Published: 2018-11-26

A case of PRES following intracranial hypotension, with spontaneous resolution with epidural blood patch

Sarada Murali Mamilla


Posterior reversible encephalopathy syndrome (PRES (also known as reversible posterior leukoencephalopathy syndrome)) presents with rapid onset of symptoms including headache, seizures, altered consciousness, and visual disturbance. It is often but by no means always associated with acute hypertension. Diffusion-weighted MRI is the most sensitive exam to confirm the diagnosis of PRES. If promptly recognized and treated, the clinical syndrome usually resolves within a week, and the changes seen in magnetic resonance imaging (MRI) resolve over days to weeks. Posterior reversible encephalopathy syndrome is an increasingly recognized disorder, with a wide clinical spectrum of both symptoms and triggers, and yet it remains poorly understood. Differential diagnosis includes venous sinus thrombosis, cerebral haemorrhage, encephalitis, vasculititis and metabolic encephalopathys. No clinical trials have evaluated the management of PRES, but rapid withdrawal of the trigger appears to hasten recovery and to avoid complications: for example, aggressive blood pressure management, withdrawal of the offending drug, or delivery in eclampsia. We report a case of women presenting with severe headache, tonic clonic convulsions 7 days after spinal anaesthesia for caesarean delivery, MRI showed evidence of intracranial hypotension and posterior reversible encephalopathy syndrome. She was treated with Blood patch which lead to complete resolution of symptoms and radiological findings. The possible pathogenetic relationship between intracranial hypotension, secondary to the inadvertent dural puncture, and PRES is discussed. Prompt diagnosis and proper treatment results in complete cure without permanent neurological sequelae.


Neurotoxic, PRES, Spinal headache

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Pugliese S, Finocchi V, Borgia ML, Nania C, Della Vella B, Pierallini A, Bozzao A. Intracranial hypotension and PRES: case report. J Headache Pain. 2010;11(5):437-40.

W.S. Bartynski,Posterior Reversible Encephalopathy Syndrome, Part 2: Controversies Surrounding Pathophysiology of Vasogenic Edema,American Journal of Neuroradiol. 2008;29(6):1043-49

Santillan A, Aamodt W, Bhavaraju-Sanka R.Pearls and Oy-sters: Spontaneous intracranial hypotension and posterior reversible encephalopathy syndrome. Neurol. 2016;86(6):e55-7.

S. Esther V. Hobson, Ian Craven, and S. Catrin Blank, Posterior Reversible Encephalopathy Syndrome: A Truly Treatable Neurologic Illness. Perit Dial Int. 2012;32(6):590-4.

Postma IR1, Slager S2, Kremer HP3, de Groot JC4, Zeeman GG, Long-term consequences of the posterior reversible encephalopathy syndrome in eclampsia and preeclampsia: a review of the obstetric and nonobstetric literature. Obstet Gynecol Surv. 2014;69(5):287-300.

Achar SK, Shetty N, Joseph TT. Posterior reversible encephalopathy syndrome at term pregnancy. Indian J Anaesth. 2011;55(44):399-401.

Ho CM, Chan KH. Posterior Reversible Encephalopathy Syndrome with Vasospasm in a Postpartum Woman After Postdural Puncture Headache Following Spinal Anesthesia. Case report. Anesthes Anal. 2007;105(3):770-2.

Mercieri M, Mercieri A, Paolini S, Arcioni R, Lupoi D, Passarelli F. et al. Postpartum cerebral ischaemia after accidental dural puncture and epidural blood patch. Br J Anaesth 2003;90(1):98-100

Rajan S, Puthenveettil N, Paul J, Kumar L, Posterior reversible encephalopathy syndrome following caesarean section under spinal anaesthesia, Indian J Anaesth. 2014;58(6):762-65.