Introduction: Posterior reversible encephalopathy syndrome (PRES) is a largely reversible disease with long-term favorable outcome. A minority of patients, however, may develop progressive cerebral edema and ischemia resulting in severe disability or death. We report a case of severe intracranial hypertension associated with PRES that was successfully treated according to intracranial pressure (ICP)- and cerebral perfusion pressure (CPP)-driven therapy. Methods: Case report. Results: A 42-year-old woman underwent bilateral lung transplantation for severe bronchiectasis. Her immunosuppressive regimen consisted of azathioprine, prednisone, and tacrolimus. She acutely developed an aggressive form of PRES that rapidly resulted in severe refractory intracranial hypertension despite discontinuation of potentially causative medications and adequate supportive therapy. Accordingly, second-tier therapies, including barbiturate infusion, were instituted and immunosuppression was switched to anti-thymocyte globulin followed by mycophenolate mofetil. Within 10 h of barbiturate administration, ICP dropped to 20 mmHg. Thiopental was administered for two days and then rapidly tapered because of severe urosepsis. Six months after discharge from the intensive care unit the patient returned to near-normal life, her only complaint being short-term amnesia. Conclusions: The decision to undertake ICP monitoring in medical conditions in which no clear recommendations exist greatly relies on physicians' judgment. This case suggests that ICP monitoring may be considered in the setting of acute PRES among selected patients, when severe intracranial hypertension is suspected, provided that a multidisciplinary team of neurocritical care specialists is readily available. © 2013 Springer Science+Business Media New York.

Refractory intracranial hypertension in posterior reversible encephalopathy syndrome / A. Facchini, S. Magnoni, V. Civelli, F. Triulzi, M. Nosotti, N. Stocchetti. - In: NEUROCRITICAL CARE. - ISSN 1541-6933. - 19:3(2013), pp. 376-380. [10.1007/s12028-013-9852-z]

Refractory intracranial hypertension in posterior reversible encephalopathy syndrome

A. Facchini
;
S. Magnoni;F. Triulzi;M. Nosotti;N. Stocchetti
2013

Abstract

Introduction: Posterior reversible encephalopathy syndrome (PRES) is a largely reversible disease with long-term favorable outcome. A minority of patients, however, may develop progressive cerebral edema and ischemia resulting in severe disability or death. We report a case of severe intracranial hypertension associated with PRES that was successfully treated according to intracranial pressure (ICP)- and cerebral perfusion pressure (CPP)-driven therapy. Methods: Case report. Results: A 42-year-old woman underwent bilateral lung transplantation for severe bronchiectasis. Her immunosuppressive regimen consisted of azathioprine, prednisone, and tacrolimus. She acutely developed an aggressive form of PRES that rapidly resulted in severe refractory intracranial hypertension despite discontinuation of potentially causative medications and adequate supportive therapy. Accordingly, second-tier therapies, including barbiturate infusion, were instituted and immunosuppression was switched to anti-thymocyte globulin followed by mycophenolate mofetil. Within 10 h of barbiturate administration, ICP dropped to 20 mmHg. Thiopental was administered for two days and then rapidly tapered because of severe urosepsis. Six months after discharge from the intensive care unit the patient returned to near-normal life, her only complaint being short-term amnesia. Conclusions: The decision to undertake ICP monitoring in medical conditions in which no clear recommendations exist greatly relies on physicians' judgment. This case suggests that ICP monitoring may be considered in the setting of acute PRES among selected patients, when severe intracranial hypertension is suspected, provided that a multidisciplinary team of neurocritical care specialists is readily available. © 2013 Springer Science+Business Media New York.
Barbiturate; Immunosuppressive agents; Intracranial hypertension; Lung transplantation; Reversible posterior leukoencephalopathy syndrome; Status epilepticus; Adult; Antilymphocyte Serum; Barbiturates; Cerebrovascular Circulation; Female; Humans; Hypnotics and Sedatives; Immunosuppressive Agents; Intracranial Pressure; Mycophenolic Acid; Thiopental; Treatment Outcome; Posterior Leukoencephalopathy Syndrome
Settore MED/37 - Neuroradiologia
Settore MED/21 - Chirurgia Toracica
Settore MED/41 - Anestesiologia
21-mag-2013
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Utilizza questo identificativo per citare o creare un link a questo documento: http://hdl.handle.net/2434/821537
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