Imaging Patterns and Outcome of Posterior Reversible Encephalopathy Syndrome During Childhood Cancer Treatment

BackgroundDiagnosis of posterior reversible encephalopathy syndrome (PRES) requires presence of headache, seizures, impaired vision, or altered mentation accompanied by specific imaging findings. We aimed to study long-term clinical and radiologic outcome of PRES in children with cancer to augment limited available data. ProcedureRetrospective review of children with cancer who were diagnosed with PRES. ResultsWe identified PRES in 21 males and 16 females among 5,217 children treated during the study period. Median time from cancer diagnosis to PRES was 6.6 months in 25 leukemia (1.6%), five brain tumor (0.3%), and seven other solid tumor (0.4%) patients; P=<0.0001 for leukemia versus all other tumors. Symptoms included seizures (97%), headaches (40%), altered mentation (68%), and vision impairment (27%). Hypertension was seen in 97%, and steroids use was seen in 78%. Headaches, visual disturbance, and mental status resolved within a median of <3 days, whereas epilepsy developed in 19%. T2 hyperintense signal was present in 100% of occipital, 47% of temporal, 75% of parietal, and 55% of frontal lobes, as well as 22% of cerebellum and 5% of basal ganglia. Follow-up magnetic resonance imaging (MRI) in 34 patients showed partial or complete T2 resolution in 79%, development of laminar necrosis in five, microhemorrhages in six, and focal atrophy in three. ConclusionPRES in children is more common in hematological malignancy compared with other tumors and is associated with hypertension and steroid use. Seizure is the most common acute manifestation. Most MRI changes resolve, but persistent imaging abnormality and epilepsy may develop in a significant minority.