Posterior reversible encephalopathy syndrome associated with hemorrhage

Neurocrit Care. 2009;10(3):306-12. doi: 10.1007/s12028-009-9200-5. Epub 2009 Feb 19.


Background: Posterior Reversible Encephalopathy Syndrome (PRES) is a clinico-radiological entity characterized by headache, encephalopathy, visual disturbances, and seizures in association with reversible vasogenic edema on neuroimaging. Intracerebral hemorrhage associated with PRES (PRES-ICH) is generally considered an atypical finding.

Methods: Retrospective case series.

Results: Seven patients were identified with PRES-ICH, four males and three females. The presenting clinical symptoms included headache (2), encephalopathy (5), vision changes (2), seizures (2), and hemiparesis (1). The co-morbid conditions included acute renal dysfunction (3), solid organ transplantation (3), bone marrow transplant (1), use of calcineurin inhibitor agents (4), and pre-eclampsia (1). Neuroimaging revealed intraparenchymal hemorrhage in six patients and subarachnoid hemorrhage in one patient. Six of the seven patients with PRES-related ICH had underlying bleeding diathesis, including one patient who was anti-coagulated with a heparin drip. The mean platelet count was 82.1 x 10(3)/microl (range, 4-232 x 10(3)/microl), and the mean INR value was 2.18 (range, 0.9-6.7). Two patients died during the acute hospitalization. Among the five survivors, only two patients had good functional outcome (pre-defined as mRS < or = 1).

Conclusion: In our series, the majority of patients with PRES-ICH (85%) had an underlying bleeding diathesis or coagulopathy. Although PRES is typically considered to have a favorable prognosis, the clinical outcome of PRES with associated ICH can be more variable.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Cerebral Hemorrhage / diagnosis*
  • Cerebral Hemorrhage / etiology
  • Cerebral Hemorrhage / therapy*
  • Cohort Studies
  • Critical Care*
  • Female
  • Humans
  • Magnetic Resonance Imaging
  • Male
  • Middle Aged
  • Posterior Leukoencephalopathy Syndrome / complications*
  • Posterior Leukoencephalopathy Syndrome / diagnostic imaging
  • Posterior Leukoencephalopathy Syndrome / pathology
  • Retrospective Studies
  • Risk Factors
  • Thrombocytopenia / complications
  • Tomography, X-Ray Computed
  • Treatment Outcome
  • Young Adult