Case ReportVariant Type of Posterior Reversible Encephalopathy Syndrome Associated with Deep Brain Hemorrhage: Case Report and Review of the Literature
Introduction
Posterior reversible encephalopathy syndrome (PRES) describes a disorder of reversible subcortical vasogenic brain edema in patients with acute neurologic syndromes ranging from seizure, headache, altered mental status, or visual disturbance.1,2 PRES was first described in 1996,3 and various patterns of clinical features and radiologic findings of PRES have been reported to date.2,4, 5, 6, 7 Although the pathophysiology of PRES is not completely understood, it is suspected that endothelial injury related to urgent hypertension or the direct effect of cytokines on the endothelium causes a breakdown of the blood–brain barrier and subsequent cerebral edema.1 The typical radiologic finding of PRES is remarkable vasogenic edema, predominantly involving parieto-occipital regions in both hemispheres.2 However, a number of radiologic variants involving the brainstem, thalamus, or basal ganglia have been described.2,8 PRES in general has a benign course, and is considered as a treatable disorder.1,5 Meanwhile, intracranial hemorrhage (ICH) is common in PRES, and such hemorrhage may cause functional defecits.5 Herein, we report a rare case of variant type of PRES associated with deep brain hemorrhage, and discuss the characteristics of PRES-related ICH via a literature review.
Section snippets
Case Description
A woman aged 41 years with a history of untreated hypertension presented to our emergency department with sudden-onset right hemiparesis and mild aphasia. She had no past medical history other than hypertension and had taken no oral medicine before arrival. She complained of severe headache and her blood pressure was elevated at 237/142 mmHg on admission. Her neurologic examination indicated mildly impaired consciousness with a Glasgow Coma Scale score of 13 (E4V3M6), mild motor aphasia, right
Discussion
We described a rare case of variant type of PRES associated with deep brain hemorrhage. To the best of our knowledge, only 2 cases of PRES-related ICH in the thalamus or basal ganglia have been reported to date.4
ICH is common in PRES, and has been described to be complicated in 10%–25% of cases.1 The most common type of ICH related to PRES is IPH followed by sulcal subarachnoid hemorrhage.1 However, few studies have reported details regarding IPH in patients with PRES (Table 1).4,5,8, 9, 10, 11
Conclusions
We described a rare case of variant type of PRES associated with deep brain hemorrhage. Variant type of PRES may be associated with hemorrhage in the thalamus, basal ganglia, or brainstem, which are not common locations for PRES-related ICH. Although PRES has a benign clinical course in general, PRES-related ICH could cause more detrimental outcomes. It is important to recognize the presence of variant patterns of clinical features and radiologic findings of PRES to facilitate early
Acknowledgments
The authors would like to thank Editage (www.editage.com) for English language editing.
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.