When prescribed for headaches, the mechanism of action is the combination of the three compounds, acetaminophen which is analgesic, butalbital which reduces anxiety, and caffeine which augments the effects of the analgesic. It is commonly prescribed for tension headaches. įioricet is a combination of butalbital, acetaminophen, and caffeine. However, since PRES is often accompanied by severe complications, neurological sequelae may persist, most commonly persistent epilepsy being reported. The prognosis of PRES is mainly determined by the underlying condition since the neurological manifestations are reversible in majority of patients. The management of the underlying disease or pathology leading to PRES development is of major importance, with reduction of blood pressure levels by 25% from baseline values to avoid acute blood pressure fluctuations or elimination of the triggering factor. The treatment of PRES is symptomatic since no specific therapeutic strategy is currently available. Lesions in other areas such as the cerebellum, brain stem, basal ganglia, or spinal cord are less common. MRI is the most important diagnostic tool and commonly shows vasogenic edema frequently following a parieto-occipital pattern. The presence of neurological symptoms of acute onset, concurrent blood pressure fluctuations, vasogenic edema as the leading neuroimaging finding, and a clinical context of associated comorbidities or trigger factors are suggestive of PRES. Therefore, the diagnosis of PRES can often only be made after excluding important other diagnoses. Established diagnostic criteria have been lacking so far and clinical, as well as imaging findings, are often not specific. While PRES is generally reversible, early diagnosis is key to reduce possible damage. PRES is characterized by rapid onset of symptoms including headache, seizures, altered consciousness, visual disturbances, and focal neurological deficits. This entity has been described mainly related to hypertension, renal failure, eclampsia, sepsis and multiorgan failure, autoimmune diseases, the use of chemotherapy, immunosuppressive (tacrolimus, cyclosporine, and chemotherapeutics), and illicit drugs (cocaine), or organ transplantation. While the incidence of PRES is unknown, it has been seen in patients ranging from 2 to 90 years of age, with the syndrome being more common in women. PRES is also known as acute hypertensive encephalopathy or reversible posterior leukoencephalopathy. Hyperperfusion with resultant disruption of the blood-brain barrier or circulating toxins result in vascular leakage and vasogenic edema formation, but not infarction, most commonly seen in the parieto-occipital regions. It can be triggered by endothelial dysfunction caused by circulating endogenous or exogenous toxins.
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Posterior reversible encephalopathy syndrome (PRES) is a neurotoxic state that occurs secondary to the inability of the posterior circulation to autoregulate in response to acute changes in blood pressure. Due to her inability to work and the constant pain, the patient continues to struggle with depression.
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Although the patient received appropriate treatment, she was unable to make full recovery. Her brain imaging studies completely normalized at 10 months after diagnosis. Repeat brain MRI showed slight improvement of edema. The patient returned within the week with severe headaches, visual hallucinations, and a blood pressure of 150/80 mmHg. Posterior reversible encephalopathy syndrome (PRES) was diagnosed. A brain MRI showed edema in the subcortical white matter of the right occipital lobe, right parietal lobe, and left occipital lobe. We report a case of a 54-year-old female who developed the worst headache of her life after taking 2 tablets of butalbital-acetaminophen-caffeine every six hours for three days before presenting to the emergency department, where her blood pressure was 178/87 mmHg. A common side effect of Fioricet (butalbital-acetaminophen-caffeine) is high blood pressure caused by the caffeine content.