Escape from the Claws of Death


About :

Posterior Reversible Encephalopathy Syndrome (PRES) also known as reversible posterior leukoencephalopathy syndrome (RPLS), is a syndrome characterised by headache, confusion, seizure and visual loss.
It may occur due to a number of causes, predominantly malignant hypertension, Eclampsia and some medical treatments. On Magnetic Resonance Imaging (MRI) of the brain, areas of Edema (swelling) are seen. The symptoms tend to resolve after a period of time, although visual changes sometimes remain. It was first described in 1996.

History :

A 27 year old G3P2L2 at 34 week pregnancy presented to Casualty with:

  • Vomiting and high blood pressure since 7 days
  • Headache since 3 days
  • Loss of vision for 3 hours followed by 1 episode of GTC convulsions
  • Severe IUGR and moderate Oligohydramnios.

Patient had BP of 220/130mmhg; Ualb 4+; Fundoscopy (N) was intubated for airway protection MgSo4 given (Pritchard regimen) Antihypertensives given, Emergency LSCS was done; Baby weight was 1.4 kg, Supportive NICU and MICU measures were given for baby and mother.

Diagnosis and Treatment :

MRI showed multiple cortico-subcortical areas of T2 weighted hyper intense (white) signals involving bilateral frontal parietal and occipital lobes.
Diagnosis is typically made clinically with supportive findings on MRI of the brain. This may show hyper intensities on T2 weighed imaging. Cerebral Angiography may provide a more definite diagnosis.
Treatment of PRES depends on the underlying cause for instance, if the main problem is BP, BP control will accelerate resolution of the abnormalities. If the likely cause is medication the withdrawal of the drug in question is needed.

Prognosis :

Many cases resolve within 1-2 weeks of controlling the BP and eliminating the inciting factor. However long lasting or even permanent Neurologic Dysfunction may remain. Though, uncommon death may occur due to progressive swelling of brain (Cerebral Edema) or a bleed in the brain (Intracerebral Haemorrhage).

Post Treatment :

After 2 days BP gradually settled down, vision improved to VA 6/6 on 5th day. Mother and baby went home on 7th post of day.

A case study by : Dr. Sophia Rodrigues
Department of Obstetrics and Gynaecology (OBG)
Manipal Hospital, Goa