Treatment of Reversible Posterior Leukoencephalopathy Syndrome with Glasgow Coma Scale Score Below 8
This protocol covers the management of malignant PRES — the most severe presentation — characterised by a Glasgow Coma Scale (GCS) score below 8, ongoing clinical decline despite standard care for elevated intracranial pressure, and neuroimaging findings of significant mass effect.
Clinical Scenario
The patient has a GCS score of less than 8 and continues to deteriorate despite standard medical management for elevated intracranial pressure. Neuroimaging shows cerebral oedema or intracerebral haemorrhage exerting mass effect — which may include effacement of basal cisterns or signs of herniation.
Treatment Approach
Management at this severity centres on aggressive supportive care, with further interventions determined by the nature and degree of intracranial pathology.
The complete structured regimen — including the full decision algorithm, intervention sequence, and all relevant options — is available via the link below.
References
DOI: 10.1136/practneurol-2021-003194
- Malignant PRES is defined based on clinical criteria consisting of a Glasgow Coma Scale (GCS) score of <8 and clinical decline despite standard medical management for elevated intracranial pressure.
- In addition, there must be radiological evidence of oedema or intracerebral haemorrhage exerting mass effect, such as effacement of basal cisterns, transtentorial, tonsillar or uncal herniation.
- Malignant PRES requires aggressive supportive care that may include mechanical ventilation, transfusion of blood products for reversal of coagulopathy and corticosteroids for those with autoimmune disorders.
- Patients with PRES whose GCS score is ≤8 should have intracranial pressure monitoring whenever possible.
- Various interventions undertaken in patients with raised intracranial pressure include osmotherapy, CSF drainage by external ventricular drain, craniectomy and evacuation of haematomas; these are reported to reduce mortality rates in comparison to historic reports.
- Patients with acute obstructive hydrocephalus may require an external ventricular drain.
View source ↗