SARS-CoV-2 associated posterior reversible encephalopathy syndrome (PRES) - a review of 82 cases.

OBJECTIVES: Severe, acute, respiratory syndromecoronavirus- 2 (SARS-CoV-2) infections can be complicated by central nervous system (CNS) disease. One of the CNS disorders associated with Coronavirus Disease-19 (COVID- 19) is posterior reversible encephalopathy syndrome (PRES). This narrative review summarises and discusses previous and recent findings on SARS-CoV-2 associated PRES. METHODS: A literature search was carried out in PubMed and Google Scholar using suitable search terms and reference lists of articles found were searched for further articles. RESULTS: By the end of February 2023, 82 patients with SARS-CoV-2 associated PRES were recorded. The latency between the onset of COVID-19 and the onset of PRES ranged from 1 day to 70 days. The most common presentations of PRES were mental deterioration (n=47), seizures (n=46) and visual disturbances (n=18). Elevated blood pressure was reported on admission or during hospitalisation in 48 patients. The most common comorbidities were arterial hypertension, diabetes, hyperlipidemia and atherosclerosis. PRES was best diagnosed by multimodal cerebral magnetic resonance imaging (MRI). Complete recovery was reported in 35 patients and partial recovery in 21 patients, while seven patients died. CONCLUSIONS: PRES can be a CNS complication associated with COVID-19. COVID-19 patients with mental dysfunction, seizures or visual disturbances should immediately undergo CNS imaging through multimodal MRI, electroencephalography (EEG) and cerebrospinal fluid (CSF) studies in order not to miss PRES.

Posterior reversible encephalopathy syndrome in critical COVID-19 patients: Report of 2 cases.

Posterior reversible encephalopathy syndrome is an acute neurological disorder characterized by variable symptoms and radiological images characteristic of vasogenic parietal-occipital edema. It is associated with clinical conditions such as high blood pressure, infection/sepsis, or cytotoxic/immunosuppressive drugs, among others. It is characterized pathophysiologically by endothelial damage with breakdown of blood-brain barrier, cerebral hypoperfusion, and vasogenic edema. The cases are presented on 2 critical COVID-19 patients who were admitted to pneumonia requiring mechanical ventilation and who, after removing sedation, developed acute and reversible neurological symptoms consisting of epilepsy and encephalopathy, associated with hyperintense subcortical lesions on brain magnetic resonance imaging compatible with posterior reversible encephalopathy syndrome. SARS-CoV-2 coronavirus would activate an inflammatory response that would damage brain endothelium. It could be triggered by cytokine release, as well as by direct viral injury, given that endothelium expresses ACE2 receptors. It could explain the possible association between posterior reversible encephalopathy syndrome and COVID-19.

Posterior reversible encephalopathy syndrome in a child with severe multisystem inflammatory syndrome due to COVID-19. / Síndrome da encefalopatia posterior reversível em uma criança com síndrome inflamatória multissistêmica grave devido à COVID-19.

Posterior reversible encephalopathy syndrome is a rare clinical and radiological syndrome characterized by vasogenic edema of the white matter of the occipital and parietal lobes, which are usually symmetrical, resulting from a secondary manifestation of acute dysfunction of the posterior cerebrovascular system. We describe a case of posterior reversible encephalopathy syndrome secondary to SARS-CoV-2 infection in a 9-year-old boy who developed acute hypoxemic respiratory failure and required assisted mechanical ventilation. The child developed multisystem inflammatory syndrome, and he was monitored in the pediatric intensive care unit and was provided mechanical ventilation and vasoactive agents for hemodynamic support. Additionally, he developed pulmonary and extrapulmonary clinical manifestations along with neuropsychiatric manifestations that required close follow-up and were verified using brain magnetic resonance imaging for timely intervention. Currently, there are few reports of children with posterior reversible encephalopathy syndrome associated with multisystem inflammatory syndrome.

A síndrome da encefalopatia posterior reversível é uma rara síndrome clínica e radiológica caracterizada por edema vasogênico da matéria branca dos lobos occipital e parietal, que geralmente são simétricos, resultante de uma manifestação secundária de disfunção aguda do sistema cerebrovascular posterior. Descrevemos um caso de síndrome de encefalopatia posterior reversível secundária à infecção por SARS-CoV-2 em um menino de 9 anos de idade que desenvolveu insuficiência respiratória hipoxêmica aguda e necessitou de ventilação mecânica assistida. A criança desenvolveu síndrome inflamatória multissistêmica e foi monitorada na unidade de terapia intensiva pediátrica, tendo-lhe sido fornecidos ventilação mecânica e agentes vasoativos para suporte hemodinâmico. Além disso, desenvolveu manifestações clínicas pulmonares e extrapulmonares juntamente de manifestações neuropsiquiátricas que necessitavam de seguimento cuidadoso, tendo sido verificadas por ressonância magnética cerebral para intervenção oportuna. Atualmente, há poucos relatos de crianças com síndrome da encefalopatia posterior reversível associada à síndrome inflamatória multissistêmica.

[Haemorrhagic posterior reversible encephalopathy syndrome and COVID-19]. / Síndrome de encefalopatía posterior reversible hemorrágica y COVID-19.

TITLE: Síndrome de encefalopatía posterior reversible hemorrágica y COVID-19.

Posterior reversible encephalopathy syndrome - A pathology that should not be overlooked in the era of COVID-19.

BACKGROUND AND OBJECTIVES: Severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) that causes Coronavirus Disease 2019 (COVID-19) may determine a series of neurological complications directly, by invasion of the nervous system or indirectly, secondary to systemic organ failure. Posterior reversible encephalopathy syndrome (PRES) represents a clinical and radiological neurological entity involving predominantly the occipital lobes. PRES was observed in patients receiving cytotoxic drugs, patients suffering from infectious diseases and sepsis, hypertensive emergencies and eclampsia, renal or autoimmune diseases. As more infectious SARS-COV-2 variants are now dominant in most of the Europe, an increasing number of patients is presenting to the Emergency Department. MATERIALS AND METHODS: Case report of a 38-year-old patient, with previous exposure to SARS-COV-2 presented to the Emergency Department (ED) with generalized tonic-clonic seizures, dyspnea, cortical blindness and aphasia. The patient had been exhibiting fever, cough and shortness of breath in the previous 10 days. He had no relevant medical history and was receiving antibiotics and corticosteroids as prescribed by his general practitioner. RESULTS: Laboratory findings together with the thoracic computed tomography scan were consistent with the diagnosis of severe SARS-COV-2 pneumonia. The cerebral MRI scans showed bilateral T2-weighted/FLAIR hyperintensities that were suggestive for PRES. The patient was diagnosed with COVID-19 complicated with PRES. He received adequate treatment and the symptoms resolved in 48 h. CONCLUSIONS: This is a rare and interesting case of a patient with PRES and COVID-19 as underlying pathology, in whom rapid diagnosis in the ED and early initiation of appropriate treatment led to full recovery. Immediate extensive work-up in patients with COVID-19 and neurological symptoms proves to be paramount for best outcome. To our knowledge this is the first case of PRES described in a patient with Delta variant of SARS-COV-2.

Posterior reversible encephalopathy syndrome in the puerperium: a case report.

Headache is a common presentation to the physician. Although most causes of a headache in pregnancy are benign, the pregnant woman is at risk of a life-threatening secondary headache such as eclampsia, venous sinus thrombosis or posterior reversible encephalopathy syndrome (PRES). Pregnancy and the puerperium are prothrombotic risk factors. Although the aetiology of PRES remains to be fully elucidated, hypertension with failed autoregulation results in brain oedema. An alternative hypothesis includes endothelial injury and hypoperfusion leading to an alteration in the integrity of the blood-brain barrier. It occurs in complex, systemic conditions such as pre-eclampsia, following bone marrow transplantation, chemotherapy, sepsis and autoimmune diseases. The most common clinical presentation is headache, altered alertness, seizures and visual disturbance such as hemianopia, visual neglect and cortical blindness. It can also develop in normotensive individuals. Symmetric vasogenic oedema in a watershed distribution involving the parieto-occipital regions are typically evident on MRI. Management is determined by the underlying aetiological risk factor. The authors present the case of a 32-year-old multiparous woman presenting with tonic-clonic seizures 16 days following an elective caesarean section. Her pregnancy was complicated by hypertension and headache. There was no history of pre-eclampsia. She required intubation and ventilation. The diagnosis of PRES was established on MRI. Early recognition and treatment provide a favourable prognosis as the clinical symptoms and imaging characteristics are reversible in a large cohort of affected individuals.

Posterior reversible encephalopathy syndrome in a patient submitted to extracorporeal membrane oxygenation for COVID-19. / Síndrome da encefalopatia posterior reversível em paciente com COVID-19 submetida à oxigenação por membrana extracorpórea.

A 63-year-old woman presented to the emergency department with an acute history of fever, prostration and dyspnea. She was diagnosed with severe COVID-19 acute respiratory distress syndrome and, despite optimized critical care support, met the indications for veno-venous extracorporeal membrane oxygenation. On day 34, after 7 days of wean sedation with a positive evolution of neurologic status, she presented a limited generalized tonic-clonic seizure not related to hydroelectrolytic or metabolic imbalance, which led to a diagnostic investigation; her brain imaging tests showed a posterior reversible encephalopathy syndrome. This case emphasizes the issue of neurological complications in patients with severe COVID-19 infection and the importance of early diagnosis and support.

Uma mulher com 63 anos de idade compareceu ao pronto-socorro com história aguda de febre, prostração e dispneia. Recebeu diagnóstico de quadro grave da COVID-19 e síndrome do desconforto respiratório agudo. Apesar de suporte clínico intensivo, cumpriu os critérios para ser submetida à oxigenação venovenosa por membrana extracorpórea. No dia 34, após 7 dias de desmame da sedação com evolução positiva de seu quadro neurológico, apresentou uma crise tônico-clônica generalizada limitada, não relacionada com desequilíbrio hidroeletrolítico ou metabólico, que levou à necessidade de investigação diagnóstica. Seus exames de imagem cerebral revelaram síndrome da encefalopatia posterior reversível. Este caso enfatiza a questão das complicações neurológicas em pacientes com COVID-19 grave e a importância do diagnóstico e suporte precoces.

Afferent and Efferent Neuro-Ophthalmic Complications of Coronavirus Disease 19.

PURPOSE: To provide a summary of the neuro-ophthalmic manifestations of coronavirus disease 19 (COVID-19) documented in the literature thus far. METHODS: The PubMed and Google Scholar databases were searched using the keywords: Neuro-Ophthalmology, COVID-19, SARS-CoV-2, and coronavirus. A manual search through reference lists of relevant articles was also performed. RESULTS/CONCLUSIONS: The literature on COVID-associated neuro-ophthalmic disease continues to grow. Afferent neuro-ophthalmic complications associated with COVID-19 include optic neuritis, papillophlebitis, papilledema, visual disturbance associated with posterior reversible encephalopathy syndrome, and vision loss caused by stroke. Efferent neuro-ophthalmic complications associated with COVID-19 include cranial neuropathies, Miller Fisher syndrome, Adie's pupils, ocular myasthenia gravis, nystagmus and eye movement disorders. Proposed mechanisms of neurologic disease include immunologic upregulation, vasodilation and vascular permeability, endothelial dysfunction, coagulopathy, and direct viral neurotropism. When patients present to medical centers with new onset neuro-ophthalmic conditions during the pandemic, COVID-19 infection should be kept on the differential.

Not all is COVID19: a case of eclampsia and posterior reversible encephalopathy syndrome in the emergency room.

In the so called COVID19 era, headache, fever and gastrointestinal symptoms are highly suggestive for SARS-CoV-2 infection, but in all the cases presenting to the emergency room, clinicians should always keep in mind alternative diagnoses, particularly if the patient is pregnant.  Life-threatening diseases, such as eclampsia and posterior reversible encephalopathy syndrome (PRES), should be promptly recognized and treated. Eclampsia is defined as a seizure occurring in association with pre-eclampsia, and it represents one of the major and serious obstetric disorders associated with significant maternal and perinatal morbidity and mortality. PRES is a distinctive clinical and imaging syndrome characterized by acute headaches, visual impairment, seizures, and altered sensorium, that can be associated with severe eclampsia. Emergency clinicians should always consider eclampsia in the differential diagnosis of headache in pregnant women. The prompt and accurate diagnosis of eclampsia/PRES is crucial to prevent adverse maternal and perinatal outcomes. Here we describe the case of a young pregnant woman admitted to our emergency department for fever, dyspnea, headache, nausea and vomiting, who developed generalized tonic clonic seizures and a subsequent status epilepticus due to eclampsia and PRES.

Miller Fischer and posterior reversible encephalopathy syndromes post COVID-19 infection.

COVID-19 infection displays heterogeneity of clinical manifestations in symptomatic and asymptomatic patients. We report on a child with Miller Fischer syndrome (MFS) and posterior reversible encephalopathy syndrome (PRES) post-COVID-19 infection. An 11-year-old boy presented with vomiting, headache, blurred vision, dysarthria, dysphagia, respiratory failure, muscle weakness, and unsteadiness. He had been exposed to COVID-19 through an asymptomatic elder brother two months prior to his illness. The MRI brain showed findings consistent with PRES and the diagnosis with Miller Fischer variant of the Guillain-Barré syndrome was made. A cerebrospinal fluid analysis revealed cytoalbuminous dissociation, and a nerve conduction velocity study conclusively showed polyneuropathy. A fluoroscopy of the diaphragms found that there was limited movement in both. Although children seem to be less affected by COVID-19 infection, this report highlights on an important neurological complications that can develop in children and its presence should be taken into consideration when diagnosing different forms of Guillain-Barré.

Posterior reversible encephalopathy syndrome (PRES) associated with COVID-19.

The novel human coronavirus disease (COVID-19) has been associated with vascular and thrombotic complications, some of which may result from endothelial dysfunction, including the posterior reversible encephalopathy syndrome (PRES). We report a case series of 8 patients with COVID-19 and PRES diagnosed at two academic medical centers between March and July of 2020. The clinical, laboratory and radiographic data, treatment, and short-term outcomes were retrospectively analyzed. The mean age was 57.9 ± 12 years, and 50% were women. Four patients had previous vascular comorbidities. All the patients suffered from severe pneumonia, requiring intensive care unit admission. Five patients were not hypertensive at presentation (all SBP < 127 mmHg). Neurologic symptoms included seizures in 7 patients; impaired consciousness in 5 patients; focal neurological signs in 3 patients; and visual disturbances in 1 patient. All patients underwent brain magnetic resonance imaging which indicated asymmetric T2 prolongation or diffusion changes (50%), extensive fronto-parieto-occipital involvement (25%), vascular irregularities (12.5%) and intracranial hemorrhage (25%). Four patients were treated with tocilizumab. Three patients were discharged without neurologic disability, 2 patients had persistent focal neurologic deficits and 2 expired. One patient's prognosis remains guarded. Together, these data support the relationship between PRES and endothelial dysfunction associated with severe COVID-19. In patients with severe COVID-19, PRES can be triggered by uncontrolled hypertension, or occur independently in the setting of systemic illness and certain medications. Like other infectious processes, critically ill patients with COVID-19 may be at greater risk of PRES because of impaired vasoreactivity or the use of novel agents like Tocilizumab.

Postpartum consciousness disturbance: can covid-19 cause posterior reversible encephalopathy syndrome? / Alteración del nivel de conciencia puerperal: ¿puede el COVID-19 ser causa de síndrome de encefalopatía posterior reversible?

We describe the case of a 24-year-old pregnant woman with no history of note who was admitted with a diagnosis of bilateral pneumonia caused by the new coronavirus. Due to clinical worsening, she required urgent cesarean section with general anaesthesia and intubation for decubitus intolerance. After extubation, she presented altered mental state that required a differential diagnosis of encephalitis/meningitis secondary to SARS-CoV-2. CT and CT-angiography were normal, spinal fluid tests were non-specific, and magnetic resonance imaging reported posterior reversible encephalopathy syndrome (PRES) (due to radiological features suggestive of white matter vasogenic edema affecting the parietal, temporal and occipital lobes, along with altered mental state) secondary to gestational hypertension. Eleven days after the cesarean section the patient began to develop hypertension that required treatment. PRES is associated with certain clinical (headache, altered mental state, visual disturbances and convulsions) and radiological (reversible changes in white substance mainly affecting the parietal, temporal, and occipital lobes) characteristics suggestive of vasogenic oedema In pregnant SARS-CoV-2 patients, the differential diagnosis of hypertension and altered mental state is often extremely complicated because complementary tests can be normal and there is no immediate sign of peripartum hypertension. SARS-CoV-2 genome sequencing in spinal fluid could have provided a definitive diagnosis, but the treatment would not have differed.

Postpartum Atypical Posterior Reversible Encephalopathy Syndrome in a COVID-19 Patient - An Obstetric Emergency.

Encephalopathy in COVID-19 has been widely reported with several reports of posterior reversible encephalopathy syndrome (PRES) speculated to be due to an abrupt surge in blood pressure caused by coronavirus disease. Though peripartum posterior reversible encephalopathy syndrome is well recognized, its atypical variant with hemorrhage is uncommon. Peripartum atypical posterior reversible encephalopathy syndrome with COVID-19 requires early recognition and warrants dedicated inter-disciplinary management. We present a case of postpartum atypical posterior reversible encephalopathy syndrome with good maternal and fetal outcome. Our clinical and treatment approach with differential diagnosis are discussed in this hitherto unreported obstetric emergency with COVID-19.

Pressing Issues in COVID-19: Probable Cause to Seize SARS-CoV-2 for Its Preferential Involvement of Posterior Circulation Manifesting as Severe Posterior Reversible Encephalopathy Syndrome and Posterior Strokes.

Since December 2019, a novel Severe Acute Respiratory Syndrome coronavirus 2 from China has rapidly spread worldwide. Although respiratory involvement is the mainstay of coronavirus disease 2019 (COVID-19), systemic involvement has recently drawn more attention. In particular, a number of recent articles have shed light on the nervous system as one of the possible targets. At our institution, we observed 15 patients with acute brain vascular manifestations; most interesting, we had a higher prevalence of the posterior circulation acute impairment. In our series, 7 patients had acute posterior cerebral injury: 1, hemorrhagic posterior reversible encephalopathy syndrome; 5, posterior circulation ischemic stroke; and 1, parieto-occipital hemorrhagic stroke. On the basis of our evidence and previous basic science reports, we believe a common etiopathogenetic thread may connect ischemic/hemorrhagic events of the posterior circulation and posterior reversible encephalopathy syndrome in the setting of COVID-19.

Hemorrhagic Posterior Reversible Encephalopathy Syndrome as a Manifestation of COVID-19 Infection.

We describe 2 hospitalized patients with confirmed coronavirus 19 (COVID-19) infection in whom brain imaging showed hemorrhagic posterior reversible encephalopathy syndrome, and we discuss the possible reasons for these findings and their relationship to the infection.