Posterior reversible encephalopathy syndrome (PRES): a rare complication of pre-eclampsia

Posterior Reversible Encephalopathy Syndrome (PRES) is rare complication of pre-eclampsia. We report a 21 year old woman (G2P0) with low risk pregnancy presenting at 32+5 weeks with headache, pedal edema and complete blindness for 6 hours. Mean arterial pressure (MAP) was 150-155 mm Hg with 4+urine protein and brisk reflexes. Diagnosis of severe preeclampsia was made and local severe PET protocol instituted. Emergency caesarean section was performed after stabilisation with transfer to ITU. CT head reported low attenuation cortex of both occipital regions extending to cerebral hemispheres representing ischeamia or cerebral edema. MRI brain demonstrated high signal changes in the subcortical white-matter of both parietoccipital lobes on T2 weighted and fluid attenuated inversion recovery imaging (FLAIR scans.) Diagnosis of PRES was made. Blood pressure control remained a challenge for 5 days. Clinical improvement and resolution of visual symptoms was seen with intensive supportive treatment. Discussion Associated with pre-eclampsia, sepsis, autoimmune diseases and immune suppression, PRES is rare clinicoradiological diagnosis. Symptoms include headache, seizures and visual loss invoking early brain MRI to reveal typical pattern of bilateral hyperintensities (FLAIR imaging), predominantly in the parieto-occipital region. The pathophysiology is debated and hypothesis support breakdown in cerebral autoregulation, endothelial dysfunction or vasospasm with subsequent ischaemia. PRES is best managed by monitoring and treatment in the setting of a neurointensive care unit. Prognosis is usually benign with complete reversal of symptoms, if adequate treatment (antihypertensives, withdrawal of causative agents) is immediately initiated. Delay in diagnosis and treatment may lead to permanent neurological sequelae.