Hypertensive brainstem encephalopathy

Case contributed by Daniel Chow


50 year-old female presenting to emergency department with altered mental status.

Patient Data

Age: 50
Gender: Female

ASNR 2016: This case was submitted as part of the American Society of Neuroradiology (ASNR 2016) Case Of The Day competition, in collaboration with Radiopaedia.org. 

Axial noncontrast CT at the level of the pons demonstrates diffuse hypodensity. This was noted to extend from the upper pons to the superior cerebellar hemispheres. Additionally, the adjacent ambient and basal cisterns are disproportionately small relative to the degree of global cerebral volume loss, suggestive of edema.

The remainder of the brain was unremarkable..

Brain MRI


Abnormal increased FLAIR/T2 signal and edema involving the bilateral pons, medulla, and mesodiencephalic junction inclusive of the thalami. There is no associated abnormal reduced diffusion, enhancement, or susceptibility. 

Case Discussion

In the literature, hypertensive brainstem encephalopathy is considered on the spectrum of atypical PRES. While not entirely understood, the proposed mechanism is failure of cerebral autoregulation leading to hyperperfusion and vasogenic edema. Brainstem involvement in PRES is not unusual, and has been reported in 13% of patients with PRES. 

What makes this case atypical is the isolated brainstem involvement; however, there are several case reports showing similar findings. Given the isolated brainstem findings, initial differential on the CT included brainstem glioma, osmotic demyelination, and brainstem infarct. 

Clinically, 92% of patients with PRES have acutely elevated blood pressure (mean systolic greater than 200), which was encountered in our patient. A thought is that the increased blood pressure results in failure to autoregulate intracranial pressures, which results in vasogenic edema.

Demographically, females are affected more often than males, and the peak ages are between 20 and 40. Generally, this condition resolves with blood pressure normalization.

The patient in this was case was admitted to the neuro ICU where blood pressure was slowly decreased. The patient made a full clinical recovery and discharged shortly after.

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