Introduction: First described in 1996, Posterior Reversible Encephalopathy Syndrome (PRES) is characterized by headache, altered mental status, visual changes, and seizure, as well as cerebral imaging that demonstrates extensive white-matter changes consistent with cerebral edema without infarction. The syndrome has been described in association with eclampsia, hypertensive emergency, or exposure to immunosuppressive medications. Reports of PRES in neurosurgical patients include: spinal cord injury, cranial tumor resection, and hemodynamic augmentation following subarachnoid hemorrhage. This is the first description of a patient developing PRES following an endonasal endoscopic removal of a pituitary macroadenoma.
Methods: This case was studied with pre- and post-operative computed tomography (CT) and magnetic resonance imaging (MRI). Diagnostic cerebral arteriography (DCA) was performed post-operatively.
Results: The patient, a 59-year-old female, presented with one month history of intermittent confusion, speech difficulties, as well as bitemporal hemianopsia. Preoperative MRI showed a pituitary macroadenoma. The patient subsequently underwent an endonasal endoscopic removal of the tumor with no intraoperative complications. After an uneventful initial post-operative recovery, the patient experienced sudden onset of emesis, confusion, and vision loss associated with severe hypertension. Emergent CT demonstrated normal post-operative changes, with no sign of hematoma or infarction. MRI revealed FLAIR changes in the posterior lobes and thalamus, consistent with PRES. DCA demonstrated no vascular abnormalities. The patient rapidly became obtunded. The patient’s primary treatment was blood pressure control. By the fifth post-operative day, the patient was awake and following commands. Within ten days, she was neurologically intact except for a right homonymous hemianopsia. Follow-up MRI revealed resolution of PRES with an area of small infarction in the left occipital lobe.
Conclusions: Although rare in neurosurgical patients, PRES must be considered in a patient who develops acute vision loss and mental status changes associated with hypertension following endoscopic endonasal macroadenoma resection. The primary treatment for these patients is blood pressure control.
Patient Care: We hope to make practitioners aware of this potential complication following endoscopic endonasal surgery.
Although rare, posterior reversible encephalopathy syndrome has the potential for significant neurological morbidity, if not treated in a timely manner. Immediate recognition of this syndrome is essential to limit such morbidity.
Learning Objectives: To make practitioners aware of the presentation posterior reversible encephalopathy syndrome following endoscopic endonasal surgery for skull base lesions.
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