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. 2019 Apr;9(2):58-64.
doi: 10.1177/1941874418802061. Epub 2018 Sep 27.

Cerebrospinal Fluid in Posterior Reversible Encephalopathy Syndrome: Implications of Elevated Protein and Pleocytosis

Colin A Ellis  1 , Andrew C McClelland  2 , Suyash Mohan  2 , Emory Kuo  3 , Scott E Kasner  1 , Cen Zhang  4 , Pouya Khankhanian  1 , Ramani Balu  1
Affiliations

Cerebrospinal Fluid in Posterior Reversible Encephalopathy Syndrome: Implications of Elevated Protein and Pleocytosis

Colin A Ellis et al. Neurohospitalist. 2019 Apr.

Abstract

Background and purpose: Patients with posterior reversible encephalopathy syndrome (PRES) sometimes undergo analysis of cerebrospinal fluid (CSF) to exclude alternative diagnoses. This study's objectives were to describe the CSF characteristics in patients with PRES and to identify clinical and radiologic findings associated with distinct CSF abnormalities.

Methods: We identified a retrospective cohort of patients with PRES. We compared clinical and radiographic characteristics of those who did versus did not undergo lumbar puncture, described the observed range of CSF findings, and analyzed clinical and radiographic features associated with specific CSF abnormalities.

Results: A total of 188 patients were included. Patients with (n = 77) and without (n = 111) CSF analysis had similar clinical and radiographic characteristics. Cerebrospinal fluid protein was elevated in 46 (60%) of 77, with median CSF protein 53 mg/dL (upper limit of normal 45 mg/dL). Protein elevation was significantly associated with radiographic severity (P = .0058) but not with seizure, time from symptom onset, radiographic evidence of diffusion restriction, or contrast enhancement. Five (7%) patients had elevated CSF white blood cells, all of whom had infarction and/or hemorrhage on neuroimaging, and 4 of whom had eclampsia.

Conclusion: The CSF of most patients with PRES shows a mild protein elevation commensurate with radiographic severity. Cerebrospinal fluid pleocytosis may mark a distinct subtype of PRES with predisposition toward infarction and/or hemorrhage. These findings help clinicians interpret CSF findings in these patients and generate new hypotheses about the pathophysiology of this syndrome.

Keywords: PRES; RPLS; cerebrospinal fluid; eclampsia; posterior reversible encephalopathy syndrome.

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Conflict of interest statement

Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1.
Figure 1.
Spectrum of radiographic findings in PRES. (A) mild, (B) moderate and (C) severe vasogenic edema; (D) with diffusion restriction, (E) with intracerebral hemorrhage, and (F) with subarachnoid hemorrhage, demonstrated here by diffuse sulcal contrast enhancement. Magnetic resonance imaging sequences: (A-C) FLAIR, (D) diffusion-weighted image (E) gradient echo (F) postgadolinium FLAIR. FLAIR indicates fluid attenuated inversion recovery; PRES, posterior reversible encephalopathy syndrome.
Figure 2.
Figure 2.
Distribution of (A) CSF white blood cells and (B) CSF protein (right panel) in 77 patients with PRES. Horizontal dashed lines represent upper limit of normal for each assay. In panel B, CSF protein distribution is shown first for all cases, then grouped by radiographic severity of PRES. There is a significant association between radiographic severity and CSF protein level (Spearman ρ = 0.32, P = .0058). CSF indicates cerebrospinal fluid; PRES, posterior reversible encephalopathy syndrome.
See this image and copyright information in PMC

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