Posterior reversible encephalopathy syndrome

Case contributed by Suresh Babu Boddapati


Presented with seizures for 1 day. High blood pressure - 190/110. H/o normal vaginal delivery 3 months back. The patient also complained of swelling of both legs up to knee for 20 days, associated with abdominal distention and facial puffiness. Not a known hypertensive or diabetic. No history of previous epilepsy, TB, bronchial asthma.

Patient Data

Age: 30 years
Gender: Female

T1 isointense T2/FLAIR hyperintense symmetrical cortical and subcortical foci noted in bilateral frontal, parietal, occipital and inferior temporal regions. No diffusion restriction seen.

Rest of the cerebral hemispheres show normal grey-white differentiation and signal intensity.

Features are suggestive of atypical PRES. 

Case Discussion

Posterior reversible encephalopathy syndrome (PRES) also called acute hypertensive encephalopathy and reversible posterior leukoencephalopathy syndrome (RPLS).

Etiologies include preeclampsia/eclampsia, bone marrow/organ transplantation, autoimmune diseases, high dose chemotherapy, etc. 

Imaging findings - symmetrical cortical and subcortical hyperintense signals on T2/FLAIR images in the parieto-occipital lobes of both cerebral hemispheres. Imaging findings may vary and can occur in any location. Diffusion restriction and hemorrhage are rare but can occur. 

It is a disorder of cerebrovascular autoregulation. 

Differential diagnosis includes cerebral infarction, cerebral venous thrombosis, hypoxic brain damage, hypoglycemic brain injury, and encephalitis. PRES is usually reversible, but permanent damage can occur if cerebral ischemia or hemorrhage occurs.

Treatment is targeted to the precipitating cause - such as blood pressure management in this case.

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