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PRES SYNDROME IN PARTURIENTS- A CASE SERIES
Abstract Number: F-74
Abstract Type: Case Report/Case Series
Introduction:The diagnosis of Posterior Reversible Encephalopathy Syndrome (PRES) was introduced in the 1990s to describe a clinical, neuro-radiological syndrome, which presents with unique-pattern of vasogenic brain edema in a setting of various neurotoxic states. We present a acase series of parturients with PRES syndrome with varying presentations.
CASE REPORTS:We present three parturients with PRES after neuro-axial anesthesia complicated by postdural puncture headache (PDPHA). All three patients experienced severe, witnessed tonic-clonic seizures. The full–scope of interdisciplinary management and neuroimaging findings is described in this report.
CASE 1: 29 years G3P0 female,after normal spontaneous vaginal delivery with epidural anesthesia presented with five day history of positional headache, hypertension and subsequent generalized seizure in ED.
CASE 2: 20 years G1P1 female, after normal delivery with epidural anesthesia, PDPHA and epidural blood patch presented with generalized tonic-clonic seizure and visual disturbances.
CASE 3: 23years G1P0 female, unaware of 25 weeks of gestation, presented in unresponsive status post generalized tonic-clonic seizure, hypertensive emergency and generalized facial/body edema.
Conclusion: First recognized in patients with toxemia of pregnancy and allogeneic bone marrow transplant, PRES has also been described in severe autoimmune conditions, renal failure, high-dose chemotherapy etc. Presenting symptoms include altered mental status, seizures, paresis, visual disturbances, headache and hypertension. Neuro-radiological imaging features edema in the parietal and occipital lobes, as well as the frontal lobe, the inferior temporal-occipital junction, and the cerebellum. Common watershed areas are affected in three distinctly recognized radiological patterns (holohemispheric, superior frontal-sulcal, and primary parietal-occipital), emphasizing the vasogenic nature of the condition.
Cases of concurrent PRES and PDPHA are very rare in medical practice. In a setting of hypertension, PRES has not been generally associated with PDPHA and this unique combination is scarcely described in literature. The opposing pathophysiologic features of the two conditions - decreased intracranial pressure (ICP) and increased intraparenchymal pressure (IPP) - pose an exclusive diagnostic and management challenge.
Combination of toxemia and/or vasculopathy carries a considerable risk of permanent neurological damage and mortality. Immediate recognition and goal directed, expeditious management is essential for complete resolution of symptoms. This requires complex management and decision-making capacity by an interdisciplinary team of physicians. Early involvement of critical care, neuroimaging, neurophysiology, anesthesiology and obstetrical experts cannot be overemphasized. Such strategy was employed in our series and all three patients were discharged home without residual neurological symptoms.