Case of the Week
Section Editors: Matylda Machnowska1 and Anvita Pauranik2
1University of Toronto, Toronto, Ontario, Canada
2BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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January 26, 2017
Hypertensive Brainstem Encephalopathy
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- Background:
- Posterior reversible encephalopathy syndrome (PRES) typically involves the posterior parieto-occipital structures, but variations do occur. However, isolated brainstem involvement in PRES is unusual, with a few cases reported in the literature.
- Over-distension of the cerebral vessels, breakdown of the blood brain barrier, and extravasation of fluid into the interstitium result in vasogenic edema.
- Clinical Presentation:
- Hypertensive encephalopathy is a medical emergency.
- Patients may present with headache, altered alertness/behavior, drowsiness, stupor, seizures, and/or vomiting.
- Key Diagnostic Features:
- The most commonly observed abnormalities on MRI are punctuate or confluent areas of increased signal on FLAIR and T2-weighted images.
- Restricted diffusion is usually not seen on DWI and ADC maps.
- Differential Diagnoses:
- Pontine infarct
- Osmotic demyelination syndrome
- Pontine neoplasm
- Demyelinating disease
- Treatment:
- Control blood pressure and remove precipitating factors.
- Delayed diagnosis/therapy can result in chronic neurologic sequelae.
Suggested Reading
- Ruzek KA, Campeau NG, Miller GM. Early diagnosis of central pontine myelinolysis with diffusion-weighted imaging. AJNR Am J Neuroradiol 2004;25:210–13
- Kitaguchi H, Tomimoto H, Miki Y, et al. A brainstem variant of reversible posterior leukoencephalopathy syndrome. Neuroradiology 2005;47:652–56, 10.1007/s00234-005-1399-z
- Osman Y, Imam YZ, Salem K, et al. Isolated brainstem involvement in a patient with hypertensive encephalopathy. Case Rep Neurol Med 2013;2013:540947, 10.1155/2013/540947
- Background: