Posterior Reversibile Leukoencephalopathy Syndrome and Hypertensive Crisis Due to Obstructive Sleep Apnea:searching for a Link

Objective: Posterior Reversible Encephalopathy Syndrome(PRES) is a clinic-radiological syndrome characterized by headache, nausea/vomiting, confusion, cognitive changes, seizures,cortical blindness. MRI shows bilateral hyper-intense lesions at the parieto-occipital sub-cortical level on T2 and FLAIR sequences. PRES is associated with severe hypertension, while obsstructive sleep apnesa(OSA) is a common cause of secondary hypertension but rarely causes hypertensive encephalopathy. We present a case of a 42-year-old woman who suffered of hypertensive emergency during hospitalization for dyspnea. Design and method: Clinical history revealed obesity, COPD, OSA in treatment with CPAP, HF with depressed EF (44%), adrenal hyperplasia and retroduodenal lesion under investigation. She was active smoker and BP was uncontrolled by valsartan 160 mg, furosemide 25 mg,bisoprolol 2,5 mg. During the hospitalization in November 2023, patient presented headache, seizures, respiratory distress with high BP values (220/120 mmHg, HR 78 bpm). Results: Laboratory tests revealed only a mild increase of plasma cortisol levels (27.5 mcg/dL, range 0-24); low-dose overnight dexamethasone suppression test was normal (1.5 mcg/dl). Despite anti-hypertensive therapy with B-blocker urinary metanephrine levels were normal (184 mcg/24 h, range 0-320) and 18f-FDG PET-TAC for retroduodenal lesion was normal. Cerebral CT did not show ischemic or hemorrhagic lesions while MRI documented radiological characteristics compatible with PRES (Figure 1). Electroencephalogram showed no epileptic abnormalities. Antihypertensive intravenous treatment with urapidil (25 mg as bolus injection followed by 25 mg/h as continuous infusion) was performed for 36h and followed by oral treatment with canrenoate 25 mg, amlodipine 5 mg and doxazosin 4 mg, added to the above therapy. At discharge, BP was normalized (120/84 mmHg). Checking the electronic card of CPAP, the patient used the device for more than four hours only in 35% of the nights. Conclusions: OSA is a risk factor for acute cardiovascular and cerebrovascular diseases like PRES. CPAP application has been shown to induce small reductions (about 3 mmHg) in BP, but in clinical practice the adherence of treatment is very low (30-60%). On the other hand, the improvement of BP values during hospitalization, raises the suspicion that adherence to pharmacological treatment at home was in the same way poor.