University of Kansas Medical Center, Kansas City, KS, USA.
University of Kansas Medical Center, Kansas City, KS, USA.
Am J Emerg Med. 2021 Jul;45:61-64. doi: 10.1016/j.ajem.2021.02.013. Epub 2021 Feb 11.
Posterior Reversible Encephalopathy Syndrome (PRES) and the related term Reversible Posterior Leukoencephalopathy Syndrome (RPLS) denote a constellation of clinical symptoms paired with key radiological findings. These symptoms may include headache, altered mental status, visual changes, and seizures. PRES is a rare condition and remains a challenging diagnosis to make in the emergency department. Data on risk factors and clinical presentation are limited, and there is no recent literature-supported diagnostic criteria. Our primary objective was to identify initial symptoms, clinical presentation, and risk factors that should guide the emergency clinician to consider a diagnosis of PRES. A secondary objective was to identify associations between risk factors and the outcomes of mortality and ICU admissions.
This was a retrospective, observational study that evaluated patients seen in the Emergency Department (ED) in an urban tertiary care center with the diagnosis of PRES or RPLS from 1/1/2008 to 1/1/2018. The Health System's Electronic Medical Record was used to collect data. Search criteria included any patient diagnosed with Posterior Reversible Encephalopathy Syndrome (PRES) or Reversible Posterior Leukoencephalopathy Syndrome (RPLS), and excluded patients under 18 years of age, transfer patients, or patients that were not evaluated in our emergency department.
We identified 98 patients based on our initial search criteria. After a chart review, 27 patients met our predefined eligibility criteria. In patients with confirmed diagnosis of PRES, the majority were female (70%) and 37% were either on an immunomodulator or undergoing chemotherapy at the time of presentation. 67% of patients presented with altered mental status, 41% had a focal neurologic deficit, and 37% had a witnessed seizure prior to diagnosis. Headache (48%), nausea (33%), and vision changes (30%) were the next most common reported symptoms. The majority of patients were hypertensive at time of presentation (82%) and many had a past medical history of hypertension (78%); twelve were given anti-hypertensive medications. 33% of the patients were admitted to the ICU and 26% died. There were no statistical associations found between documented ED interventions and the outcome of mortality.
PRES is difficult to identify and diagnose in the emergency department. Significant risk factors such as female gender, hypertension, and those currently undergoing active immunotherapy/chemotherapy are associated with PRES. Common presenting complaints and exam findings include headache, altered mental status, and neurologic deficits. Emergency providers should consider PRES in patients presenting with altered mental status with significant risk factors, especially with neurologic deficits for which stroke has been ruled out.
后部可逆性脑病综合征（PRES）和相关术语可逆性后部白质脑病综合征（RPLS）表示一系列临床症状与关键影像学发现相结合。这些症状可能包括头痛、精神状态改变、视力变化和癫痫发作。 PRES 是一种罕见的疾病，在急诊科做出诊断仍然具有挑战性。关于危险因素和临床表现的数据有限，并且没有最近的文献支持的诊断标准。我们的主要目标是确定初始症状、临床表现和危险因素，以指导急诊临床医生考虑 PRES 的诊断。次要目标是确定危险因素与死亡率和 ICU 入院之间的关联。
这是一项回顾性观察性研究，评估了 2008 年 1 月 1 日至 2018 年 1 月 1 日期间在城市三级护理中心急诊科就诊的诊断为 PRES 或 RPLS 的患者。使用医疗系统的电子病历收集数据。搜索标准包括任何诊断为后部可逆性脑病综合征（PRES）或可逆性后部白质脑病综合征（RPLS）的患者，并排除 18 岁以下、转院或未在我们急诊科就诊的患者。
根据我们的初步搜索标准，我们确定了 98 名患者。经过病历审查，有 27 名患者符合我们预先确定的入选标准。在确诊为 PRES 的患者中，大多数为女性（70%），37%的患者在就诊时正在接受免疫调节剂或化疗。67%的患者表现为精神状态改变，41%的患者有局灶性神经功能缺损，37%的患者在诊断前有目击性癫痫发作。头痛（48%）、恶心（33%）和视力变化（30%）是下一个最常见的报告症状。大多数患者在就诊时血压升高（82%），许多患者有高血压病史（78%）；12 人接受了抗高血压药物治疗。33%的患者入住 ICU，26%的患者死亡。在急诊科干预措施与死亡率之间没有发现统计学关联。
PRES 在急诊科很难识别和诊断。女性、高血压和正在接受主动免疫治疗/化疗等显著危险因素与 PRES 相关。常见的表现症状和检查结果包括头痛、精神状态改变和神经功能缺损。对于出现精神状态改变且存在显著危险因素的患者，特别是已经排除中风的神经功能缺损患者，急诊医生应考虑 PRES。
