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Prognostic factors and outcomes in pediatric posterior reversible encephalopathy syndrome: a 6-year single-center
Bayram Bayramov1, Alper Oglakcioglu2, Serhan Ozcan2
1Division of Pediatric Intensive Care, Department of Pediatrics, Ankara Bilkent City Hospital, University of Health Sciences, Faculty of Medicine, Ankara, Turkey. bayramov177@gmail.com.
Insights
Lower Glasgow Coma Scale (GCS) scores and vasopressor use in pediatric posterior reversible encephalopathy syndrome (PRES) patients admitted to the PICU are linked to higher mortality. These findings highlight critical indicators for assessing PRES severity in children.
Area of Science:
- Pediatric critical care medicine
- Neurology
- Radiology
Background:
- Posterior reversible encephalopathy syndrome (PRES) presents with hypertension, seizures, and altered mental status, with characteristic cerebral edema on imaging, particularly in occipital and parietal regions.
- Understanding prognostic factors in pediatric PRES is crucial for timely intervention and improved outcomes.
Purpose of the Study:
- To evaluate demographic, clinical, laboratory, and radiological characteristics of pediatric PRES patients in the PICU.
- To identify prognostic factors associated with mortality in pediatric PRES.
Main Methods:
- Retrospective cohort study of 52 MRI-confirmed pediatric PRES cases in a tertiary PICU.
- Analysis included demographic data, clinical findings, severity scores, laboratory parameters, treatments, MRI patterns, and outcomes.
- Univariable logistic regression and ROC curve analyses were used to identify mortality correlates; Firth's penalized logistic regression was applied for sensitivity analysis.
Main Results:
- Overall mortality was 15.4% (8/52). Seizures (90.4%) and hypertension (88.5%) were common.
- Non-survivors exhibited significantly lower admission Glasgow Coma Scale (GCS) scores (median 10.0 vs 13.0) and longer PICU stays.
- Vasopressor requirement was strongly associated with mortality (penalized OR = 29.75), and GCS score at admission was linked to survival (Firth-penalized estimate OR = 0.73 per unit increase).
Conclusions:
- Lower GCS score and vasopressor requirement are associated with mortality in pediatric PRES patients.
- Vasopressor use may indicate severe illness and hemodynamic compromise.
- Findings require validation in larger multicenter studies for clinical application.
Abstract:
This study aims to evaluate the demographic, clinical, laboratory, and radiological characteristics of pediatric patients with posterior reversible encephalopathy syndrome (PRES) admitted to the pediatric intensive care unit (PICU) and to identify prognostic factors associated with mortality. This retrospective cohort study included 52 MRI-confirmed pediatric PRES cases managed in a tertiary-level PICU between January 2020 and January 2026. Demographic features, etiologies, clinical findings, severity scores (PRISM/PELOD), laboratory parameters, treatment modalities, MRI patterns, and outcomes were compared between survivors and non-survivors. Univariable logistic regression and receiver operating characteristic (ROC) curve analyses were performed to identify unadjusted clinical correlates of mortality; given the small number of deaths (n = 8), a multivariable model was not fitted, and Firth's penalized logistic regression was used as a sensitivity analysis for the main associations. The study adhered to STROBE guidelines. The mean age was 120.0 ± 50.8 months; 65.4% had hematologic-oncologic diagnoses. Overall mortality was 15.4% (8/52). Seizures occurred in 90.4% and hypertension in 88.5% of patients. MRI most frequently demonstrated occipital and parietal involvement (90.4% each). Non-survivors had significantly lower admission GCS scores (median 10.0 [IQR 8.0-12.5] vs 13.0 [12.0-15.0], p = 0.012), and longer PICU length of stay (median 14.5 days [IQR 9.2-26.5] vs 5.0 days [3.0-12.2], p = 0.016). GCS demonstrated an area under the curve (AUC) of 0.777 (95% CI 0.619-0.918) with optimal cutoff ≤ 10 (sensitivity 62%, specificity 84%). In univariate logistic regression with Firth penalized correction, vasopressor requirement was strongly associated with mortality (unadjusted penalized OR = 29.75, 95% CI 2.800-315.530, p = 0.005); the wide confidence interval reflects near-complete separation (7/8 non-survivors vs 6/44 survivors required vasopressors). The Glasgow Coma Scale (GCS) score at admission was associated with survival; each one-unit increase in the GCS score was associated with a 27% lower unadjusted odds of death (Firth-penalized estimate OR 0.73, 95% CI 0.550-0.940, p = 0.016).
Conclusion:
In this large single-center pediatric series, lower GCS score, vasopressor requirement, and prolonged PICU stay were associated with mortality in univariate analysis. Vasopressor requirement may reflect the degree of hemodynamic compromise and the severity of illness rather than serve as an early clinical warning. These exploratory findings require validation in larger multicenter cohorts before clinical application.
What Is Known:
• PRES typically presents with acute hypertension, seizures, headaches, visual disturbances, and altered mental status. Radiologically, brain imaging reveals cerebral edema, which is more pronounced in the parietal and occipital regions.
What Is New:
• In univariate logistic regression with Firth penalized correction, vasopressor requirement was associated with mortality (OR = 29.75, 95% CI 2.800-315.530, p = 0.005). • Non-survivors had lower admission GCS, and GCS ≤ 10 predicted death (AUC 0.777, 95% CI 0.619-0.918; 84% specificity).