Epidural Blood Patch and PRES Syndrome-Are they related?
Abstract Number: T-71
Abstract Type: Case Report/Case Series
Posterior Reversible Encephalopathy Syndrome (PRES) is a clinico-radiological diagnosis. Incidence and etiology of this disease is unclear. PRES has been described in patients with hypertensive encephalopathy,eclampsia and with the use of cytotoxic and immunosuppressent drugs. We are presenting a case series of two parturients with PRES syndrome manifesting after receiving blood patch for treatment of post dural puncture headache (PDPH).
45 years female,P9009,s/p spontaneous vaginal delivery under CSE analgesia,complained of positional headache of two days duration. On evaluation, blood pressure (BP) was noted to be elevated and primary team notified. OB team attributed elevated BP to headache. Blood patch was performed uneventfully and successfully and patient went home. Patient returned to the hospital 48 hours later, after having a seizure episode at home. BP was noted to be 150/74 and patient was started on nifedipine and labetalol for BP control and Magnesium (Mg) infusion for seizure prophylaxis.
MRI of the brain was consistent with PRES. MRI showed bilateral parasagittal foci of increased T2 signal in the cortex and white matter and pneumocephalus compatible with recent dural puncture. MRA showed stenosis of the ACA, MCA and PCA. Patient's condition improved and was discharged home 7 days later.
20 years female P1001 with history of migraine headaches, seen for positional headache on postpartum day 3, not responding to conservative management. Epidural blood patch was performed. 16 ml of autologus blood administered with minimal relief of headache. Decided to obtain neurology consult. However, patient elected to leave against medical advise. She was brought to the ED 48 hours later after having a tonic clinic seizure and the BP was recorded to be 150/90.
The patient was started on Mg and nicardipine infusion and admitted to MICU. MRI of the brain showed global cerebral edema and evidence of PRES as well as dural thickening consistent with intracranial hypotension. MRA showed no evidence of cerebral vasospasm.
Three days later patient was discharged home.
DISCUSSION: Cases of concurrent PRES and PDPHA are rare in medical practice. In a setting of HTN, 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. Additionally, MRI is only performed on patients with seizure, which confirms the diagnosis of PRES.
Questions which need to be answered are: Could PRES be one of the manifestations of severe pre-eclampsia since it is a systemic disease affecting all the vasculature? Is there any association between epidural blood patch and onset of PRES?
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AANA Journal Vol. 74 No.3(June 2006): 207-11.