Acute neurological disorders following intraperitoneal administration of cisplatin

Posterior reversible encephalopathy syndrome (PRES) is a rare syndrome that can be caused by a variety of clinical conditions (e.g. severe hypertension) or the administration of immunosuppressive drugs or cytotoxic agents [1,2]. Symptoms can include headache, confusion, nausea, hearing loss, seizures, and visual disturbances. The pathophysiology of PRES is poorly understood, but reversible alterations in the cerebrovascular autoregulatory control mechanism and blood–brain integrity are thought to play an important role. In general, PRES has a good prognosis resulting in full recovery after removal of the causative agent, although cases with a fatal outcome have been described [1,2]. A 51-year-old womanwas diagnosed with ovarian cancer, classified as FIGO Stage IIIC. Initial treatment consisted of 3 cycles of carboplatin (600 mg) and taxol. Treatment was uneventful and resulted in a partial response. The patient provided informed consent for inclusion in a randomized multicenter clinical trial comparing optimal surgical cytoreduction versus optimal cytoreduction followed by hyperthermic intraperitoneal chemotherapy (HIPEC) currently being conducted in the Netherlands [3]. The patient was randomized to undergo an adjuvant HIPEC procedure. Heated cisplatin (41 °C, 100 mg/m) was administered into the peritoneal cavity for 90 minutes after complete cytoreduction had been achieved. The patient's body temperature increased to a maximum of 38.7 °C during the procedure, normalizing 2 hours after the procedure. On the first postoperative day the patient complained of severe headache, nausea, and hearing loss in her left ear, and became progressively confused. Neurological examination showed a slightly decreased level of consciousness (eyes 3, motor 6, vocal 4) on the Glasgow Coma Scale, but without focal symptoms. Physical examination and laboratory tests were normal with the exception of a mild increase in serum creatinine levels from 57 to 83 μmol/L on the first postoperative day. CT scan of the brain showed generalized edema and a subsequent MRI of the cerebrum revealed symmetrical bilateral occipital white matter lesions. This radiological image is typical for PRES [1]. Supportive carewas initiated and all symptoms resolved completely over the following 72 hours. The patient was treated with an additional 3 cycles of chemotherapy, during which no recurrence of the neurological symptoms occurred. Intraperitoneal administration of heated cisplatin following cytoreduction was thought to be the causative agent. Indeed, several case reports have previously described PRES following intravenous administration of cisplatin [4]. HIPEC procedures are increasingly being applied to treat a variety of malignancies confined to the peritoneal cavity, including ovarian cancer [3]. In such cases, the development of PRES should be considered when a patient develops neurological symptoms in the early postoperative period.