Posterior reversible encephalopathy syndrome in patients with COVID-19

Abstract

Objective: To report four patients with coronavirus disease 2019 (COVID-19) who developed posterior reversible encephalopathy syndrome (PRES).

Methods: Patient data was abstracted from medical records at Weill Cornell Medical Center.

Results: Four patients with SARS-CoV-2 infection and PRES were identified. The patients' ages ranged from 64 to 74 years, and two were women. All four patients were admitted to the hospital with acute respiratory distress syndrome requiring intensive care unit admission and mechanical ventilation. PRES was diagnosed after persistent confusion, lethargy, new focal neurological deficits, or seizures were noted, with evidence of seizures on electroencephalogram for two of the patients. Imaging confirmed the presence of cerebral vasogenic edema. All four patients had elevated blood pressure and renal injury in the days preceding PRES diagnosis, as well as evidence of systemic inflammation and systemic hypercoagulability. Symptoms of PRES improved with blood pressure control.

Conclusions: Our four cases demonstrate the occurrence of PRES in critically-ill patients with COVID-19. PRES should be considered in the differential for acute neurological deficits and seizures in this setting.

Keywords: COVID-19; Posterior reversible encephalopathy syndrome; SARS-CoV-2.

Fig. 1

Clinical and imaging characteristics of four patients with PRES and COVID-19. For each case, representative MRI images are shown, axial T2 FLAIR sequence demonstrating (A, top panel) involvement of not just the occipital white matter (solid arrows) but also the thalamus and internal capsule (dashed arrows), (B, top panel) bilateral subcortical occipital hyperintensity compatible with vasogenic edema (arrows), (C, top panel) mild subcortical bilateral occipital edema (arrows), and (D, top panel) occipital white matter edema typical of PRES. Daily maximum (blue circles) and minimum (orange circles) mean arterial pressure (MAP) in mmHg from admission to day of PRES diagnosis are shown for Case 1–4, with normal MAP of 70–100 represented by the light blue shaded area (middle panel). Date of tocilizumab administration (D, blue arrow) relative to day preceding PRES diagnosis is indicated. Laboratory findings for each patient are shown in the table. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 2

Imaging characteristics of Case 4. This patient demonstrated a wider spectrum of imaging findings. CT (A) demonstrates occipital white matter edema (arrows) typical of PRES. However, signal loss demonstrated on susceptibility weighted images consistent with microhemorrhage (arrows in B) as well as diffusion restriction on DWI images (arrows in C) was also observed.