Skip to main content

Advertisement

Log in

Asymmetric Posterior Reversible Encephalopathy Syndrome Complicating Hemodynamic Augmentation for Subarachnoid Hemorrhage-Associated Cerebral Vasospasm

  • Practical Pearl
  • Published:
Neurocritical Care Aims and scope Submit manuscript

Abstract

Background

Posterior reversible encephalopathy syndrome (PRES) is a rare complication of hemodynamic augmentation for subarachnoid hemorrhage (SAH)-associated vasospasm. The roles of hyperperfusion and hypoperfusion in the genesis of PRES remain uncertain.

Methods

Case report.

Results

We admitted a 35-year-old woman with Hunt & Hess grade II SAH secondary to rupture of a right middle cerebral artery (MCA) aneurysm. This was surgically clipped. Beginning on hospital day 3, she developed recurrent symptomatic vasospasm of the right MCA despite hemodynamic augmentation to a MAP as high as 130 mmHg and endovascular therapy. On hospital day 7, after 36 h of sustained MAP 120–130 mmHg, her level of arousal progressively declined, culminating in stupor and two generalized tonic–clonic seizures. MRI showed widespread, yet markedly asymmetric changes consistent with PRES largely sparing the right MCA territory. After the MAP was decreased to 85–100 mmHg, she had no further seizures. 2 days later she was fully alert with mild left hemiparesis.

Conclusions

PRES is a rare complication of hemodynamic augmentation that should be considered in the differential diagnosis of delayed neurological decline in patients with aneurysmal SAH-associated cerebral vasospasm. The markedly asymmetric distribution of PRES lesions with sparing of the territory affected by vasospasm supports the hypothesis that hyperperfusion underlies the pathophysiology of this disorder.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Suarez JI, Tarr RW, Selman WR. Aneurysmal subarachnoid hemorrhage. N Engl J Med. 2006;354(4):387–96.

    Article  PubMed  CAS  Google Scholar 

  2. Bederson JB, Connolly ES Jr, Batjer HH, Dacey RG, Dion JE, Diringer MN, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. 2009;40(3):994–1025.

    Article  PubMed  Google Scholar 

  3. Pradilla G, Chaichana KL, Hoang S, Huang J, Tamargo RJ. Inflammation and cerebral vasospasm after subarachnoid hemorrhage. Neurosurg Clin N Am. 2010;21(2):365–79.

    Article  PubMed  Google Scholar 

  4. Lee KH, Lukovits T, Friedman JA. “Triple-H” therapy for cerebral vasospasm following subarachnoid hemorrhage. Neurocrit Care. 2006;4(1):68–76.

    Article  PubMed  Google Scholar 

  5. Hinchey J, Chaves C, Appignani B, Breen J, Pao L, Wang A, et al. A reversible posterior leukoencephalopathy syndrome. N Engl J Med. 1996;334(8):494–500.

    Article  PubMed  CAS  Google Scholar 

  6. Bartynski WS, Boardman JF. Distinct imaging patterns and lesion distribution in posterior reversible encephalopathy syndrome. AJNR Am J Neuroradiol. 2007;28(7):1320–7.

    Article  PubMed  CAS  Google Scholar 

  7. Amin-Hanjani S, Schwartz RB, Sathi S, Stieg PE. Hypertensive encephalopathy as a complication of hyperdynamic therapy for vasospasm: report of two cases. Neurosurgery. 1999;44(5):1113–6.

    Article  PubMed  CAS  Google Scholar 

  8. Giraldo EA, Fugate JE, Rabinstein AA, Lanzino G, Wijdicks EF. Posterior reversible encephalopathy syndrome associated with hemodynamic augmentation in aneurysmal subarachnoid hemorrhage. Neurocrit Care. 2011;14(3):427–32.

    Article  PubMed  Google Scholar 

  9. Jang HW, Lee HJ. Posterior reversible leukoencephalopathy due to “triple H” therapy. J Clin Neurosci. 2010;17(8):1059–61.

    Article  PubMed  Google Scholar 

  10. Sanelli PC, Jacobs MA, Ougorets I, Mifsud MJ. Posterior reversible encephalopathy syndrome on computed tomography perfusion in a patient on “Triple H” therapy. Neurocrit Care. 2005;3(1):46–50.

    Article  PubMed  Google Scholar 

  11. Wartenberg KE, Parra A. CT and CT-perfusion findings of reversible leukoencephalopathy during triple-H therapy for symptomatic subarachnoid hemorrhage-related vasospasm. J Neuroimaging. 2006;16(2):170–5.

    Article  PubMed  Google Scholar 

  12. Bartynski WS. Posterior reversible encephalopathy syndrome, part 2: controversies surrounding pathophysiology of vasogenic edema. AJNR Am J Neuroradiol. 2008;29(6):1043–9.

    Article  PubMed  CAS  Google Scholar 

  13. Schiff D, Lopes MB. Neuropathological correlates of reversible posterior leukoencephalopathy. Neurocrit Care. 2005;2(3):303–5.

    Article  PubMed  Google Scholar 

  14. Bartynski WS. Posterior reversible encephalopathy syndrome, part 1: fundamental imaging and clinical features. AJNR Am J Neuroradiol. 2008;29(6):1036–42.

    Article  PubMed  CAS  Google Scholar 

  15. Schambra HM, Greer DM. Asymmetric reversible posterior leukoencephalopathy syndrome. Neurocrit Care. 2006;4(3):245–7.

    Article  PubMed  Google Scholar 

  16. Schaefer PW, Buonanno FS, Gonzalez RG, Schwamm LH. Diffusion-weighted imaging discriminates between cytotoxic and vasogenic edema in a patient with eclampsia. Stroke. 1997;28(5):1082–5.

    Article  PubMed  CAS  Google Scholar 

  17. Koch S, Rabinstein A, Falcone S, Forteza A. Diffusion-weighted imaging shows cytotoxic and vasogenic edema in eclampsia. AJNR Am J Neuroradiol. 2001;22(6):1068–70.

    PubMed  CAS  Google Scholar 

  18. Bartynski WS, Boardman JF. Catheter angiography, MR angiography, and MR perfusion in posterior reversible encephalopathy syndrome. AJNR Am J Neuroradiol. 2008;29(3):447–55.

    Article  PubMed  CAS  Google Scholar 

  19. MacKenzie ET, Strandgaard S, Graham DI, Jones JV, Harper AM, Farrar JK. Effects of acutely induced hypertension in cats on pial arteriolar caliber, local cerebral blood flow, and the blood-brain barrier. Circ Res. 1976;39(1):33–41.

    PubMed  CAS  Google Scholar 

  20. Schwartz RB, Jones KM, Kalina P, Bajakian RL, Mantello MT, Garada B, et al. Hypertensive encephalopathy: findings on CT, MR imaging, and SPECT imaging in 14 cases. AJR Am J Roentgenol. 1992;159(2):379–83.

    PubMed  CAS  Google Scholar 

  21. Schwartz R, Mulkern R, Vajapeyam S, Kacher DF. Catheter angiography, MR angiography, and MR perfusion in posterior reversible encephalopathy syndrome. AJNR Am J Neuroradiol. 2009;30(2):E19, (Author reply E20).

    Google Scholar 

  22. Trommer BL, Homer D, Mikhael MA. Cerebral vasospasm and eclampsia. Stroke. 1988;19(3):326–9.

    Article  PubMed  CAS  Google Scholar 

Download references

Conflict of interest

The authors report no conflict of interest.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Joseph D. Burns.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Voetsch, B., Tarlov, N., Nguyen, T.N. et al. Asymmetric Posterior Reversible Encephalopathy Syndrome Complicating Hemodynamic Augmentation for Subarachnoid Hemorrhage-Associated Cerebral Vasospasm. Neurocrit Care 15, 542–546 (2011). https://doi.org/10.1007/s12028-011-9635-3

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12028-011-9635-3

Keywords

Navigation