Posterior reversible encephalopathy syndrome: evolving insights in diagnosis, management, and outcomes

Abstract

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological syndrome characterised by acute or subacute neurological symptoms—including encephalopathy, seizures, headache, and visual disturbances. Recent advances in neuroimaging, biomarker research, and the increasing use of cytotoxic agents and novel immunotherapies, such as tyrosine kinase inhibitors and anti-CD19 chimeric antigen receptor T-cell therapies, have expanded the spectrum of PRES presentations and associated risk factors. PRES is thought to result from endothelial dysfunction and blood–brain barrier disruption. Emerging research into inflammatory cytokines and biomarkers, such as IL-6, IL-10, and VEGF, offers promising avenues for improved diagnosis and prognosis. Treatment is focused on removing precipitating factors and controlling blood pressure, but evidence from randomised trials is absent. Although prognosis is generally favourable, severe and recurrent PRES can occur, and complications such as epilepsy and stroke can follow. More robust observational studies with large sample sizes, prospective designs, and with more systemic imaging approaches are required to refine diagnostic criteria, clarify pathophysiological mechanisms, and identify optimal management strategies to improve outcomes in this complex and evolving syndrome.