Posterior reversible encephalopathy syndrome - temporal evolution

Case contributed by Annelise Liddicoat


Day 1: 9pm - severe headache with associated new hypertension (systolic blood pressure: 220 mmHg).

Patient Data

Age: 50 years old
Gender: Male

Small focal regions of hypoattenuation within the bilateral basal ganglia, consistent with old lacunar infarcts.
Less well defined regions of reduced attenuation are seen within the left frontal lobe, in a periventricular location, and within the left occipital lobe.  

Slurred speech, right facial palsy, elevated blood pressure (240/110 mmHg) developed on day 2 at 05:30 am. 

There is extension into the anterior limb of the left internal capsule;  an impression of minor lacunar defect also of the anterior margin head of left caudate nucleus.
Further hypodensity consistent with a lacunar infarct lies immediately posterior to the head of right caudate nucleus and extends into anterior limb of right internal capsule.
Focal hypodensity suggestive of ischemia or infarct involves the left parietal corona radiata.

The posterior circulation hypodensities are more conspicuous, involving both occipital lobes and right cerebellar hemisphere. 

On day 2 at 5pm, there was a hypertensive emergency with decreased GCS. Unable to control blood pressure. Sudden unresponsiveness.

Extensive hypodensity now affects both cerebellar hemispheres, pons and brain stem and both occipital lobes.  Significant posterior fossa mass effect with effacement of all CSF spaces. Evidence of ascending transtentorial herniation and tonsillar herniation. The caliber of the third and lateral ventricles has increased, with some evidence of CSF seepage. The sulcal CSF spaces of both hemispheres are effaced when compared with previous. The basal cisterns are preserved.  

Lacunar infarct in the left corona radiata appears acute.  Old right-sided lacunar infarct noted.  The remainder of the supratentorial neural parenchyma appears within normal limits.  

The optic nerve sheaths have become prominent with early flattening of the optic disks - this reflects raised intracranial pressure.

Case Discussion

This case demonstrates progression of the posterior circulation ischemic changes, with severe posterior fossa mass effect - transtentorial and tonsillar herniation. This produces hydrocephalus with increasing supratentorial mass effect.

This case is highly suspicious of posterior reversible encephalopathy syndrome (PRES). 

Unfortunately this patient did not recover from this episode and passed away 3 days later.

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Case information

rID: 44930
Published: 7th Jun 2016
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included

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