Atypical MRI presentation of posterior reversible encephalopathy syndrome with predominant brainstem involvement
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We report here the case of a 80-year-old woman for the assessment of an acute confusional state since 2 days asssociated with diffuse and gradual headache. Brain MRI disclosed isolated hyperintense signal on fluid-attenuated inversion recovery sequence involving the medulla and the right inferior cerebellar peduncle with moderate swelling, consistent with vasogenic oedema, without abnormalities on diffusion-weighted imaging sequence. PRES diagnosis was suspected and antihypertensive therapy was introduced to achieve a blood pressure goal < 140/90 mmHg, allowing a quickly favourable clinical course. Three months later, brain MRI demonstrated a complete clearance of the abnormalities, confirming the PRES diagnosis. Atypical MRI findings are possible with involvement of basal ganglia, brainstem or cerebellum, but in these cases, oedema is most of the time accompanied by the classical parieto-occipital region involvement. Vasogenic oedema strictly unilateral or involving exclusively the brainstem or the cerebellum are very rare and should prompt suspicion for an alternative diagnosis. That constitutes a crucial diagnosis challenge in neurology.
KeywordsPosterior reversible encephalopathy syndrome Hypertension Brainstem
BH: study concept and design. EGM: critical revision of the manuscript for important intellectual content. ATB: critical revision of the manuscript for important intellectual content. OOW: critical revision of the manuscript for important intellectual content.
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Conflict of interest
Benjamin Hebant declares that he has not conflict of interest. Evelyne Guegan-Massardier declares that she has not conflict of interest. Aude Triquenot-Bagan declares that she has not conflict of interest. Ozlem Ozkul-Wermester declares that she has not conflict of interest.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.