A Case Report of Severe Posterior Reversible Encephalopathy Syndrome Due to Accelerated Hypertension in a Young Patient

Abstract

Posterior reversible encephalopathy syndrome (PRES) refers to white matter vasogenic edema primarily affecting the brain's posterior occipital and parietal lobes, causing acute neurological symptoms like headaches, visual symptoms, seizures, and altered mental status. We present the case of a 32-year-old male with uncontrolled hypertension, altered mental status, and left-sided weakness. He had a rapid neurological decline, and a computed tomography (CT) head showed blurring of gray-white matter interfaces in the right posterior parietal lobe, suggesting infarction or PRES. Magnetic resonance imaging (MRI) of the brain suggested worsening with acute-early subacute infarction involving the right temporal, parietal, and occipital lobes and diffuse cerebral edema causing compression of the right ventricle with diffuse sulcal effacement and central downward herniation. There were flair hyperintensities in the bifrontal, pons, and cerebellum. Given the history of uncontrolled hypertension, the right hemispheric infarction and edema were thought to be due to secondary complications of severe PRES. He underwent urgent bilateral craniectomies with dural augmentation and external ventricular drain placement to control the intracranial pressure the next day. His mental status, as well as neurologic function, showed gradual improvement in the next few months. A high index of suspicion and rapid treatment can pave the way for a quick recovery and help reduce morbidity and death.

A case report of posterior reversible encephalopathy syndrome in a patient diagnosed with emphysematous necrotizing biliary pancreatitis

“…This vasogenic theory explains that development of PRES in cases of accelerated hypertension. The posterior circulation of the brain is comparably less innervated with sympathetic nerves, which is most likely the cause of PRES's preferential involvement of the posterior portion of the brain (4,5).…”

Posterior reversible encephalopathy syndrome in a child following hypovolemic shock: a case report

“…The pathophysiology of PRES remains unknown. Probable mechanisms put forth include endothelial injury or dysfunction of the blood–brain barrier, causing fluid and protein transudation, cerebral vasoconstriction, and subsequent brain infarction and vasogenic edema due to cerebral autoregulation 11 .…”

Posterior Reversible Encephalopathy Syndrome in a Patient with Septic Shock: A Case Report

“…Hydration, electrolyte correction, airway monitoring and protection, and ventilatory support should be considered, especially if the patient is altered, obtunded, or suffering from status epilepticus. 15 If hypertension is believed to be the main cause, antihypertensives should be administered and blood pressure must be continually monitored.…”