PRES: posterior ağırlıklı vazojenik ödem

Özet

Baş ağrısı, nöbet, bilinç değişikliği veya görme yakınması gelişen; hipertansiyon, preeklampsi/eklampsi, böbrek yetmezliği ya da sitotoksik ilaç maruziyeti bulunan hastada PRES akla gelmelidir. Kontrastsız beyin BT, akut başvuruda kanamayı dışlamaya ve posterior ağırlıklı ödemi göstermeye yarar; inceleme normal ya da özgül olmayan görünümde olabilir ve MR daha duyarlıdır. BT'de iki taraflı posterior hipodensite klinik bağlamla eşleşirse tanıyı destekler, fakat tek başına vazojenik ödemi arteriyel infarkttan kesin ayıramaz. PRES'in atlanması, nöbet ve görme bulgularının nedeninin gecikmeli tanınmasına; eşlik eden kanama veya infarkt benzeri hasarın gözden kaçmasına yol açabilir.

Faz ve pencere

Kontrastsız tanısal

Parieto-oksipital subkortikal beyaz cevherde, bazen kortekse uzanan, sınırları silik hipodens ödem alanları görülebilir; dağılım çoğunlukla iki taraflı ve yaklaşık simetriktir. Kontrastsız BT normal veya özgül olmayan olabilir; kontrastlı faz klasik PRES ödemini göstermek için gerekli değildir.

Önerilen pencereler: Beyin (G 80 / M 40).

BT bulguları

• İki taraflı parietal ve oksipital subkortikal beyaz cevher hipodensitesi
• Posterior hemisferlerde birbirine yakın dağılımlı, sınırları belirsiz ödem
• Hipodens alanın kortikal giruslara eşlik edebilmesi
• Şiddetli olgularda ödem ile birlikte kitlesel etki, hidrosefali veya intraventriküler kanama görülebilir.
• BT'nin belirgin parankim bulgusu göstermemesi PRES'i dışlamaz

Normalde

Aynı lateral ventrikül atriumu düzeyindeki normal BT'de parietal ve oksipital subkortikal beyaz cevher, karşı hemisferle benzer atenüasyonda ve belirgin sulkus basısı olmadan izlenir. Kıyaslarken iki tarafta posterior beyaz cevher yoğunluğunun simetrisini, korteks-beyaz cevher sınırını ve oksipital sulkusların açıklığını birlikte kontrol et.

Ayırıcı tanı

PRES'te lezyonlar vasküler alan sınırlarını aşabilir; bu dağılım PCA infarktından ayrımda yardımcıdır.

Hipoksik-iskemik hasar

korteks ve derin gri çekirdeklerde yaygın gri-beyaz cevher ayrım kaybı görülebilir.

Toksik-metabolik ensefalopati

dağılım etkenine göre simetrik olabilir; klinik ve laboratuvar bağlamı ayırıcıdır.

Ensefalit

temporal veya limbik ağırlıklı fokal şişme, klasik posterior-subkortikal örüntüden ayrılır.

Nöbet ilişkili ödem

nöbetlerle ilişkili görüntülemede akut ödem bulguları görülebilir.

Tuzaklar

• Erken veya hafif PRES'te kontrastsız BT normal olabilir; klinik kuşku sürüyorsa normal BT'yi dışlama testi gibi yorumlama.
• Posterior hipodensiteyi otomatik olarak PCA infarktı sayma; PRES çoğu kez arter sınırlarını aşan ve iki hemisferi benzer biçimde tutan ödem oluşturur.
• Asimetri PRES'i dışlamaz; tek taraflı ya da belirgin asimetrik örüntüde eşlik eden infarkt, kanama ve alternatif tanıları ayrıca ara.
• Atipik PRES formlarında beyinsap veya bazal ganglia tutulumu, hipoksik-iskemik ensefalopati, toksik-metabolik ensefalopati veya derin serebral ven trombozu ile karışabilir.

Kendini dene

1. Eklampsi sonrası görme bulanıklığı olan hastada BT'de iki oksipital bölgede silik atenüasyon azalması görülüyor. En olası tanı hangisidir?

   • PRES
   • Glioblastom
   • Beyin apsesi
   • Subdural hematom
   Cevabı göster

   PRES. Peripartum klinik ve iki taraflı posterior parankim değişikliği PRES'i destekler. Glioblastom ve apse genellikle fokal kitle/enfeksiyon örüntüsü verir; subdural hematom ekstraaksiyel kan koleksiyonudur.

2. Hipertansif hastada nöbet sonrası BT'de parieto-oksipital beyaz cevher yoğunluğu azalmış; lezyonlar arter alanı sınırlarını aşmış. En uygun tanı hangisidir?

   • PRES
   • Menenjit
   • Akut hidrosefali
   • Serebral venöz tromboz
   Cevabı göster

   PRES. Arteriyel dağılıma uymayan posterior ödem, hipertansif nöbet bağlamında PRES lehinedir. Menenjitte BT'deki parankim örüntüsü bu tanıyı koydurmaz; hidrosefali ventrikül genişlemesi yapar; venöz trombozda sinüs/ven bulguları ve drenaj alanına uyan lezyon aranır.

İlgili konular

• PRES santral ve atipik dağılımı
• PRES hemorajisi ve infarkt benzeri komplikasyonlar
• PCA alanı infarktı

Kaynaklar

Bu sayfadaki 35 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla otomatik olarak karşılaştırıldı; 3 cümle bu karşılaştırmada düzeltildi (2026-10-09).

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