709: SAFETY OF 4-FACTOR PCC FOR REVERSAL OF FXA INHIBITORS VERSUS WARFARIN IN NEUROCRITICAL CARE PATIENTS

Abstract

Learning Objectives: Posterior reversible encephalopathy syndrome (PRES) is a state of hyperperfusion and endothelial dysfunction that can present with headache, seizure, encephalopathy, visual impairment, severe hypertension, and cerebral edema on magnetic resonance imaging (MRI). We present a rare case of PRES secondary to pazopanib. Methods: A 66-year-old female with metastatic Hurthle cell thyroid carcinoma presented to the hospital with acute encephalopathy and headache for two days. Her cancer had metastasized to bone and lungs, and a solitary left parietal brain metastasis was resected two years earlier. Twenty months prior to her presentation to the hospital, oral pazopanib was initiated. During transport to the ER, the patient became unresponsive with seizure-like activity. Upon presentation, she was hypertensive at 196/109 mmHg and complained of headache, nausea, and acute vision loss. She was alert but not oriented. CT of the brain showed no acute process. Electroencephalography showed status epilepticus (SE) originating from a focal area in the left temporal parietal region. 1g of intravenous levetiracetam was administered. She had recurrent complex partial SE leading to right sided Todd’s paralysis and continued encephalopathy such that phenytoin and valproic acid were added to her regimen. Repeat EEG showed resolution of SE. MRI of the brain revealed extensive areas of abnormal hyperintensity in the bilateral temporal, occipital and posterior parietal gyri as well as the left frontal gyri. The MRI findings and patient’s clinical presentation were consistent with PRES. Pazopanib was discontinued and the patient required antihypertensives for 48 hours. The patient’s mental status, right sided hemiparesis, acute vision loss, and blood pressure dramatically improved over her 5-day hospitalization. The patient was discharged on levetiracetam. Repeat MRI four weeks after discharge showed significant improvement in PRES abnormalities with corresponding resolution of all her neurologic abnormalities. The patient was continued on levetiracetam with no further seizure activity. Results: Pazopanib belongs to the tyrosine kinase inhibitor class of chemotherapeutic agents. Different agents within the class have been rarely associated with the development of PRES. Thirty cases of PRES secondary to pazopanib have been reported by the FDA, with two-thirds presenting in the first month of treatment. This is the first reported case of pazopanib-induced PRES occurring twenty months after initiation.