2. Past History
• 47 / Female
• K/C/O advanced carcinoma esophagus
• S/P esophageal stenting (SEMS)
• On Chemotherapy (Paclitaxel,5-FU,Cisplatin) - for past 6
months
• Last chemotherapy on 29/6/2019 evening - only Paclitaxel
• No other co-morbidities
3. Presenting complaints
H/O loss of vision since 30/6/2019
Bilateral
Painless
Sudden onset
H/O on&off headache , vomiting ,giddiness for past 6
months - only during chemotherapy
4. Examination
• BP : 120/80 mmHg
• PR : 140 /min
• RR : 18 / min
• SPO2 : 98% on RA
• Poorly built & nourished
• Afebrile
• No pallor/ictreus/cyanosis
6. CNS
• Conscious
• Oriented to time/place/person
• B/L Visual acuity & colour vision - not possible
• No counting fingers close to eyes
• Pupils - 3 mm & Reacting to light
• EOM - full
• No signs of other cranial nerve involvement
• Motor & Sensory system - normal
• No cerebellar signs
• Fundus - Normal
8. MRI Brain
• B/L asymmetric bright signals in parieto occipital lobe
• Mild diffusion restriction & gyral edema
• Effacement of ventricular system and sulci
• No evidence of SOL/Hemorrhage/Infarct
• More in favour of PRES
9.
10. Treatment
• Medical oncology opinion
• Inj. Mannitol 300 mg iv TDS
• Inj. G-CSF 300 mcg SC
• Supportive measures
• Patient regained vision in both eyes in 2 days
15. Paclitaxel in PRES
• Paclitaxel - peripheral neuropathy(sensory predominant)
• PRES - very rare
• Few case reports - available
• Increased incidence - in combination chemotherapy
• In our case - Possible etiology - Paclitaxel
16. Pathogenesis
• Hypertensive patients - disordered cerebral autoregulation
( if BP > 180/120 mmHg)
• Non - Hypertensive patients - Endothelial dysfunction
Capillary leak and BBB disruption
Axonal swelling and vasogenic edema ,
Protein extravasation ,Fibrinoid necrosis
17. • Posterior circulation - more commonly involved
Not well known
Higher adrenergic innervation in anterior circulation
arterioles - protects from hyperperfusion and edema
• White matter > Cortex
Cortex - tightly packed cells - resists edema
24. Treatment
• Hypertension management - i.v drugs
• Stop the offending drug
• Anti epileptics for seizures
• Anti edema meaures
• Treat the underlying cause
• Steroids - contraindicated
26. PRES - A misnomer??
• Not always reversible (15% irreversible neurological
deficit or death)
• Not always confined to white matter
• Not always confined to posterior regions of brain
27. References
• Hinchey J, Chaves C, Appignani B, et al. A reversible
posterior leukoencephalopathy syndrome. N Engl J Med
1996; 334:494.
• Kamiya-Matsuoka C, Paker AM, Chi L, et al. Posterior
reversible encephalopathy syndrome in cancer patients: a
single institution retrospective study. J Neurooncol
2016;128:75.
• Liman TG, Bohner G, Heuschmann PU, et al. The clinical
and radiological spectrum of posterior reversible
encephalopathy syndrome: the retrospective Berlin PRES
study. J Neurol 2012; 259:155.