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NEUROIMAGE
Year : 2021  |  Volume : 69  |  Issue : 2  |  Page : 536-537

Brainstem Predominant Posterior Reversible Encephalopathy Syndrome


Medstar Georgetown University Hospital, Department of Neurology, 3800 Reservoir Road NW, Washington, DC, USA

Date of Submission06-Apr-2020
Date of Decision06-Apr-2020
Date of Acceptance09-Jun-2020
Date of Web Publication24-Apr-2021

Correspondence Address:
Dr. Guillaume Lamotte
Department of Neurology, Medstar Georgetown University Hospital, 3800 Reservoir Road, Washington, DC
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.314564

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How to cite this article:
Lamotte G, Lenka A. Brainstem Predominant Posterior Reversible Encephalopathy Syndrome. Neurol India 2021;69:536-7

How to cite this URL:
Lamotte G, Lenka A. Brainstem Predominant Posterior Reversible Encephalopathy Syndrome. Neurol India [serial online] 2021 [cited 2021 Sep 17];69:536-7. Available from: https://www.neurologyindia.com/text.asp?2021/69/2/536/314564




A 51-year-old African American male with a history of nasopharyngeal carcinoma in remission presented with 5 days history of dysarthria and gait instability. Blood pressure on admission was 185/125 mm Hg. General examination was unremarkable. Neurological examination revealed a right facial palsy, mild dysarthria, dysmetria in both upper and lower extremities as well as subtle asterixis. Mental status was preserved. Brain MRI without contrast showed T2-hyperintensities in the bilateral cerebellum, brainstem, and temporal lobes [Figure 1a]. Laboratory tests revealed acute renal failure (blood urea nitrogen 135 mg/dL, serum creatinine 19.4 mg/dL), and proteinuria (300 mg/dL). Hemodialysis was initiated and the neurological symptoms resolved within 3 days. Subsequent MRIs after hemodialysis and optimal control of blood pressure showed progressive resolution of the signal abnormalities [Figure 1b and c], consistent with the diagnosis of posterior reversible encephalopathy syndrome (PRES). PRES is a clinical-radiological syndrome. It classically presents with symptoms of hypertensive encephalopathy associated with radiological findings of reversible vasogenic sub-cortical edema, that preferentially affects the posterior regions (occipital lobe).[1] Our case is atypical both from the clinical (focal neurological symptoms without encephalopathy) and radiological standpoint (predominant involvement of the brainstem), highlighting the varied clinical and radiological heterogeneity of PRES. Brainstem predominant vasogenic edema can be seen in PRES and this radiological variant is important to recognize to avoid unnecessary investigations and to provide immediate medical management. Higher rate of renal dysfunction has been reported in cases with infratentorial PRES and further study is necessary to better understand the pathophysiology of PRES and its variants.[2]
Figure 1: Brain MRI axial fluid-attenuated inversion recovery on admission (a), 5 days after initiation of hemodialysis (b), and at 2 months follow-up (c). Initial MRI showed patchy hyperintense T2 signal in the bilateral cerebellum, brainstem, and bilateral temporal lobes anteriorly as well as left temporal lobe encephalomalacia. Follow-up MRIs showed progressive resolution of signal abnormalities

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hinchey J, Chaves C, Appignani B, Breen J, Pao L, Wang A, et al. A reversible posterior leukoencephalopathy syndrome. N Engl J Med 1996;334:494-500.  Back to cited text no. 1
    
2.
Fitzgerald RT, Samant RS, Kumar M, Van Hemert R, Angtuaco EJ. Features of infratentorial-predominant posterior reversible encephalopathy syndrome. Acta Neurol Belg 2015;115:629-34.  Back to cited text no. 2
    


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