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PRES — SCE Medical Oncology MCQ

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HardOncological EmergenciesPRESSCE Medical Oncology

A 62-year-old man with metastatic renal cell carcinoma develops acute severe hypertension (BP 220/120 mmHg) with headache and visual disturbance after starting a VEGFR-TKI. MRI brain shows bilateral posterior white matter changes consistent with posterior reversible encephalopathy syndrome (PRES). What is the immediate management?

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Correct answer: C — Immediately stop the VEGFR-TKI, urgent blood pressure control (IV labetalol/nicardipine), seizure prophylaxis

PRES is a rare but serious complication of VEGFR-TKIs and anti-VEGF antibodies, caused by severe hypertension disrupting cerebral autoregulation and blood-brain barrier integrity. It presents with headache, visual disturbance, confusion and seizures. MRI shows characteristic bilateral posterior white matter vasogenic oedema. Management requires immediate VEGFR-TKI cessation, aggressive IV antihypertensive therapy (avoid hypotension) and seizure management. PRES is usually reversible with prompt treatment but permanent neurological damage can occur if delayed.

Reference: ESMO 2024 Supportive Care; BNF VEGFR-TKI monographs; Fugate et al Lancet Neurol 2015