PRES caused by Induced-Hypertension for Cerebral Vasospasm secondary to Aneurysmal SAH

Abstract Objective The aim of this study was to describe a patient who presented with inducing-hypertension Posterior Reversible Encephalopathy Syndrome (IH-PRES) to a university hospital as well as review the literature for all other reports of such patients. Methods The clinical course of a patient who presented to the university hospital neurosurgical department was described. Furthermore, a systematic review was performed for articles related to incidences of PRES caused by the use of IH in the treatment of cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH). Results The patient presented with acute onset headache, found to have SAH due to anterior communicating artery aneurysm rupture and was coiled the next day. Over the following days she demonstrated fluctuating clinical exam, aphasia, and decreased level of arousal. Digital subtraction angiography (DSA) was performed and showed concern for mild vasospasm of the anterior and middle cerebral arteries. Systolic blood pressure goal increased to 180-220 for an IH trial, which initially showed some transient clinical improvement in her level of arousal but was not sustained. Over the next 36 hours, patient exam worsened and developed a left middle cerebral artery syndrome. Given concern for possible ischemic event, Magnetic Resonance Imaging (MRI) was performed which demonstrated interval development of multiple areas of cortical based Fluid-Attenuated Inversion Recovery (FLAIR) hyperintensity consistent with PRES. SBP goal was then relaxed to normotension and approximately 48 hours later the patient’s clinical exam significantly improved. Conclusion IH-PRES is a rare complication that should be kept in the differential for at-risk patients.