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AJNR - American Journal of Neuroradiology

Published ahead of print on April 22, 2009
doi: 10.3174/ajnr.A1588

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American Journal of Neuroradiology 30:1371-1379, August 2009
© 2009 American Society of Neuroradiology

BRAIN

Hemorrhage in Posterior Reversible Encephalopathy Syndrome: Imaging and Clinical Features

H.M. Hefzy^a, W.S. Bartynski^b, J.F. Boardman^b and D. Lacomis^a

^a Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pa
^b Department of Neuroradiology, University of Pittsburgh Medical Center, Pittsburgh, Pa

Please address correspondence to Walter S. Bartynski, MD, Department of Radiology, Division of Neuroradiology, Presbyterian University Hospital, University of Pittsburgh, 200 Lothrop St, D132, Pittsburgh, PA 15213; e-mail: bartynskiws{at}upmc.edu

BACKGROUND AND PURPOSE: Hemorrhage is known to occur in posterior reversible encephalopathy syndrome (PRES), but the characteristics have not been analyzed in detail. The purpose of this study was to evaluate the imaging and clinical features of hemorrhage in PRES.

MATERIALS AND METHODS: Retrospective assessment of 151 patients with PRES was performed, and 23 patients were identified who had intracranial hemorrhage at toxicity. Hemorrhage types were identified and tabulated, including minute focal hemorrhages (<5 mm), sulcal subarachnoid hemorrhage, and focal hematoma. Clinical features of hemorrhage and nonhemorrhage PRES groups were evaluated, including toxicity blood pressure, coagulation profile/platelet counts, coagulation-altering medication, and clinical conditions associated with PRES. Toxicity mean arterial pressure (MAP) groups were defined as normal (<106 mm Hg), mildly hypertensive (106–116 mm Hg), or severely hypertensive (>116 mm Hg).

RESULTS: The overall incidence of hemorrhage was 15.2%, with borderline statistical significance noted between the observed clinical associations (P = .07). Hemorrhage was significantly more common (P = .02) after allogeneic bone marrow transplantation (allo-BMT) than after solid-organ transplantation. The 3 hemorrhage types were noted with equal frequency. A single hemorrhage type was found in 16 patients, with multiple types noted in 7. Patients undergoing therapeutic anticoagulation were statistically more likely to develop hemorrhage (P = .04). No difference in hemorrhage incidence was found among the 3 blood pressure subgroups (range, 14.9%–15.9%).

CONCLUSIONS: Three distinct types of hemorrhage (minute hemorrhage, sulcal subarachnoid hemorrhage, hematoma) were identified in PRES with equal frequency. The greatest hemorrhage frequency was seen after allo-BMT and in patients undergoing therapeutic anticoagulation. Hemorrhage rate was independent of the toxicity blood pressure.