Title : A case of posterior reversible encephalopathy syndrome leading to bilateral occipital strokes
Abstract:
Introduction:
Posterior reversible encephalopathy syndrome (PRES) is a rare neurological disorder that classically presents with sudden onset of visual disturbances, seizures, headaches, and altered mentation in the context of uncontrolled hypertension. The diagnosis of PRES can be made both clinically and radiographically. The radiographic findings would reveal white matter edema typically in the posterior cerebrum in a symmetric fashion, though can also localize in other areas. Though PRES is potentially reversible, if not recognized at an appropriate time it can lead to irreversible neurological deficits.
Case:
68 year old female with a past medical history of type 2 diabetes mellitus, major depressive disorder, hypertension, fibromyalgia, heart block, sinus bradycardia status post dual chamber pacemaker, IBS, and GERD presented to the ED after a ground level fall with unknown down time. Upon arrival to the ED, the patient was confused and agitated with elevated systolic blood pressures. Later, she expressed that she had a new onset of blurry vision and bilateral lower extremity numbness and weakness with worse weakness in the left leg. Physical exam revealed decreased visual acuity in both eyes and severe vibration and proprioception loss in the bilateral lower extremities. CT head showed hypoattenuation in the bilateral parietal occipital lobes which worsened on repeat imaging. MRI imaging later showed bilateral acute posterior parietal-occipital infarcts with hemorrhagic petechial conversion, an acute left PICA infarct involving the inferior dorsal medial left cerebellar hemisphere, and parapontine perforator ischemic change with gliosis of the pons. Additionally, the patient was found to have decreased folate and vitamin B12 levels. Patient was put on B-vitamin supplementation, hypertension medications to control blood pressure, and Plavix, and a statin medication for secondary stroke prevention.
Discussion:
Adequate additions to blood pressure medications improved some of the patient’s symptoms such as the blurry vision and confusion. However, the patient’s repeat CTs continued to show hypoattenuation of the parietal occipital lobes bilaterally, likely explained by malignant PRES from the unknown time of uncontrolled hypertension, resulting in multi-territorial ischemic infarcts leading to permanent neurological deficits. Despite having these imaging findings, localization of patient symptoms is important to accurately assess the underlying cause of presentation. It was noted that the patient’s severe vibration and proprioception loss in the bilateral lower extremities do not localize to the imaging results seen and fit more with a large fiber sensory neuropathy. In this case, it is suspected that the patient's
confusion caused by the malignant PRES, she was unable to provide an accurate history of symptoms and that she most likely has an undiagnosed large fiber sensory neuropathy for some time.
Conclusion:
Posterior Reversible Encephalopathy Syndrome requires prompt identification and treatment to control the underlying cause of the uncontrolled hypertension to avoid long term neurological consequences. PRES can have many diverse presentations, but it is important to recognize its manifestation and employ therapeutic strategies. The careful and comprehensive treatment of PRES can allow patients to have a full course of recovery.
Audience Take Away
- Broaden the spectrum of knowledge of posterior reversible encephalopathy syndrome to aid in more accurate diagnosis and proper treatment
- To highlight the importance of localization of imaging findings when discussing patient symptoms
- Review the consequences of delay of treatment of posterior reversible encephalopathy syndrome and severity of prognosis
