Drawing the Curtains: A case of Posterior Reversible Encephalopathy Syndrome (PRES) Post Upper GI Endoscopy
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Background
Posterior reversible encephalopathy syndrome (PRES) is a devastating condition with distinct clinical and radiological manifestations. Clinical features vary from acute illness with symptoms of transient headache, changes of mental status, seizures, and visual loss. Radiological features associated with PRES include extensive white matter changes mainly in posterior and parietal lobes consistent with brain oedema 1,2.
Clinical Case
A57-year-old man with oesophageal stricture presented to Endoscopy Unit planned for Upper GI Endoscopy and oesophageal dilatation. He has background history of benign stricture, GORD, and CLL. After the procedure, patient had low blood pressure associated with headache followed by sudden loss of vision and seizure. Urgent referral to Anaesthesia and on call medical team were requested. Initial CT Angiogram showed no intra or extracranial atheromatous disease and patent vertebra-basilar system. This was followed with MRI scan which showed high signal on diffusion with cerebellar and occipital hemispheres bilaterally with results favouring vasogenic PRES syndrome. Due to patient condition, he was admitted to ICU and treated medically with amlodipine and levetiracetam. Patient’s symptoms gradually resolved with medical treatment and was discharged home after a week.
Patient was then seen in outpatient clinic and was doing well. No further symptoms. As patient requiring repeated Endoscopy and dilatations, further procedures were conductedunder GA. No intra or post procedural complications were observed.
Conclusion
Patients who develop PRES could have catastrophic neurological complications. Hence, high level of suspicion for PRES must be considered in patient who develops altered mental status, seizures and acute visions with hypertension post endoscopic procedure or administration of medications. The gold standard diagnostic imaging is MRI. Blood pressure control and discontinuation of any causative agents is the treatment.
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