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Posterior Reversible Encephalopathy Syndrome Associated with FOLFOX Chemotherapy

Posterior Reversible Encephalopathy Syndrome Associated with FOLFOX Chemotherapy Hindawi Publishing Corporation Case Reports in Oncological Medicine Volume 2013, Article ID 306983,3 pages http://dx.doi.org/10.1155/2013/306983 Case Report Posterior Reversible Encephalopathy Syndrome Associated with FOLFOX Chemotherapy Luiz Carlos Porcello Marrone, Bianca Fontana Marrone, Tharick Ali Pascoal, Lucas Porcello Schilling, Ricardo Bernardi Soder, Sheila Schuch Ferreira, Giovani Gadonski, and Jaderson Costa da Costa ˜ ´ ´ Hospital Sao Lucas/Instituto do Cerebro (Inscer), Pontificia Universidade Cat olica do Rio Grande do Sul (PUCRS), Avenida Ipiranga 6690, 90610-000 Porto Alegre, RS, Brazil Correspondence should be addressed to Luiz Carlos Porcello Marrone; lcpmarrone@gmail.com Received 28 December 2012; Accepted 27 January 2013 Academic Editors: K. Aogi, C. Gennatas, C. V. Reyes, and J. M. Ribera Copyright © 2013 Luiz Carlos Porcello Marrone et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiologic entity characterized by headaches, altered mental status, seizures, visual loss, and characteristic imaging pattern in brain MRI. The cause of PRES is not yet understood. We report a case of a 27-year-old woman that developed PRES aer ft the use of FOLFOX 5 (oxaliplatin/5-Fluoracil/Leucovorin) chemotherapy for a colorectal cancer. 1. Introduction function, and immunosuppressive therapy. Other possi- ble etiologies are eclampsia, transplantation, neoplasia and Posterior reversible encephalopathy syndrome (PRES) is a chemotherapy treatment, systemic infections, and a renal clinicoradiologic entity characterized by headaches, altered disease, acute or chronic [1, 5]. mental status, seizures, and visual loss and is associated with white matter vasogenic edema predominantly aeff cting the occipital and parietal lobes of the brain [1]. The cause of PRES 2. Case Report is not yet understood. Autoregulatory failure with resultant vasodilation, as A 27-year-old woman with an advanced colorectal adenocar- seen in hypertensive encephalopathy, is oeft n cited as the cinoma with peritoneal metastasis (T3N1 M1; clinical stage underlying mechanism. On the other hand, vasospasm with IV) was admitted in the emergency room due to abdom- ischaemicchangeisalsoobservedinsomepatients[2, 3]. inal pain, vomiting, and suspect of intestinal obstruction. The most characteristic imaging pattern in PRES is the She was submitted to resection of the primary tumor 3 presence of edema involving the white matter of the posterior months before the admission and she underwent the sec- portions of both cerebral hemispheres, especially the parieto- ond cycle of chemotherapy with FOLFOX 5 (oxaliplatin/5- occipital regions, in a relatively symmetric pattern that spares u fl orouacil/leucovorin). the calcarine and paramedian parts of the occipital lobes She was without fever and her blood pressure was [1]. However, other structures (such as the brain stem, 200/120mmHg. In thebasic bloodtest, therewereno cerebellum, and frontal and temporal lobes) may also be abnormalities except an increased of creatinine (1.9 mg/dL, involved, and although the abnormality primarily affects the previous creatinine was 0.7 mg/dL three months ago). subcortical white matter, the cortex and the basal ganglia may During the hospital stay she presented two seizures and also be involved [4]. aer ft the second seizure she developed confusional mental Numerous factors can trigger the syndrome, most com- state that progressed to obnubilation. In her clinical exam- monly: acute elevation of blood pressure, abnormal renal ination, there was no focal neurologic deficit; however the 2 Case Reports in Oncological Medicine the rectum who received modiefi d FOLFOX6 chemotherapy. She presented seizures and altered mental status ten days aeft r the start of fourth cycle of chemotherapy. Her blood pressure was increased at 170/110 mmHg with and increased creatinine (1.5 mg/dL). Brain MRI demonstrated a hyperintensity in the white matter of the posterior hemispheres. One week aer ft the hospitalization, a follow-up MRI on the brain revealed a dramatic improvement in the MRI image abnormalities, and this was consistent with a resolving picture of PRES [8]. In 2011, Kim et al. reported a case of a 52-year-old Figure 1: Brain MRI-FLAIR showing an increase of signal in both womanwithadvancedgastric cancer,presented with low- occipital and frontal lobes. back pain duetospinalmetastasisatthe 4thlumbarver- tebra. The primary tumor was not resectable, and 10 cycles of chemotherapy with FOLFOX had been completed. An patient was poorly cooperative secondary to her confusional elective surgical spinal decompression and stabilization was state. The patient was submitted to a gradual reduction of the scheduled. Twenty-three days aer ft the end of chemotherapy, blood pressure and it was initiated with anticonvulsive drugs a generalized tonic-clonic seizure occurred. Her systolic (valproate sodium 1000 mg/day). blood pressure was 166 mmHg at the time of the seizure and A brain MRI (FLAIR/T2) was performed two days aeft r no electrolyte abnormality was observed. After the seizure, a the onset seizure. This rfi st brain MRI showed an increase of brain computed tomography was conducted, with no den fi ite signal in both occipital and frontal lobes (in watershed zones), abnormality. One day aer ft the seizure a brain MRI was with a symmetric pattern (Figure 1). After three days, when conducted, and a signal change was observed in both parieto- thepatientbecamemoreawake,shereportedabilateralvisual occipital lobes in T2-weighted and FLAIR images. As a disturbance that persisted for one week. result of typical imaging features, PRES was diagnosed. An After ten days, a new brain MRI was performed that antiepileptic drug was administered and no more seizures shows no evidence of edema or other abnormalities. Three were reported [9]. months aer ft the situation described, the patient died due to In this paper, we showed a new case of PRES aeft r the complications of cancer. use of FOLFOX with imaging findings not yet described in this situation. In this case, hypertension and/or renal failure can be another trigger for this syndrome. eTh rst fi brain MRI 3. Discussion of our patient showed typical increased signal intensity in This syndrome was firstly described by Hinchey and col- both occipital lobes but also revealed a watershed/junctional leagues as a clinicoradiologic entity with numerous triggers. pattern of distribution aeff cting the superior frontal sulcus of In 2000, Casey et al. established the term posterior reversible frontal lobes. encephalopathy syndrome (PRES). eTh pathophisiology is In typical PRES, the parietal and occipital lobes are most commonlyaeff cted,followedbythefrontallobes.However,in usually associated with cerebral blood flow autorregulation disruption and/or endothelial dysfunction. Cytotoxic med- watershed imaging distribution of PRES, three hemispheric ications can cause endothelial dysfunction. Hypertension is pattern variants involving cortex, subcortical, and deep white matter to varying degrees may be encountered with the main cause of PRES. However, PRES is not associated with hypertension in 20 to 30% of patients, and a lack of similar frequency: holo-hemispheric (23%), superior frontal hypertension does not rule out the possibility of PRES [1, 6]. sulcus (27%), and primary parietal-occipital (22%) [10]. Previous reports described the association between These demarcate border zones between anterior, middle, and chemotherapy and antiangiogenic drugs with PRES. No sin- posterior circulations and reflect the junctional/watershed gle antineoplastic class or agent has been consistently associ- nature of PRES. er Th e is a fourth imaging pattern distribution ated with PRES although some chemotherapeutic agents may named “partial or asymmetric expression of the primary cause direct CNS microvascular injury. eTh re are few articles patterns” (28%), which occurs when the previous three forms are found in a partial way or asymmetric fashion. Here, we in the literature that report the correlation between PRES, cancert and neoplastic treatments (like chemotherapy). describe the first reported case of PRES with a watershed FOLFOX (oxaliplatin/5-fluorouacil/leucovorin) was pattern aeff cting both superior frontal sulcui aer ft the use of approved by the US Food and Drug Administration as FOLFOX. indicated for first-line therapy for advanced colorectal cancer PRES caused by cytotoxic medications should be man- in 2000. One of the most common adverse effects of the aged with control of hypertension, management of seizures, FOLFOX is the neuropathy [7]. and withdrawal medication. The initial aim of treatment The relationship between PRES and FOLFOX was not in hypertension is to lower the diastolic pressure to about 100 mmHg, with the maximum initial fall in BP not exceeding well established. In a review performed in Pubmed, we found two cases that showed the use of FOLFOX preceding this 25 percent of the presenting value. More aggressive lowering syndrome [8, 9]. may reduce the blood pressure below the autoregulatory range, possibly leading to ischemic events. Oral antihyper- In 2007, Skelton and colleagues reported a case of PRES in a 19-year-old woman with metastatic adenocarcinoma of tensive agents are not usually eeff ctive in lowering the blood Case Reports in Oncological Medicine 3 pressure to an appropriate range in hypertensive crises to [9] C. H. Kim, C. H. Kim, C. K. Chung, and T. A. Jahng, “Unexpected seizure attack in a patient with spinal metastasis prevent and treat PRES. diagnosed as posterior reversible encephalopathy syndrome,” Patients should also receive antiepileptic medications that Journal of Korean Neurosurgical Society,vol.50, no.1,pp. 60– can probably be safely tapered as symptoms and neuroimag- 63, 2011. ing ndin fi gs resolve, usually aeft r one to two weeks. In some [10] W. S. Bartynski and J. F. Boardman, “Distinct imaging patterns cases patients have reported seizures months aeft r PRES, and and lesion distribution in posterior reversible encephalopathy these patients were maintained on antiepileptic drug therapy. syndrome,” American Journal of Neuroradiology,vol.28, no.7, Removal of the cytotoxic drug is usually recommended pp. 1320–1327, 2007. in cases of PRES associated with cytotoxic agents. It is not recommended that agents known to induce PRES be reintroduced, as recurrence has been reported in this setting. In summary, PRES is an entity not well known by neurol- ogists and oncologists and the delay in diagnosis can lead to aworse clinical recovery.Due to theincreaseinthe number of neuroimaging studies that have been conducted as well as the increase of cases of patients submitted to chemotherapies treatments that can induce PRES, this syndrome is becoming more frequent. A peculiar neuroimaging pattern observed by T2/FLAIR signal alteration is first reported in FOLFOX chemotherapy. Conflict of Interest eTh authors declare that they have no conflict of interests. References [1] J. Hinchey, C. Chaves, B. Appignani et al., “A reversible posterior leukoencephalopathy syndrome,” eTh New England Journal of Medicine,vol.334,no. 8, pp.494–500,1996. [2] R.D.Sheth,J.E.Riggs,J.B.Bodenstenier, A. R. Gutierrez, L. M. Ketonen, and O. A. Ortiz, “Parietal occipital edema in hypertensive encephalopathy: a pathogenic mechanism,” European Neurology,vol.36, no.1,pp. 25–28, 1996. [3] R.A.Hauser, D. M. Lacey, andM.R.Knight,“Hypertensive encephalopathy: magnetic resonance imaging demonstration of reversible cortical and white matter lesions,” Archives of Neurology, vol. 45, no. 10, pp. 1078–1083, 1988. [4] P. W. Schaefer, F. S. Buonanno, R. G. Gonzalez, and L. H. Schwamm, “Diffusion-weighted imaging discriminates between cytotoxic and vasogenic edema in a patient with eclampsia,” Stroke,vol.28, no.5,pp. 1082–1085, 1997. [5] O. Ogunneye, J. A. Hernandez-Montfort, Y. Ogunneye, I. Ogu, and D. Landry, “Parainfluenza v ´ırus infection associated with posterior reversible encephalopathy syndrome: a case report,” Journal of Medical Case Reports,vol.6,article 89,2012. [6] S.O.Casey,R.C.Sampaio,E.Michel, andC.L.Truwit, “Posterior reversible encephalopathy syndrome: utility of uid- fl attenuated inversion recovery mr imaging in the detection of cortical and subcortical lesions,” American Journal of Neurora- diology,vol.21, no.7,pp. 1199–1206, 2000. [7] R. M. Goldberg, D. J. Sargent, R. F. Morton et al., “A randomized controlled trial of uo fl rouracil plus leucovorin, irinotecan, and oxaliplatin combinations in patients with previously untreated metastatic colorectal cancer,” Journal of Clinical Oncology,vol. 22,no. 1, pp.23–30,2004. [8] M.R.Skelton,R.M.Goldberg, andB.H.O’Neil, “A case of oxaliplatin-related posterior reversible encephalopathy syn- drome,” Clinical Colorectal Cancer,vol.6,no. 5, pp.386–388, 2007. MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Case Reports in Oncological Medicine Hindawi Publishing Corporation

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Abstract

Hindawi Publishing Corporation Case Reports in Oncological Medicine Volume 2013, Article ID 306983,3 pages http://dx.doi.org/10.1155/2013/306983 Case Report Posterior Reversible Encephalopathy Syndrome Associated with FOLFOX Chemotherapy Luiz Carlos Porcello Marrone, Bianca Fontana Marrone, Tharick Ali Pascoal, Lucas Porcello Schilling, Ricardo Bernardi Soder, Sheila Schuch Ferreira, Giovani Gadonski, and Jaderson Costa da Costa ˜ ´ ´ Hospital Sao Lucas/Instituto do Cerebro (Inscer), Pontificia Universidade Cat olica do Rio Grande do Sul (PUCRS), Avenida Ipiranga 6690, 90610-000 Porto Alegre, RS, Brazil Correspondence should be addressed to Luiz Carlos Porcello Marrone; lcpmarrone@gmail.com Received 28 December 2012; Accepted 27 January 2013 Academic Editors: K. Aogi, C. Gennatas, C. V. Reyes, and J. M. Ribera Copyright © 2013 Luiz Carlos Porcello Marrone et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiologic entity characterized by headaches, altered mental status, seizures, visual loss, and characteristic imaging pattern in brain MRI. The cause of PRES is not yet understood. We report a case of a 27-year-old woman that developed PRES aer ft the use of FOLFOX 5 (oxaliplatin/5-Fluoracil/Leucovorin) chemotherapy for a colorectal cancer. 1. Introduction function, and immunosuppressive therapy. Other possi- ble etiologies are eclampsia, transplantation, neoplasia and Posterior reversible encephalopathy syndrome (PRES) is a chemotherapy treatment, systemic infections, and a renal clinicoradiologic entity characterized by headaches, altered disease, acute or chronic [1, 5]. mental status, seizures, and visual loss and is associated with white matter vasogenic edema predominantly aeff cting the occipital and parietal lobes of the brain [1]. The cause of PRES 2. Case Report is not yet understood. Autoregulatory failure with resultant vasodilation, as A 27-year-old woman with an advanced colorectal adenocar- seen in hypertensive encephalopathy, is oeft n cited as the cinoma with peritoneal metastasis (T3N1 M1; clinical stage underlying mechanism. On the other hand, vasospasm with IV) was admitted in the emergency room due to abdom- ischaemicchangeisalsoobservedinsomepatients[2, 3]. inal pain, vomiting, and suspect of intestinal obstruction. The most characteristic imaging pattern in PRES is the She was submitted to resection of the primary tumor 3 presence of edema involving the white matter of the posterior months before the admission and she underwent the sec- portions of both cerebral hemispheres, especially the parieto- ond cycle of chemotherapy with FOLFOX 5 (oxaliplatin/5- occipital regions, in a relatively symmetric pattern that spares u fl orouacil/leucovorin). the calcarine and paramedian parts of the occipital lobes She was without fever and her blood pressure was [1]. However, other structures (such as the brain stem, 200/120mmHg. In thebasic bloodtest, therewereno cerebellum, and frontal and temporal lobes) may also be abnormalities except an increased of creatinine (1.9 mg/dL, involved, and although the abnormality primarily affects the previous creatinine was 0.7 mg/dL three months ago). subcortical white matter, the cortex and the basal ganglia may During the hospital stay she presented two seizures and also be involved [4]. aer ft the second seizure she developed confusional mental Numerous factors can trigger the syndrome, most com- state that progressed to obnubilation. In her clinical exam- monly: acute elevation of blood pressure, abnormal renal ination, there was no focal neurologic deficit; however the 2 Case Reports in Oncological Medicine the rectum who received modiefi d FOLFOX6 chemotherapy. She presented seizures and altered mental status ten days aeft r the start of fourth cycle of chemotherapy. Her blood pressure was increased at 170/110 mmHg with and increased creatinine (1.5 mg/dL). Brain MRI demonstrated a hyperintensity in the white matter of the posterior hemispheres. One week aer ft the hospitalization, a follow-up MRI on the brain revealed a dramatic improvement in the MRI image abnormalities, and this was consistent with a resolving picture of PRES [8]. In 2011, Kim et al. reported a case of a 52-year-old Figure 1: Brain MRI-FLAIR showing an increase of signal in both womanwithadvancedgastric cancer,presented with low- occipital and frontal lobes. back pain duetospinalmetastasisatthe 4thlumbarver- tebra. The primary tumor was not resectable, and 10 cycles of chemotherapy with FOLFOX had been completed. An patient was poorly cooperative secondary to her confusional elective surgical spinal decompression and stabilization was state. The patient was submitted to a gradual reduction of the scheduled. Twenty-three days aer ft the end of chemotherapy, blood pressure and it was initiated with anticonvulsive drugs a generalized tonic-clonic seizure occurred. Her systolic (valproate sodium 1000 mg/day). blood pressure was 166 mmHg at the time of the seizure and A brain MRI (FLAIR/T2) was performed two days aeft r no electrolyte abnormality was observed. After the seizure, a the onset seizure. This rfi st brain MRI showed an increase of brain computed tomography was conducted, with no den fi ite signal in both occipital and frontal lobes (in watershed zones), abnormality. One day aer ft the seizure a brain MRI was with a symmetric pattern (Figure 1). After three days, when conducted, and a signal change was observed in both parieto- thepatientbecamemoreawake,shereportedabilateralvisual occipital lobes in T2-weighted and FLAIR images. As a disturbance that persisted for one week. result of typical imaging features, PRES was diagnosed. An After ten days, a new brain MRI was performed that antiepileptic drug was administered and no more seizures shows no evidence of edema or other abnormalities. Three were reported [9]. months aer ft the situation described, the patient died due to In this paper, we showed a new case of PRES aeft r the complications of cancer. use of FOLFOX with imaging findings not yet described in this situation. In this case, hypertension and/or renal failure can be another trigger for this syndrome. eTh rst fi brain MRI 3. Discussion of our patient showed typical increased signal intensity in This syndrome was firstly described by Hinchey and col- both occipital lobes but also revealed a watershed/junctional leagues as a clinicoradiologic entity with numerous triggers. pattern of distribution aeff cting the superior frontal sulcus of In 2000, Casey et al. established the term posterior reversible frontal lobes. encephalopathy syndrome (PRES). eTh pathophisiology is In typical PRES, the parietal and occipital lobes are most commonlyaeff cted,followedbythefrontallobes.However,in usually associated with cerebral blood flow autorregulation disruption and/or endothelial dysfunction. Cytotoxic med- watershed imaging distribution of PRES, three hemispheric ications can cause endothelial dysfunction. Hypertension is pattern variants involving cortex, subcortical, and deep white matter to varying degrees may be encountered with the main cause of PRES. However, PRES is not associated with hypertension in 20 to 30% of patients, and a lack of similar frequency: holo-hemispheric (23%), superior frontal hypertension does not rule out the possibility of PRES [1, 6]. sulcus (27%), and primary parietal-occipital (22%) [10]. Previous reports described the association between These demarcate border zones between anterior, middle, and chemotherapy and antiangiogenic drugs with PRES. No sin- posterior circulations and reflect the junctional/watershed gle antineoplastic class or agent has been consistently associ- nature of PRES. er Th e is a fourth imaging pattern distribution ated with PRES although some chemotherapeutic agents may named “partial or asymmetric expression of the primary cause direct CNS microvascular injury. eTh re are few articles patterns” (28%), which occurs when the previous three forms are found in a partial way or asymmetric fashion. Here, we in the literature that report the correlation between PRES, cancert and neoplastic treatments (like chemotherapy). describe the first reported case of PRES with a watershed FOLFOX (oxaliplatin/5-fluorouacil/leucovorin) was pattern aeff cting both superior frontal sulcui aer ft the use of approved by the US Food and Drug Administration as FOLFOX. indicated for first-line therapy for advanced colorectal cancer PRES caused by cytotoxic medications should be man- in 2000. One of the most common adverse effects of the aged with control of hypertension, management of seizures, FOLFOX is the neuropathy [7]. and withdrawal medication. The initial aim of treatment The relationship between PRES and FOLFOX was not in hypertension is to lower the diastolic pressure to about 100 mmHg, with the maximum initial fall in BP not exceeding well established. In a review performed in Pubmed, we found two cases that showed the use of FOLFOX preceding this 25 percent of the presenting value. More aggressive lowering syndrome [8, 9]. may reduce the blood pressure below the autoregulatory range, possibly leading to ischemic events. Oral antihyper- In 2007, Skelton and colleagues reported a case of PRES in a 19-year-old woman with metastatic adenocarcinoma of tensive agents are not usually eeff ctive in lowering the blood Case Reports in Oncological Medicine 3 pressure to an appropriate range in hypertensive crises to [9] C. H. Kim, C. H. Kim, C. K. Chung, and T. A. Jahng, “Unexpected seizure attack in a patient with spinal metastasis prevent and treat PRES. diagnosed as posterior reversible encephalopathy syndrome,” Patients should also receive antiepileptic medications that Journal of Korean Neurosurgical Society,vol.50, no.1,pp. 60– can probably be safely tapered as symptoms and neuroimag- 63, 2011. ing ndin fi gs resolve, usually aeft r one to two weeks. In some [10] W. S. Bartynski and J. F. Boardman, “Distinct imaging patterns cases patients have reported seizures months aeft r PRES, and and lesion distribution in posterior reversible encephalopathy these patients were maintained on antiepileptic drug therapy. syndrome,” American Journal of Neuroradiology,vol.28, no.7, Removal of the cytotoxic drug is usually recommended pp. 1320–1327, 2007. in cases of PRES associated with cytotoxic agents. It is not recommended that agents known to induce PRES be reintroduced, as recurrence has been reported in this setting. In summary, PRES is an entity not well known by neurol- ogists and oncologists and the delay in diagnosis can lead to aworse clinical recovery.Due to theincreaseinthe number of neuroimaging studies that have been conducted as well as the increase of cases of patients submitted to chemotherapies treatments that can induce PRES, this syndrome is becoming more frequent. A peculiar neuroimaging pattern observed by T2/FLAIR signal alteration is first reported in FOLFOX chemotherapy. Conflict of Interest eTh authors declare that they have no conflict of interests. References [1] J. Hinchey, C. Chaves, B. Appignani et al., “A reversible posterior leukoencephalopathy syndrome,” eTh New England Journal of Medicine,vol.334,no. 8, pp.494–500,1996. [2] R.D.Sheth,J.E.Riggs,J.B.Bodenstenier, A. R. Gutierrez, L. M. Ketonen, and O. A. Ortiz, “Parietal occipital edema in hypertensive encephalopathy: a pathogenic mechanism,” European Neurology,vol.36, no.1,pp. 25–28, 1996. [3] R.A.Hauser, D. M. Lacey, andM.R.Knight,“Hypertensive encephalopathy: magnetic resonance imaging demonstration of reversible cortical and white matter lesions,” Archives of Neurology, vol. 45, no. 10, pp. 1078–1083, 1988. [4] P. W. Schaefer, F. S. Buonanno, R. G. Gonzalez, and L. H. Schwamm, “Diffusion-weighted imaging discriminates between cytotoxic and vasogenic edema in a patient with eclampsia,” Stroke,vol.28, no.5,pp. 1082–1085, 1997. [5] O. Ogunneye, J. A. Hernandez-Montfort, Y. Ogunneye, I. Ogu, and D. Landry, “Parainfluenza v ´ırus infection associated with posterior reversible encephalopathy syndrome: a case report,” Journal of Medical Case Reports,vol.6,article 89,2012. [6] S.O.Casey,R.C.Sampaio,E.Michel, andC.L.Truwit, “Posterior reversible encephalopathy syndrome: utility of uid- fl attenuated inversion recovery mr imaging in the detection of cortical and subcortical lesions,” American Journal of Neurora- diology,vol.21, no.7,pp. 1199–1206, 2000. [7] R. M. Goldberg, D. J. Sargent, R. F. Morton et al., “A randomized controlled trial of uo fl rouracil plus leucovorin, irinotecan, and oxaliplatin combinations in patients with previously untreated metastatic colorectal cancer,” Journal of Clinical Oncology,vol. 22,no. 1, pp.23–30,2004. [8] M.R.Skelton,R.M.Goldberg, andB.H.O’Neil, “A case of oxaliplatin-related posterior reversible encephalopathy syn- drome,” Clinical Colorectal Cancer,vol.6,no. 5, pp.386–388, 2007. MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Journal

Case Reports in Oncological MedicineHindawi Publishing Corporation

Published: Feb 27, 2013

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