, Volume 51, Issue 6, pp 373–383 | Cite as

Posterior reversible encephalopathy syndrome: do predisposing risk factors make a difference in MRI appearance?

  • Christina Mueller-Mang
  • Thomas Mang
  • Agnes Pirker
  • Katharina Klein
  • Christine Prchla
  • Daniela Prayer
Diagnostic Neuroradiology



Posterior reversible encephalopathy syndrome (PRES) is a clinico-neuroradiological entity, characterized by typical neurological deficits, distinctive magnetic resonance imaging (MRI) features, and a usually benign clinical course. Although frequently seen in association with hypertensive conditions, many other predisposing factors, notably cytotoxic and immunosuppressant drugs have been associated with PRES. The aim of this study was to determine differences in the MR appearance of PRES according to various risk factors.


Thirty consecutive patients with clinical and MRI findings consistent with PRES were included. We identified 24 patients with hypertension-related conditions, including 14 patients with preeclampsia–eclampsia, and six patients without hypertension, in whom PRES was associated with exposition to neurotoxic substances. Lesion distribution, extent of disease, and number of affected brain regions were compared between patients with PRES with and without hypertension, and patients with PRES with and without preeclampsia–eclampsia, respectively.


No statistically significant differences in distribution of lesions and extent of disease were observed between patients with PRES with or without hypertension, and patients with or without preeclampsia–eclampsia, respectively. The number of affected brain regions was significantly higher in patients with preeclampsia–eclampsia (p = 0.046), and the basal ganglia region was more frequently involved in these patients (p = 0.066).


Apart from a significant higher number of involved brain regions and a tendency for basal ganglia involvement in patients with PRES associated with preeclampsia–eclampsia, the MRI appearance of patients with PRES does not seem to be influenced by predisposing risk factors.


Posterior reversible encephalopathy syndrome Hypertensive encephalopathy Eclampsia MRI Neurotoxicity 


Conflict of interest statement

We declare that we have no conflict of interest.


  1. 1.
    Hinchey J, Chaves C, Appignani B, Breen J, Pao L, Wang A, Pessin MS, Lamy C, Mas JL, Caplan LR (1996) A reversible posterior leukoencephalopathy syndrome. N Engl J Med 334:494–500. doi: 10.1056/NEJM199602223340803 PubMedCrossRefGoogle Scholar
  2. 2.
    McKinney AM, Short J, Truwit CL, McKinney ZJ, Kozak OS, SantaCruz KS, Teksam M (2007) Posterior reversible encephalopathy syndrome: incidence of atypical regions of involvement and imaging findings. AJR Am J Roentgenol 189:904–912. doi: 10.2214/AJR.07.2024 PubMedCrossRefGoogle Scholar
  3. 3.
    Covarrubias DJ, Luetmer PH, Campeau NG (2002) Posterior reversible encephalopathy syndrome: prognostic utility of quantitative diffusion-weighted MR images. AJNR Am J Neuroradiol 23:1038–1048PubMedGoogle Scholar
  4. 4.
    Bartynski WS, Boardman JF (2007) Distinct imaging patterns and lesion distribution in posterior reversible encephalopathy syndrome. AJNR Am J Neuroradiol 28:1320–1327. doi: 10.3174/ajnr.A0549 PubMedCrossRefGoogle Scholar
  5. 5.
    Bartynski WS, Boardman JF, Zeigler ZR, Shadduck RK, Lister J (2006) Posterior reversible encephalopathy syndrome in infection, sepsis, and shock. AJNR Am J Neuroradiol 27:2179–2190PubMedGoogle Scholar
  6. 6.
    Ito Y, Arahata Y, Goto Y, Hirayama M, Nagamutsu M, Yasuda T, Yanagi T, Sobue G (1998) Cisplatin neurotoxicity presenting as reversible posterior leukoencephalopathy syndrome. AJNR Am J Neuroradiol 19:415–417PubMedGoogle Scholar
  7. 7.
    Russell MT, Nassif AS, Cacayorin ED, Awwad E, Perman W, Dunphy F (2001) Gemcitabine-associated posterior reversible encephalopathy syndrome: MR imaging and MR spectroscopy findings. Magn Reson Imaging 19:129–132. doi: 10.1016/S0730-725X(01)00217-X PubMedCrossRefGoogle Scholar
  8. 8.
    Kastrup O, Maschke M, Wanke I, Diener HC (2002) Posterior reversible encephalopathy syndrome due to severe hypercalcemia. J Neurol 249:1563–1566. doi: 10.1007/s00415-002-0895-x PubMedCrossRefGoogle Scholar
  9. 9.
    Ito Y, Niwa H, Iida T, Nagamatsu M, Yasuda T, Yanagi T, Sobue G (1997) Post-transfusion reversible posterior leukoencephalopathy syndrome with cerebral vasoconstriction. Neurology 49:1174–1175PubMedGoogle Scholar
  10. 10.
    Strandgaard S, Paulson OB (1984) Cerebral autoregulation. Stroke 15:413–416PubMedGoogle Scholar
  11. 11.
    Tamaki K, Sadoshima S, Baumbach GL, Iadecola C, Reis DJ, Heistad DD (1984) Evidence that disruption of the blood–brain barrier precedes reduction in cerebral blood flow in hypertensive encephalopathy. Hypertension 6:I75–I81PubMedGoogle Scholar
  12. 12.
    Mukherjee P, McKinstry RC (2001) Reversible posterior leukoencephalopathy syndrome: evaluation with diffusion-tensor MR imaging. Radiology 219:756–765PubMedGoogle Scholar
  13. 13.
    Rodgers GM, Taylor RN, Roberts JM (1988) Preeclampsia is associated with a serum factor cytotoxic to human endothelial cells. Am J Obstet Gynecol 159:908–914PubMedGoogle Scholar
  14. 14.
    National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescent (2004) The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics 114:555–576. doi: 10.1542/peds.114.2.S2.555 CrossRefGoogle Scholar
  15. 15.
    Port JD, Beauchamp NJ Jr (1998) Reversible intracerebral pathologic entities mediated by vascular autoregulatory dysfunction. Radiographics 18:353–367PubMedGoogle Scholar
  16. 16.
    Ay H, Buonanno FS, Schaefer PW, Le DA, Wang B, Gonzalez RG, Koroshetz WJ (1998) Posterior leukoencephalopathy without severe hypertension: utility of diffusion-weighted MRI. Neurology 51:1369–1376PubMedGoogle Scholar
  17. 17.
    Jansen O, Krieger D, Krieger S, Sartor K (1996) Cortical hyperintensity on proton density-weighted images: an MR sign of cyclosporine-related encephalopathy. AJNR Am J Neuroradiol 17:337–344PubMedGoogle Scholar
  18. 18.
    Rangi PS, Partridge WJ, Newlands ES, Waldman AD (2005) Posterior reversible encephalopathy syndrome: a possible late interaction between cytotoxic agents and general anaesthesia. Neuroradiology 47:586–590. doi: 10.1007/s00234-005-1376-6 PubMedCrossRefGoogle Scholar
  19. 19.
    Benigni A, Morigi M, Perico N, Zoja C, Amuchastegui CS, Piccinelli A, Donadelli R, Remuzzi G (1992) The acute effect of FK506 and cyclosporine on endothelial cell function and renal vascular resistance. Transplantation 54:775–780. doi: 10.1097/00007890-199211000-00002 PubMedCrossRefGoogle Scholar
  20. 20.
    Zoja C, Furci L, Ghilardi F, Zilio P, Benigni A, Remuzzi G (1986) Cyclosporin-induced endothelial cell injury. Lab Invest 55:455–462PubMedGoogle Scholar
  21. 21.
    Kochi S, Takanaga H, Matsuo H, Naito M, Tsuruo T, Sawada Y (1999) Effect of cyclosporin A or tacrolimus on the function of blood–brain barrier cells. Eur J Pharmacol 372:287–295. doi: 10.1016/S0014-2999(99)00247-2 PubMedCrossRefGoogle Scholar
  22. 22.
    Kochi S, Takanaga H, Matsuo H, Ohtani H, Naito M, Tsuruo T, Sawada Y (2000) Induction of apoptosis in mouse brain capillary endothelial cells by cyclosporin A and tacrolimus. Life Sci 66:2255–2260. doi: 10.1016/S0024-3205(00)00554-3 PubMedCrossRefGoogle Scholar
  23. 23.
    Marsen TA, Weber F, Egink G, Suckau G, Baldamus CA (1999) Cyclosporin A induces prepro endothelin-1 gene transcription in human endothelial cells. Eur J Pharmacol 379:97–106. doi: 10.1016/S0014-2999(99)00447-1 PubMedCrossRefGoogle Scholar
  24. 24.
    Truwit CL, Denaro CP, Lake JR, DeMarco T (1991) MR imaging of reversible cyclosporin A-induced neurotoxicity. AJNR Am J Neuroradiol 12:651–659PubMedGoogle Scholar
  25. 25.
    Badros A, Goloubeva O, Dalal JS, Can I, Thompson J, Rapoport AP, Heyman M, Akpek G, Fenton RG (2007) Neurotoxicity of bortezomib therapy in multiple myeloma: a single-center experience and review of the literature. Cancer 110:1042–1049. doi: 10.1002/cncr.22921 PubMedCrossRefGoogle Scholar
  26. 26.
    Bartynski WS (2008) Posterior reversible encephalopathy syndrome, part 2: controversies surrounding pathophysiology of vasogenic edema. AJNR Am J Neuroradiol 29:1043–1049. doi: 10.3174/ajnr.A0929 PubMedCrossRefGoogle Scholar
  27. 27.
    Horbinski C, Bartynski WS, Carson-Walter E, Hamilton RL, Tan HP, Cheng S (2009) Reversible Encephalopathy after Cardiac Transplantation: Histologic Evidence of Endothelial Activation, T-cell Specific Trafficking, and Vascular Endothelial Growth Factor Expression. AJNR Am J Neuroradiol. doi: 10.3174/ajnr.A1311
  28. 28.
    Schoch HJ, Fischer S, Marti HH (2002) Hypoxia-induced vascular endothelial growth factor expression causes vascular leakage in the brain. Brain 125:2549–2557. doi: 10.1093/brain/awf257 PubMedCrossRefGoogle Scholar
  29. 29.
    Bartynski WS, Boardman JF (2008) Catheter angiography, MR angiography, and MR perfusion in posterior reversible encephalopathy syndrome. AJNR Am J Neuroradiol 29:447–455. doi: 10.3174/ajnr.A0839 PubMedCrossRefGoogle Scholar
  30. 30.
    Brubaker LM, Smith JK, Lee YZ, Lin W, Castillo M (2005) Hemodynamic and permeability changes in posterior reversible encephalopathy syndrome measured by dynamic susceptibility perfusion-weighted MR imaging. AJNR Am J Neuroradiol 26:825–830PubMedGoogle Scholar
  31. 31.
    Sundgren PC, Edvardsson B, Holtas S (2002) Serial investigation of perfusion disturbances and vasogenic oedema in hypertensive encephalopathy by diffusion and perfusion weighted imaging. Neuroradiology 44:299–304. doi: 10.1007/s00234-001-0721-7 PubMedCrossRefGoogle Scholar
  32. 32.
    Demirtas O, Gelal F, Vidinli BD, Demirtas LO, Uluc E, Baloglu A (2005) Cranial MR imaging with clinical correlation in preeclampsia and eclampsia. Diagn Interv Radiol 11:189–194PubMedGoogle Scholar
  33. 33.
    Schwartz RB, Feske SK, Polak JF, DeGirolami U, Iaia A, Beckner KM, Bravo SM, Klufas RA, Chai RY, Repke JT (2000) Preeclampsia–eclampsia: clinical and neuroradiographic correlates and insights into the pathogenesis of hypertensive encephalopathy. Radiology 217:371–376PubMedGoogle Scholar
  34. 34.
    Watanabe Y, Mitomo M, Tokuda Y, Yoshida K, Choi S, Hosoki T, Ban C (2002) Eclamptic encephalopathy: MRI, including diffusion-weighted images. Neuroradiology 44:981–985. doi: 10.1007/s00234-002-0867-y PubMedCrossRefGoogle Scholar
  35. 35.
    Servillo G, Striano P, Striano S, Tortora F, Boccella P, De Robertis E, Rossano F, Briganti F, Tufano R (2003) Posterior reversible encephalopathy syndrome (PRES) in critically ill obstetric patients. Intensive Care Med 29:2323–2326. doi: 10.1007/s00134-003-1901-1 PubMedCrossRefGoogle Scholar
  36. 36.
    Rappaport VJ, Hirata G, Yap HK, Jordan SC (1990) Anti-vascular endothelial cell antibodies in severe preeclampsia. Am J Obstet Gynecol 162:138–146PubMedGoogle Scholar
  37. 37.
    Feekes JA, Cassell MD (2006) The vascular supply of the functional compartments of the human striatum. Brain 129:2189–2201. doi: 10.1093/brain/awl158 PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2009

Authors and Affiliations

  • Christina Mueller-Mang
    • 1
  • Thomas Mang
    • 1
  • Agnes Pirker
    • 3
  • Katharina Klein
    • 2
  • Christine Prchla
    • 4
  • Daniela Prayer
    • 1
  1. 1.Department of RadiologyMedical University of ViennaViennaAustria
  2. 2.Department of Obstetrics and GynecologyMedical University of ViennaViennaAustria
  3. 3.Department of NeurologyMedical University of ViennaViennaAustria
  4. 4.Department of PediatricsSMZ-Ost Danube HospitalViennaAustria

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