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NEUROIMAGE
Year : 2021  |  Volume : 69  |  Issue : 6  |  Page : 1621-1622

Asymmetric Posterior Reversible Encephalopathy Syndrome Mimicking Massive Cerebral Hemispheric Infarction after Cardiac Surgery


1 Department of Neurology, The Catholic University of Korea, College of Medicine, Seoul, South Korea
2 Department of Neurology, Yonsei University Medical College, Seoul, South Korea

Date of Submission31-May-2019
Date of Decision28-Nov-2019
Date of Acceptance15-May-2021
Date of Web Publication23-Dec-2021

Correspondence Address:
Woojun Kim
Department of Neurology, The Catholic University of Korea, College of Medicine, 222 Banpo-daero, Seocho-gu, Seoul
South Korea
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.333490

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How to cite this article:
An JY, Lee YH, Kim W. Asymmetric Posterior Reversible Encephalopathy Syndrome Mimicking Massive Cerebral Hemispheric Infarction after Cardiac Surgery. Neurol India 2021;69:1621-2

How to cite this URL:
An JY, Lee YH, Kim W. Asymmetric Posterior Reversible Encephalopathy Syndrome Mimicking Massive Cerebral Hemispheric Infarction after Cardiac Surgery. Neurol India [serial online] 2021 [cited 2022 Jan 18];69:1621-2. Available from: https://www.neurologyindia.com/text.asp?2021/69/6/1621/333490




A 29-year-old female with underlying aplastic anemia, who underwent peripheral blood stem cell transplantation and tacrolimus therapy six months ago, presented with fever. Sepsis with methicillin-resistant Staphylococcus epidermidis and endocarditis with vegetation of the tricuspid valve was diagnosed, and surgery for artificial tricuspid valve replacement was performed successfully. During and after surgery, blood pressure was maintained within a normal to the slightly upper-normal range. Six hours after the surgery, the patient became stuporous and showed right gaze preponderance with left visual field defect and left hemiparesis, suggesting massive cerebral infarction involving the right hemisphere. 2 h later, consecutive seizures occurred, which stopped after intravenous infusion of lorazepam and high-dose of fosphenytoin.

Routine blood tests revealed elevated urea nitrogen (77.8 mg/dL) and creatinine (2.37 mg/dL). Brain MRI showed vasogenic edema in the right cerebral hemisphere, which suggested posterior reversible encephalopathy syndrome (PRES) [Figure 1]a. CT angiography was normal [Figure 1]b. Electroencephalography performed the next day showed intermittent slow waves over the right hemisphere. Under conservative treatment, neurological deficits slowly resolved and became normal after 1 month. In the follow-up, MRI performed two months later, the edematous lesion on the right hemisphere had disappeared [Figure 1]c.
Figure 1: (a) Axial fluid attenuation inversion recovery (FLAIR) (left), diffusion-weighted images (DWIs) (center), and apparent diffusion coefficient (ADC) images performed 6 h after symptom onset. High signal intensity lesions occupy almost the whole right cerebral hemisphere in the FLAIR and DWIs (arrows). Iso- or hyperintensities seen in the ADC images suggest vasogenic edema. The lesions are also seen in the left frontal cortex (arrowheads); (b) CT angiography reveals no significant abnormalities; (c) the follow-up MRI performed 2 months later shows the previous lesions have disappeared

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Considering the clinical findings, including the history of immunosuppressant therapy, acute deterioration of mental status, seizures, and complete recovery, this case is compatible with PRES,[1] although the initial symptoms possibly indicated massive cerebral infarction. Typically, PRES shows reversible, vasogenic edema, and the lesions are usually located in the bilateral parieto-occipital regions.[2] However, there have been reports about atypical imaging findings,[3],[4] like those seen in our case.

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Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fischer M, Schmutzhard E. Posterior reversible encephalopathy syndrome. J Neurol 2017;264:1608-16.  Back to cited text no. 1
    
2.
Fugate JE, Robinstein AA. Posterior reversible encephalopathy syndrome: Clinical and radiological manifestations, pathophysiology, and outstanding questions. Lancet Neurol 2015;14:914-25.  Back to cited text no. 2
    
3.
McKinney AM, Short J, Truwit CL, McKinney ZJ, Kozak OS, SantaCruz KE, et al. Posterior reversible encephalopathy syndrome: Incidence of atypical regions of involvement and imaging findings. AJR Am J Roentgenol 2007;189:904-12.  Back to cited text no. 3
    
4.
Camlidag I, Cho YJ, Park M, Lee SK. Atypical unilateral posterior reversible encephalopathy syndrome mimicking a middle cerebral artery infarction. Korean J Radiol 2015;16:1104-8.  Back to cited text no. 4
    


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