TY - JOUR
T1 - Posterior Reversible Encephalopathy Syndrome as a Complication of Induced Hypertension in Subarachnoid Hemorrhage
T2 - A Case-Control Study
AU - Allen, Michelle L.
AU - Kulik, Tobias
AU - Keyrouz, Salah G.
AU - Dhar, Rajat
N1 - Publisher Copyright:
© 2018 by the Congress of Neurological Surgeons.
PY - 2019/8/1
Y1 - 2019/8/1
N2 - BACKGROUND: Induced hypertension (IH) remains the mainstay of medical management for delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH). However, raising blood pressure above normal levels may be associated with systemic and neurological complications, of which posterior reversible encephalopathy syndrome (PRES) has been increasingly recognized. OBJECTIVE: To ascertain the frequency and predisposing factors for PRES during IH therapy. METHODS: We identified 68 patients treated with IH from 345 SAH patients over a 3-yr period. PRES was diagnosed based on clinical suspicion, confirmed by imaging. We extracted additional data on IH, including baseline and highest target mean arterial pressure (MAP), comparing PRES to IH-treated controls. RESULTS: Five patients were diagnosed with PRES at median 6.6 d (range 1-8 d) from vasopressor initiation. All presented with lethargy, 3 had new focal deficits, and 1 had a seizure. Although baseline MAP (prior to DCI) did not differ between cases and controls, both MAP immediately prior to IH (112 vs 90) and highest MAP targeted were greater (140 vs 120 mm Hg, both P <. 01). Magnitude of MAP elevation was greater (54 vs 34 above baseline, P =. 004) while degree of IH was not (37 vs 38 above pre-IH MAP). All 4 surviving PRES patients had complete resolution with IH discontinuation. CONCLUSION: PRES was diagnosed in 7% of SAH patients undergoing IH therapy, most often when MAP was raised well above baseline to levels that exceed traditional autoregulatory thresholds. High suspicion for this reversible disorder appears warranted in the face of unexplained neurological deterioration during aggressive IH.
AB - BACKGROUND: Induced hypertension (IH) remains the mainstay of medical management for delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH). However, raising blood pressure above normal levels may be associated with systemic and neurological complications, of which posterior reversible encephalopathy syndrome (PRES) has been increasingly recognized. OBJECTIVE: To ascertain the frequency and predisposing factors for PRES during IH therapy. METHODS: We identified 68 patients treated with IH from 345 SAH patients over a 3-yr period. PRES was diagnosed based on clinical suspicion, confirmed by imaging. We extracted additional data on IH, including baseline and highest target mean arterial pressure (MAP), comparing PRES to IH-treated controls. RESULTS: Five patients were diagnosed with PRES at median 6.6 d (range 1-8 d) from vasopressor initiation. All presented with lethargy, 3 had new focal deficits, and 1 had a seizure. Although baseline MAP (prior to DCI) did not differ between cases and controls, both MAP immediately prior to IH (112 vs 90) and highest MAP targeted were greater (140 vs 120 mm Hg, both P <. 01). Magnitude of MAP elevation was greater (54 vs 34 above baseline, P =. 004) while degree of IH was not (37 vs 38 above pre-IH MAP). All 4 surviving PRES patients had complete resolution with IH discontinuation. CONCLUSION: PRES was diagnosed in 7% of SAH patients undergoing IH therapy, most often when MAP was raised well above baseline to levels that exceed traditional autoregulatory thresholds. High suspicion for this reversible disorder appears warranted in the face of unexplained neurological deterioration during aggressive IH.
KW - Delayed cerebral ischemia
KW - Induced hypertension
KW - Posterior reversible encephalopathy syndrome
KW - Subarachnoid hemorrhage
KW - Vasopressor complication
UR - http://www.scopus.com/inward/record.url?scp=85069689443&partnerID=8YFLogxK
U2 - 10.1093/neuros/nyy240
DO - 10.1093/neuros/nyy240
M3 - Article
C2 - 29889274
AN - SCOPUS:85069689443
SN - 0148-396X
VL - 85
SP - 223
EP - 230
JO - Neurosurgery
JF - Neurosurgery
IS - 2
ER -