Posterior reversible encephalopathy syndrome: role of transorbital ultrasound
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LETTER TO THE EDITOR
Posterior reversible encephalopathy syndrome: role of transorbital ultrasound Piergiorgio Lochner 1 Andrea Naldi 5
&
Martin Lesmeister 1
&
Raffaele Nardone 2,3
&
Andrea Orioli 2
&
Antonio Siniscalchi 4
&
Received: 25 May 2020 / Accepted: 12 September 2020 # The Author(s) 2020
Dear Editor, Posterior reversible encephalopathy syndrome (PRES) presents most often with unspecific symptoms such as headache, confusion, decreased alertness, visual dysfunction, and seizures, which sometimes develop to status epilepticus. The diagnosis should be suspected when some triggers (abrupt arterial hypertension, preeclampsia, immunosuppressive therapy, transplantation, autoimmune diseases, etc.) are associated with an encephalopathy syndrome in the context of typical magnetic resonance (MR) findings indicative of vasogenic edema (areas of increased signal on fluid-attenuated inversion recovery (FLAIR) predominantly localized to the posterior cerebral hemispheres) [1]. Although its pathogenesis is not completely understood, two hypotheses have been postulated: the first theory consists of a rapidly developing hypertension exceeding the upper limit of cerebral blood flow autoregulation and leading to increased cerebral perfusion, breakdown of the blood-brain barrier with endothelial dysfunction, and consequent extravasation of fluid and blood products into the brain parenchyma. The second theory supports endothelial damage due to direct effects of excessive circulation cytokines, promoted by immunosuppressive or cytotoxic drugs, or autoimmune disorders releasing vasoactive factors, which induce an increase of vascular permeability and interstitial brain edema [1].
* Piergiorgio Lochner [email protected] 1
Department of Neurology, Saarland University Medical Center, Homburg, Germany
2
Department of Neurology, Franz Tappeiner Hospital, Merano, Italy
3
Department of Neurology, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria
4
Department of Neurology and Stroke Unit, Annunziata Hospital, Cosenza, Italy
5
Department of Neuroscience Rita Levi Montalcini, University of Turin, Turin, Italy
In about 90% of patients, complete remission of clinical symptoms occurs within weeks and a restitution of abnormal conditions in MR images is observed in about 70% of cases, whereas complications are described in up to 10%, henceforth leading to death in 3–6% [2]. Therefore, rapid and early identification and strict monitoring of patients threatened with the worst outcome is needed. Because symptoms’ severity mostly depends on the development of high intracranial pressure (ICP), a bedside and quick tool for its detection may be particularly useful. Transorbital sonography (TOS) for optic nerve sheath diameter (ONSD) and optic disc elevation (ODE) assessment is a promising technique, which is able to identify raised ICP and may represent a valid alternative to the standard referring invasive methods for ICP measurement. However, to date, only one report about its application in
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