Letter to the Editor
Recurrent reversible posterior encephalopathy syndrome with a response to nimodipine
Síndrome de encefalopatía posterior reversible recurrente con respuesta a nimodipino
J.A. Matías-Guiu
, S. García-Ptacek, C.M. Ordás, A. Marcos-Dolado, J. Porta-Etessam
Corresponding author
Servicio de Neurología, Hospital Clínico San Carlos, Madrid, Spain
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Matías-Guiu, S. García-Ptacek, C.M. Ordás, A. Marcos-Dolado, J. Porta-Etessam" "autores" => array:5 [ 0 => array:4 [ "nombre" => "J.A." "apellidos" => "Matías-Guiu" "email" => array:1 [ 0 => "jordimatiasguiu@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "S." "apellidos" => "García-Ptacek" ] 2 => array:2 [ "nombre" => "C.M." "apellidos" => "Ordás" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Marcos-Dolado" ] 4 => array:2 [ "nombre" => "J." "apellidos" => "Porta-Etessam" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio de Neurología, Hospital Clínico San Carlos, Madrid, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome de encefalopatía posterior reversible recurrente con respuesta a nimodipino" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1311 "Ancho" => 1750 "Tamanyo" => 268755 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A–C) Hyperintense parietal-occipital lesions in T2-weighted and FLAIR sequences in the first episode. (D–E) Disappearance of lesions in MR image taken one month later. (F) New right occipital lesion, hyperintense in FLAIR sequence, in a second episode 6 months later.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Posterior reversible encephalopathy syndrome (PRES) is the association of a set of clinical characteristics (headache, epileptic seizures, changes in alertness, visual loss and other focal deficits) and radiological signs indicating reversible changes in white matter, especially in the parietal-temporal-occipital area.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> It has been linked to high blood pressure and immunosuppressive agents, among other factors. Recurrence is infrequent; a recent study of 25 patients with long-term follow-up<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> reported it in 8% of the study cases.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Various physiopathological mechanisms have been suggested, including vasoconstriction, increased perfusion, and endothelial damage. A study of recurrent cases may help us answer some of the unresolved questions about this syndrome. We present the case of a patient with recurrent PRES episodes which were effectively treated with nimodipine. The patient was a 60-year-old female who came to the emergency department in May 2009. She had a history of smoking, high blood pressure, high cholesterol, and ischaemic heart disease. She presented with headache, drowsiness, nausea, vomiting, and aphasic comprehension which had developed over 2 days, coinciding with an attack of hypertension (blood pressure 220/110<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg). Once the hypertension had been resolved, the patient gradually regained her baseline state and was asymptomatic 48 to 72<span class="elsevierStyleHsp" style=""></span>hours after being admitted. The patient had been treated with chemotherapy during the preceding 2 years for stage IV ovarian adenocarcinoma. Magnetic resonance (MR) scan showed predominantly parietal-occipital white matter lesions with no restrictions in the diffusion sequences. The lesions disappeared one month later (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Following that, the patient presented with 3 similar episodes in January, April, and June 2010; all episodes coincided with a marked increase in blood pressure. The MR scan showed changes similar to those described in PRES, which disappeared once the episode had resolved. The patient discontinued chemotherapy following the first episode and started antihypertensive treatment with beta blockers, ARBs, alpha blockers and diuretics; blood pressure control between episodes was good. Treatment with nimodipine was begun in June 2010; at 15 months of follow-up, no new episodes had occurred.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">There are currently 2 hypotheses regarding PRES physiopathology. The first postulates that high blood pressure would cause arterial vasoconstriction, thereby producing ischaemia and cytotoxic oedema. The second supports there being a disturbance in cerebrovascular autoregulation secondary to uncontrolled high blood pressure. That condition subsequently leads to vasodilation, endothelial dysfunction and vasogenic oedema. The fact that parietal-occipital areas are predominantly involved is probably due to the sparse sympathetic innervation in posterior circulation. MRI findings seem to support the second hypothesis, as they revealed no restrictions in the diffusion sequence. However, cerebral vasoconstriction may be common in PRES, and it may also be related to reversible cerebral vasoconstriction syndrome (RCVS). Ducros et al. describe radiological findings for PRES in 10% of all cases of patients with RCVS.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In turn, vasoconstriction has also been described in some published PRES case studies.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> It is not clear whether high blood pressure triggers the episode, or if in fact the episode causes high blood pressure.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Recurrence is uncommon in this syndrome. To our knowledge, there are only 15 published cases of recurrence at present, with a prevalence of 8% according to the series published by Roth et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Various factors may be involved, including high blood pressure, chemotherapy, kidney failure, and eclampsia; however, persistence of these conditions has not been associated with episode recurrence.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> For example, our patient left chemotherapy following the first episode. Prior infection has been suggested as a possible episode trigger, but no such infection was present during any of the episodes in the clinical case we present here.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Most published cases of recurrence list 2 episodes, and the case we describe here has the highest number of recurrences recorded in the literature. Favourable response to nimodipine may be due to its role in preventing vasospasm, or caused by its effect on the endothelium. In fact, nimodipine has been put forth as a possible treatment for RCVS,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> but no clinical trials have been carried out for this use. Although ours is merely an isolated case, we suggest trying nimodipine as preventive treatment for new recurrent episodes of PRES.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Matías-Guiu JA, et al. Síndrome de encefalopatía posterior reversible recurrente con respuesta a nimodipino. Neurología. 2012;27:378–80.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1311 "Ancho" => 1750 "Tamanyo" => 268755 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A–C) Hyperintense parietal-occipital lesions in T2-weighted and FLAIR sequences in the first episode. (D–E) Disappearance of lesions in MR image taken one month later. (F) New right occipital lesion, hyperintense in FLAIR sequence, in a second episode 6 months later.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A reversible posterior leukoencephalopathy syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Hinchey" 1 => "C. Chaves" 2 => "B. Appignani" 3 => "J. Breen" 4 => "L. Pao" 5 => "A. 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| 2024 July | 38 | 5 | 43 |
| 2024 June | 55 | 6 | 61 |
| 2024 May | 58 | 8 | 66 |
| 2024 April | 32 | 24 | 56 |
| 2024 March | 47 | 9 | 56 |
| 2024 February | 44 | 9 | 53 |
| 2024 January | 51 | 6 | 57 |
| 2023 December | 36 | 7 | 43 |
| 2023 November | 54 | 5 | 59 |
| 2023 October | 55 | 10 | 65 |
| 2023 September | 30 | 5 | 35 |
| 2023 August | 20 | 5 | 25 |
| 2023 July | 60 | 4 | 64 |
| 2023 June | 29 | 7 | 36 |
| 2023 May | 40 | 6 | 46 |
| 2023 April | 36 | 4 | 40 |
| 2023 March | 44 | 3 | 47 |
| 2023 February | 43 | 7 | 50 |
| 2023 January | 56 | 8 | 64 |
| 2022 December | 46 | 4 | 50 |
| 2022 November | 43 | 18 | 61 |
| 2022 October | 38 | 12 | 50 |
| 2022 September | 45 | 6 | 51 |
| 2022 August | 55 | 13 | 68 |
| 2022 July | 37 | 12 | 49 |
| 2022 June | 22 | 4 | 26 |
| 2022 May | 22 | 6 | 28 |
| 2022 April | 32 | 9 | 41 |
| 2022 March | 43 | 5 | 48 |
| 2022 February | 43 | 4 | 47 |
| 2022 January | 58 | 3 | 61 |
| 2021 December | 46 | 7 | 53 |
| 2021 November | 41 | 7 | 48 |
| 2021 October | 74 | 10 | 84 |
| 2021 September | 55 | 9 | 64 |
| 2021 August | 33 | 10 | 43 |
| 2021 July | 50 | 11 | 61 |
| 2021 June | 30 | 8 | 38 |
| 2021 May | 33 | 12 | 45 |
| 2021 April | 134 | 34 | 168 |
| 2021 March | 88 | 9 | 97 |
| 2021 February | 46 | 14 | 60 |
| 2021 January | 43 | 16 | 59 |
| 2020 December | 52 | 8 | 60 |
| 2020 November | 37 | 12 | 49 |
| 2020 October | 40 | 6 | 46 |
| 2020 September | 42 | 10 | 52 |
| 2020 August | 30 | 3 | 33 |
| 2020 July | 38 | 8 | 46 |
| 2020 June | 38 | 8 | 46 |
| 2020 May | 39 | 14 | 53 |
| 2020 April | 34 | 11 | 45 |
| 2020 March | 41 | 14 | 55 |
| 2020 February | 39 | 14 | 53 |
| 2020 January | 44 | 14 | 58 |
| 2019 December | 48 | 23 | 71 |
| 2019 November | 26 | 11 | 37 |
| 2019 October | 31 | 10 | 41 |
| 2019 September | 30 | 6 | 36 |
| 2019 August | 25 | 18 | 43 |
| 2019 July | 18 | 15 | 33 |
| 2019 June | 40 | 20 | 60 |
| 2019 May | 78 | 26 | 104 |
| 2019 April | 51 | 10 | 61 |
| 2019 March | 16 | 11 | 27 |
| 2019 February | 12 | 6 | 18 |
| 2019 January | 6 | 4 | 10 |
| 2018 December | 8 | 10 | 18 |
| 2018 November | 26 | 4 | 30 |
| 2018 October | 7 | 16 | 23 |
| 2018 September | 25 | 5 | 30 |
| 2018 August | 8 | 2 | 10 |
| 2018 July | 5 | 0 | 5 |
| 2018 June | 2 | 4 | 6 |
| 2018 May | 3 | 4 | 7 |
| 2018 April | 8 | 4 | 12 |
| 2018 March | 15 | 3 | 18 |
| 2018 February | 1 | 5 | 6 |
| 2018 January | 7 | 3 | 10 |
| 2017 December | 6 | 0 | 6 |
| 2017 November | 6 | 3 | 9 |
| 2017 October | 14 | 4 | 18 |
| 2017 September | 7 | 2 | 9 |
| 2017 August | 14 | 5 | 19 |
| 2017 July | 15 | 3 | 18 |
| 2017 June | 16 | 15 | 31 |
| 2017 May | 18 | 8 | 26 |
| 2017 April | 14 | 16 | 30 |
| 2017 March | 13 | 15 | 28 |
| 2017 February | 14 | 2 | 16 |
| 2017 January | 20 | 1 | 21 |
| 2016 December | 19 | 6 | 25 |
| 2016 November | 9 | 3 | 12 |
| 2016 October | 16 | 10 | 26 |
| 2016 September | 20 | 7 | 27 |
| 2016 August | 20 | 13 | 33 |
| 2016 July | 17 | 1 | 18 |
| 2016 June | 23 | 9 | 32 |
| 2016 May | 24 | 22 | 46 |
| 2016 April | 27 | 14 | 41 |
| 2016 March | 33 | 26 | 59 |
| 2016 February | 27 | 19 | 46 |
| 2016 January | 21 | 20 | 41 |
| 2015 December | 16 | 15 | 31 |
| 2015 November | 14 | 13 | 27 |
| 2015 October | 17 | 14 | 31 |
| 2015 September | 27 | 8 | 35 |
| 2015 August | 13 | 8 | 21 |
| 2015 July | 6 | 4 | 10 |
| 2015 June | 4 | 3 | 7 |
| 2015 May | 22 | 2 | 24 |
| 2015 April | 21 | 7 | 28 |
| 2015 March | 23 | 9 | 32 |
| 2015 February | 16 | 8 | 24 |
| 2015 January | 29 | 10 | 39 |
| 2014 December | 50 | 13 | 63 |
| 2014 November | 20 | 3 | 23 |
| 2014 October | 31 | 5 | 36 |
| 2014 September | 21 | 1 | 22 |
| 2014 August | 31 | 8 | 39 |
| 2014 July | 26 | 4 | 30 |
| 2014 June | 17 | 0 | 17 |
| 2014 May | 18 | 0 | 18 |
| 2014 April | 12 | 2 | 14 |
| 2014 March | 19 | 2 | 21 |
| 2014 February | 17 | 2 | 19 |
| 2014 January | 16 | 4 | 20 |
| 2013 December | 19 | 2 | 21 |
| 2013 November | 16 | 14 | 30 |
| 2013 October | 24 | 4 | 28 |
| 2013 September | 27 | 3 | 30 |
| 2013 August | 37 | 5 | 42 |
| 2013 July | 13 | 1 | 14 |
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