Posterior reversible encephalopathy syndrome (PRES) in a toddler

Case contributed by Dr Joseph Scheller

Presentation

A toddler has an unprovoked seizure. History of head banging behavior.

Patient Data

Age: 18 months
Gender: Male

Small left acute subdural hematoma seen at the posterior vertex, along the falx, and over the left tentorium.

Bilateral FLAIR hyperintensity in the posterior temporal and occipital regions. Corresponding restricted diffusion, right greater than left.

Case Discussion

This toddler presented with an unprovoked seizure and was found on CT to have a small acute subdural hemorrhage. The child developed intermittent elevated blood pressure on hospital day 2 and 3, and was found to have PRES on head MR on day 4.

PRES in children has been reported in association with hematologic and immunologic conditions as well as systemic inflammatory conditions. It is also associated with dramatic increases in blood pressure. In this case, the sequence of events was trauma, then seizure, then elevated blood pressure, then PRES.

PRES has been reported in children as young as 2 years. PRES in an 18-month-old toddler is very unusual.

DIFFERENTIAL DIAGNOSIS

-Neonatal hypoglycemia can cause increased FLAIR signal bilaterally in the parieto occipital regions, the pulvinar nucleus is often involved

-Status epilepticus can cause a similar picture but the corpus callosum will demonstrate restricted diffusion.

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Case information

rID: 56643
Published: 24th Nov 2017
Last edited: 28th Nov 2017
Inclusion in quiz mode: Included

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