Occipital Lobe Seizures as the Major Clinical Manifestation of Reversible Posterior Leukoencephalopathy Syndrome: Magnetic Resonance Imaging Findings

Abstract

Summary:Purpose: Reversible posterior leukoencephalopathy syndrome (RPLS) is an increasingly recognized brain disorder most commonly associated with malignant hypertension, toxemia of pregnancy, or the use of immunosuppressive agents. When associated with acute hypertension, RPLS typically occurs concurrently with the fulminant clinical syndrome of hypertensive encephalopathy. We describe occipital lobe seizures, in the setting of only moderate elevations of blood pressure, as the major clinical manifestation of RPLS.Methods: Two patients from the Dent Neurologic Institute are presented with clinical and magnetic resonance imaging (MRI) correlation.Results: New onset secondarily generalized occipital seizures were noted, with MRI findings consistent with RPLS. Both of the patients had chronic renal failure and a moderate acute exacerbation of chronic hypertension. Other features of hypertensive encephalopathy were lacking, such as headache, nausea, papilledema, and an altered sensorium. Magnetic resonance imaging (MRI) showed edematous lesions primarily involving the posterior supratentorial white matter and corticomedullary junction, consistent with RPLS. With lowered blood pressure, the MRI lesions resolved and the patients became seizure-free without requiring chronic anticonvulsant therapy.Conclusions: Occipital seizures may represent the only major neurologic manifestation of RPLS due to acute hypertension, especially in patients with renal failure. Other evidence of hypertensive encephalopathy, such as cerebral signs and symptoms, need not be present. Blood pressure elevations may be only moderate. Early recognition of this readily treatable cause of occipital seizures may obviate the need for extensive, invasive investigations. Despite the impressive lesions on MRI, prompt treatment of this disorder carries a favorable prognosis. Key Words: Hypertensive encephalopathy-leukoencephalopathy-MRI-Seizures-Occipital lobe.Occipital lobe seizures are a rare form of partial epilepsy (I), with a variety of underlying causes that may be detected by magnetic resonance imaging (MRI). Commonly recognized etiologies include fixed causes such as traumatic brain injury, mass lesions, developmental anomalies, and chronic encephalitis (1-3). In addition, reversible posterior leukoencephalopathy syndrome (RLPS), elaborated by Hinchey et al. (4), is an increasingly recognized brain disorder of various etiologies which may include occipital lobe dysfunction and seizures accompanied by posterior MRI brain lesions (5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20). When secondary to malignant hypertension, RPLS typically occurs on MRI along with the fulminant clinical syndrome of hypertensive encephalopathy (4,12-15,2 1,22 hypertension who developed new-onset, secondarily generalized occipital seizures with disappearing posteriorly-predominant MRI brain lesions. Occipital lobe epilepsy is a known manifestation of RPLS-eclampsia (23). However, occipital seizures have not been previously reported as the major manifestatio...

Cerebrospinal fluid changes after intravenous injection of gadolinium chelate: assessment by FLAIR MR imaging

“…The usefulness of FLAIR as compared with T2-weighted spin-echo MR imaging has been tested in a wide variety of brain diseases, including stroke [2,3], multiple sclerosis [4,5], infections [6,7], hypertensive encephalopathy/reversible posterior leukoencephalopathy syndrome [8], brain neoplasms [9,10,11], and hypoxic-ischemic encephalopathy [12].…”

Cortical-subcortical lesions in "reversible posterior leukoencephalopathy syndrome". Encephalopathy or seizures?

“…Many unrelated etiologies for this "syndrome" have been reported including hypertensive encephalopathy, glomerulonephritis with hypertension, eclampsia, and the use of immunosuppressive agents [1][2][3][4][5][6][7][8][9][10] (Table 1 [6] and progressive lupus while followed by multifocal seizures white matter of frontal and receiving prednisone and parieto-occipital lobes monthly cyclophosphamide bilaterally therapy studies in the 28 cases of RPLS reported in the literature showed increased T2 signal involving the white and, less consistently, gray matter with some predominance of the posterior portion of the cerebral hemispheres. Our patient became acutely confused, had visual hallucinations, generalized tonicclonic seizures and a MRI picture similar to the reported cases of RPLS.…”

A Case of posterior reversible encephalopathy syndrome in a pregnant woman with sickle cell anemia

“…4,6,19 Other antiepileptics drugs can be used while considering the patient's coexisting medical disorders and prescribed drugs. 30 While long-term follow-up studies are limited, seizure recurrence or epilepsy appears to be rare.…”

“…31 Although some case series report continuation of therapy for one to three months, phenytoin can probably be safely tapered as symptoms and neuroimaging findings resolve, usually after one to two weeks. 19 When recurrent, unprovoked seizures have occurred after recovery from an RPLS episode, it is reasonable to resume or initiate antiepileptic drug therapy. 29,31,32 Management of patients with PRES with Eclampsia being the underlying cause is different from that due to other causes.…”