Posterior reversible encephalopathy syndrome following cervical spine surgery: insights from an interesting case
Manoj Phalak1, Akshay Ganeshkumar2, Ravi Sharma2
1Department of Neurosurgery, All India Institute of Medical Sciences, 720, CNC, AIIMS, New Delhi, 110029, India. manojphalak@gmail.com.
Insights
Posterior reversible encephalopathy syndrome (PRES) is a rare complication following spinal surgery in children. This case highlights PRES development after a cysto-subarachnoid shunt in a 14-month-old, emphasizing potential CSF hypotension as a contributing factor.
Area of Science:
- Pediatric Neurology
- Neurosurgery
- Neuroradiology
Background:
- Spastic paraplegia in infants can be caused by spinal cord pathologies like intramedullary cysts.
- Surgical intervention, such as cysto-subarachnoid shunting, is a treatment option for such conditions.
- Posterior Reversible Encephalopathy Syndrome (PRES) is a neurological condition characterized by specific brain imaging findings.
Purpose of the Study:
- To report a rare case of PRES following spinal surgery in a pediatric patient.
- To discuss the potential etiologies and clinical presentation of PRES in this context.
- To highlight the importance of recognizing PRES in post-operative pediatric neurosurgical cases.
Main Methods:
- A 14-month-old child with spastic paraplegia underwent a cysto-subarachnoid shunt for an intramedullary cyst.
- Post-operative neurological monitoring and neuroimaging (NCCT head, MRI brain) were performed.
- Clinical management included anti-epileptic treatment.
Main Results:
- The patient developed generalized tonic-clonic seizures and altered sensorium on post-operative day 2.
- Neuroimaging revealed bilateral parieto-occipital hypodensities (NCCT) and hyperintensities (MRI T2WI/FLAIR), consistent with PRES.
- The patient improved with anti-epileptic treatment, and follow-up MRI showed resolution of abnormalities.
Conclusions:
- PRES is an exceptionally rare complication after spinal surgery, particularly in pediatric patients.
- Cerebrospinal fluid (CSF) hypotension is a potential contributing factor to PRES development in the post-operative setting.
- Prompt recognition and management are crucial for favorable outcomes in pediatric PRES.
Abstract:
A 14-month child presenting with complaints of spastic paraplegia was diagnosed with C6-D1 intramedullary cyst. A cysto-subarachnoid shunt was performed; the patient was clinically stable in the immediate post-operative period. On post-operative day 2, the patient developed multiple episodes of generalized tonic-clonic seizures (GTCS) with altered sensorium, NCCT head revealed bilateral diffuse parieto-occipital hypodensities. MRI brain showed on T2WI and FLAIR, diffuse hyperintensities in bilateral parieto-occipital region suggestive of posterior reversible encephalopathy syndrome (PRES). The patient never experienced hypertensive episodes and was treated with anti-epileptics. The patient's symptoms improved and repeat MRI after 10 weeks revealed normal signal intensity in bilateral parieto-occipital areas. PRES after spinal surgeries is very rare and more so in pediatric cases, CSF hypotension may contribute to PRES in such cases.
