The pathogenesis and neuropathology of reversible posterior leukoencephalopathy (RPLE; a clinical and radiographical syndrome linked to malignant hypertension, eclampsia, immunosuppressive drugs, and chemotherapy) remain poorly understood. Autopsies on patients with hypertensive encephalopathy have demonstrated arteriolar fibrinoid necrosis with micro-infarcts and failed to show brain edema; nonetheless, magnetic resonance imagings (MRIs) of patients with RPLE generally show findings most consistent with vasogenic edema. This article reports a patient with RPLE in whom brain biopsy revealed edematous white matter with no evidence of vessel wall damage or infarction. This supports the concept that the imaging changes on MRI represent vasogenic edema and suggests that the changes observed on autopsy in malignant hypertension may be an epiphenomenon.