□
PICTURES IN CLINICAL MEDICINE
□
Asymmetric Posterior Reversible Encephalopathy Syndrome due to Hypertensive Encephalopathy Haruo Nishijima 1,2, Rie Haga 1, Chieko Suzuki 1 and Masahiko Tomiyama 1,2 Key words: hypertensive encephalopathy, posterior reversible encephalopathy syndrome, asymmetry, carotid artery, stenosis (Intern Med 54: 993-994, 2015) (DOI: 10.2169/internalmedicine.54.3762)
Picture.
A 41-year-old man was referred to our hospital presenting with drowsiness and left hemiparesis. He had a history of hypertension and chronic renal failure without any medication. He noticed hematuria one month before admission. On admission his blood pressure was 210/125 mmHg. Magnetic
resonance imaging of the brain revealed hyperintensities in fluid-attenuated inversion recovery imaging at the brainstem and cerebellum bilaterally and right supratentorial white matter with mass effect (Picture A, B). Magnetic resonance angiography revealed stenosis of the left internal carotid ar-
１
Department of Neurology, Aomori Prefectural Central Hospital, Japan and ２Department of Neurophysiology, Institute of Brain Science, Hirosaki University Graduate School of Medicine, Japan Received for publication July 27, 2014; Accepted for publication September 10, 2014 Correspondence to Dr. Haruo Nishijima,
[email protected]
993
Intern Med 54: 993-994, 2015
DOI: 10.2169/internalmedicine.54.3762
tery (Picture C). Three weeks of anti-hypertensive therapy resulted in a marked improvement of the lesions (Picture D, E). Most of the lesions showed increased apparent diffusion coefficient values, thus indicating that they were caused by a vasogenic edema (Picture F). We diagnosed the patient with posterior reversible encephalopathy syndrome (PRES) caused by hypertensive encephalopathy. The left supratentorial region was intact probably due to a low perfusion pressure. We believed that the severe hypertension exceeded the limits of autoregulation leading to breakthrough brain edema. Marked asymmetry in PRES has been rarely reported (1) and the pathophysiology of PRES remains controversial (2). This case supports the notion that hyperperfu-
sion plays a causative role in the development of PRES. The authors state that they have no Conflict of Interest (COI).
References 1. Voetsch B, Tarlov N, Nguyen TN, et al. Asymmetric posterior reversible encephalopathy syndrome complicating hemodynamic augmentation for subarachnoid hemorrhage-associated cerebral vasospasm. Neurocrit Care 15: 542-546, 2011. 2. Bartynski WS. Posterior reversible encephalopathy syndrome, part 2: controversies surrounding pathophysiology of vasogenic edema. Am J Neuroradiol 29: 1043-1049, 2008.
Ⓒ 2015 The Japanese Society of Internal Medicine http://www.naika.or.jp/imonline/index.html
994
