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Fig 1. The patient is a 28-year-old man with a history of alcohol abuse and drug use, presenting with a necrotic pneumonia and empyema growing Pseudomonas and Klebsiella species. He developed altered mentation and asymmetric neurologic findings on examination. Blood pressure at toxicity fluctuated between 130/100 mm Hg and 130/77 mm Hg. A and B, Axial MR images (fluid-attenuated inversion recovery) demonstrate extensive vasogenic edema in the frontal lobes (arrows), parietal region (curved arrows), occipital lobes (open arrows), and temporal lobes (arrowheads), bilaterally, consistent with PRES. The edema distribution clearly separates medial (ACA and PCA) from lateral (MCA) hemispheric regions typical of the holohemispheric PRES pattern. Cerebellar involvement was also present (not shown). C, Lateral view of the left internal carotid artery injection with left and right ACA opacification. Areas of vessel dilation and constriction are noted in the secondary and tertiary branches of both medial hemispheric vessels (left [arrows] and right [arrowheads] ACAs) and lateral hemispheric vessels (left MCA [curved arrows]) consistent with vasculopathy. D, Lateral view of the vertebral artery CA injection demonstrates a string-of-beads appearance (arrowheads) and areas of vasodilation/vasoconstriction (arrows) in parietal branches of the PCA. E, Oblique 3D TOF MRA reconstructed images of the posterior circulation demonstrate areas of focal vasodilation and vasoconstriction in the PCAs bilaterally (arrows), consistent with vasculopathy, similar to the vertebral artery CA appearance. Posterior inferior cerebellar artery (arrowheads) irregularity is also present.
