A 38-year-old patient with no relevant personal history underwent cesarean section due to a lack of progression of labor.
Twenty-four hours after the procedure, the patient presented occipital headache and neck stiffness with no other added symptoms, initially associated with lumbar puncture (LP) in the context of epidural anesthesia, with recovery, volume and analgesia.
The following days the patient continues with an unfavourable evolution with persistent headache, mean blood pressure (BP) above 100 mm Hg and low fever.
Suddenly, the patient had an episode of generalized tonic-clonic seizures, which is why, after initial assessment in the ward, she was admitted to the ICU.
The ICU presents a new generalized tonic-clonic seizure with benzodiazepines remaining with post-critical stupor.
Physical examination revealed: TA 140/76, HR 68 bpm, blood glucose 135 mg/dl, temperature 37.7oC, oxygen saturation 96% with nasal glasses at 2 bpm.
neurological impairment: initially stuporous, disoriented in time and space with gradual recovery to recover a Glasgow score of 15/15, PINLA, no involvement of conservative craneal pairs, no focal bilateral reflex osteotendon flexor skin.
Emergency skull CT was performed after admission, ruling out cerebral hemorrhage and contraindication for LP.
CSF was extracted and complete blood count, biochemistry, venous gas, CRP, procalcitonin and coagulation were all normal.
Urgent CSF biochemistry is rigorously normal including Gram, cell count, ADA and CSF culture.
Ritsias serology, Borrelia and LUES: normal.
Horses, normal microsomal antibodies
Serology of hepatitis, HIV and cytomegalovirus: normal.
Chest X-ray at admission was normal.
a left ventricular septal defect, a left ventricular septal defect and a left ventricular septal defect were detected; a left ventricular septal defect with a high suspicion of dural puncture was ruled out.
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With the high clinical suspicion of PRES, MRI images, and after ruling out the infectious origin of the lesions, treatment with usual analgesics is maintained and starting with hypotensive drugs (calcium agonists 70 mm Hg).
The clinical evolution is favorable with disappearance of headache and no other symptoms or neurological focality during admission to the ICU.
The patient is discharged from our unit to an asymptomatic hospitalization unit and pending the performance of cranial diffusion MRI, which shows that the findings are considerably attenuated as a sign of reversibility a week later.
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PRES has been related to several diseases, risk factors and drugs where endothelial injury4,5 and cerebral perfusion impairment with alteration in self-regulation are the common denominator.
The selection of drugs involved is increasing and are mostly associated with immunosuppression, including among others: cyclosporine A, tacrolimus, cisplatin, alpha interferon, erythropoietin and antiretroviral therapy.
Among the most frequently involved systemic diseases are: hypertensive encephalopathy, eclampsia7, collagen diseases such as systemic lupus erythematosus (SLE) and panarteritis nodosa (PAN).
There are also cases described in the literature in thrombotic thrombocytopenic purpura (TTP), post kidney transplantation, alcohol intoxication8 and inadvertent lumbar puncture of the dura mater during obstetric analgesia.
Its pathophysiology is not completely defined by theories that attempt to explain cerebral edema and the diffusion of proteins and cells to the extracellular space, on the one hand vasogenic theory and, on the other hand, cytotoxic theory9,10.
Among the most frequent symptoms of PRES are headache, altered level of consciousness and visual disturbances in addition to hypertension.
The diagnosis is established when there is clinical suspicion, the findings and the retrospective confirmation of the disappearance of the symptoms and the resolution of the images.
The differential diagnosis should include vascular affection: bilateral A. basilar infarction, venous thrombosis and hemorrhage.
Infectious diseases such as encephalitis and meningitis, and finally, inflammatory/autoimmune causes such as vasculitis.
The neurocognitive consequences of PRES in obstetric patients are not well known; insisting on the transitory condition of their clinical and radiological characteristics; however, irreversible lesions have been reported where the diagnosis and the inadequate treatment were.
This can lead to the development of refractory seizure syndrome, cerebral infarctions or bleeding with permanent neurological deficit and, less frequently, death.
We also do not know its real prevalence in pregnant women because of the transitory character that defines the syndrome and the added difficulty of the indication of imaging tests in these patients, since its later discovery should include the most prevalent symptoms and the current therapies.
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C. Gómez-Gonzla Radio P. Rubio-Murillob, J. González-Maestrea and J. Martin de Pablosb aSevil Luis Infanta Hospital, Infanta
