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Posterior reversible encephalopathy syndrome (PRES) is a clinical syndrome with characteristic findings of reversible vasogenic edema. As intracranial hemorrhage (ICH) can be seen in 10-25% of PRES cases, interaction with acute stroke reperfusion therapies, including intravenous tissue plasminogen activator (IVtPA) or mechanical thrombectomy (MT), would be expected to increase ICH risk. The ideal acute ischemic stroke (AIS) management of PRES patients is unclear.

We performed a retrospective review of patients with PRES treated with AIS reperfusion therapy. Data was collected on demographics, last known normal time (LKN), National Institutes of Health Stroke scale (NIHSS), neuroimaging findings, and discharge disposition.

We reviewed 5 patients with PRES who underwent AIS reperfusion treatment (2 female, 3 male). The mean age was 61.8 years (range, 53-66). The mean NIHSS was 17.4 (range 9 to 22). Four patients received IVtPA and 1 patient underwent MT with LKN to groin puncture of 176 minutes. The mean time from LKN to IVtPA administered was 189.3 minutes (range, 87 to 229). Three PRES patients presented acutely as an AIS mimic and received IVtPA, of which 2 (75%) patients developed ICH. Two patients had known diagnosis of PRES and developed new AIS symptoms: 1 patient with PRES diagnosed 4 days prior with new LM1 occlusion that underwent successful MT, and 1 patient with PRES diagnosed 3 weeks prior (neither patients developed ICH). In hospital mortality was 2 (40%). Among survivors, 1 patient was discharged home, and 2 patients were discharged to facilities.

In our small case series, PRES patients presenting as AIS mimics who received IVtPA had high risk of ICH (75%). However, remote PRES (3 weeks prior) and PRES undergoing MT did not develop ICH. Further studies are warranted to better understand the risk of ICH in PRES patients undergoing AIS reperfusion therapies.