title: Refractory intracranial hypertension in posterior reversible encephalopathy syndrome.
abstract: BACKGROUND
  Posterior reversible encephalopathy syndrome (PRES) is a largely reversible disease with long-term favorable outcome. A minority of patients, however, may develop progressive cerebral edema and ischemia resulting in severe disability or death. We report a case of severe intracranial hypertension associated with PRES that was successfully treated according to intracranial pressure (ICP)- and cerebral perfusion pressure (CPP)-driven therapy.
  
  
  METHODS
  Case report.
  
  
  RESULTS
  A 42-year-old woman underwent bilateral lung transplantation for severe bronchiectasis. Her immunosuppressive regimen consisted of azathioprine, prednisone, and tacrolimus. She acutely developed an aggressive form of PRES that rapidly resulted in severe refractory intracranial hypertension despite discontinuation of potentially causative medications and adequate supportive therapy. Accordingly, second-tier therapies, including barbiturate infusion, were instituted and immunosuppression was switched to anti-thymocyte globulin followed by mycophenolate mofetil. Within 10 h of barbiturate administration, ICP dropped to 20 mmHg. Thiopental was administered for two days and then rapidly tapered because of severe urosepsis. Six months after discharge from the intensive care unit the patient returned to near-normal life, her only complaint being short-term amnesia.
  
  
  CONCLUSIONS
  The decision to undertake ICP monitoring in medical conditions in which no clear recommendations exist greatly relies on physicians' judgment. This case suggests that ICP monitoring may be considered in the setting of acute PRES among selected patients, when severe intracranial hypertension is suspected, provided that a multidisciplinary team of neurocritical care specialists is readily available.
authors.affiliation: Milan University, Milan, Italy, facchini.alberto@gmail.com.
authors.forename: Alberto
authors.initials: A
authors.lastname: Facchini
authors.forename: Sandra
authors.initials: S
authors.lastname: Magnoni
authors.forename: Vittorio
authors.initials: V
authors.lastname: Civelli
authors.forename: Fabio
authors.initials: F
authors.lastname: Triulzi
authors.forename: Mario
authors.initials: M
authors.lastname: Nosotti
authors.forename: Nino
authors.initials: N
authors.lastname: Stocchetti
mesh_terms: D000328:Adult; D000961:Antilymphocyte Serum / Q000008:administration & dosage / Q000494:pharmacology; D001463:Barbiturates / Q000008:administration & dosage / Q000494:pharmacology; D002560:Cerebrovascular Circulation / Q000187:drug effects / Q000502:physiology; D005260:Female; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage / Q000009:adverse effects / Q000494:pharmacology; D007166:Immunosuppressive Agents / Q000008:administration & dosage / Q000009:adverse effects / Q000494:pharmacology; D007427:Intracranial Pressure / Q000187:drug effects* / Q000502:physiology; D009173:Mycophenolic Acid / Q000008:administration & dosage / Q000031:analogs & derivatives / Q000494:pharmacology; D054038:Posterior Leukoencephalopathy Syndrome / Q000188:drug therapy / Q000473:pathology / Q000503:physiopathology; D013874:Thiopental / Q000008:administration & dosage / Q000009:adverse effects / Q000494:pharmacology; D016896:Treatment Outcome
chemical_list: D000961:Antilymphocyte Serum; D001463:Barbiturates; D006993:Hypnotics and Sedatives; D007166:Immunosuppressive Agents; D009173:Mycophenolic Acid; D013874:Thiopental