Central-variant posterior reversible encephalopathy syndrome (PRES)
Presentation
4 months headache and diplopia. Also complaints of night sweats and 10 kg weight loss (unwanted). No fever. RR: 197/145 mmHg
Patient Data
Supratentorial: several periventricular and subcortical white matter lesions without significant mass-effect.
Infratentorial: there is diffuse T2 hyperintensity involving the vermis, both cerebellar hemispheres and the pons. Also note diffuse swelling due to vasogenic edema in the posterior fossa and exaggerated flow void in the prepontine cistern.
No gadolinium enhancement.
There is a small focus showing restricted diffusion in the periventricular white matter on the right.
MRI Follow up after 2,5 weeks
After adequate blood pressure control there is complete resolution of earlier changes (except for some nonspecific white matter lesions.
Also note the decrease in volume of the pons and cerebellum on axial T2 and sagittal T1 images.
Case Discussion
Imaging features of typical PRES include T2 hyperintensity (vasogenic edema) with a parietal and occipital distribution.
This case however shows a central-variant of PRES which is considered an uncommon variant. There should be involvement of the brainstem or basal ganglia. It is said there should be no involvement of subcortical white matter.
Although this case shows a few supratentorial locations with white matter T2 hyperintensity, the most of the T2 hyperintensity is located in the pons and cerebellum. We believe this should be considered a central-variant of PRES.
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