION
BASAL
GANGLIA
LESION

11. CASE-8 POST TRANSPLANT,
UNCONTROLLED HYPERTENSION &
ATAXIA
CEREBELLAR
LESION

12. CASE-9 POST TRANSPLANT H/O
SEIZURES
UNILATRRAL
LESION

13. LOCATIONS OF BRAIN LESIONS
Location % Patients
Occipital/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

14. 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

15. ETIOLOGY
 Severe 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
transplantation
 Sepsis
 Hyperammonemia

16. 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%

17. DIFFERENTIALS
 Progressive 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 stroke
 Gliomatosis cerebri: Diffusely infiltrative glial
tumour that involves at least three lobes by
definition
 Sagital sinus thrombosis
 Hypoxic-ischaemic encephalopathy: Primarily
affects gray matter structure.

18. DIFFERENTIALS
 Progressive multifocal leukoencephalopathy
(PML)
 Severe hypoglycaemia
 Posterior circulation stroke
 Gliomatosis cerebri
 Sagital sinus thrombosis
 Hypoxic-ischaemic encephalopathy

19. TYPICAL PATTERNS
Dominant Parietal-Occipital Pattern
Superior Frontal Sulcus Pattern
Holohemispheric watershed pattern

20. 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

21. REFERENCES
 Posterior 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

22. THANK YOU