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Título

PRES or not PRES?: atypical MRI lesions in a male adult with hipertensive encephalopathy

RESUMO

Case report: A 44-year old man with uncontrolled hypertension presented to the emergency department with severely increased blood pressure and altered mental status in the past two hours. At admission, he had acute hypertension (220/110 mmHg) and impaired kidney function. He was uncooperative, agitated and confused. Head CT without contrast showed only mild effacement of cortical sulci, suggesting edema. A fundoscopic examination showed hypertensive retinopathy with retinal hemorrhage. A presumptive diagnosis of hypertensive encephalopathy was made and high doses of intravenous nitroprusside were immediately initiated for blood pressure control. Cerebrospinal fluid and electroencephalography were completely normal. After five days, the blood pressure was well controlled and the patient recovered without any neurologic deficits. Brain MRI performed one-week after admission symmetric enlargment and increased signal on T2-weighted images of the basal ganglia and base of the pons without restricted diffusion. Contrast was not used due to chronic kidney disease. A control MRI after three-months showed complete resolution of the aforementioned neuroimaging findings.

Discussion: This patient showed classical symptoms of posterior reversible encephalopathy syndrome (PRES), however, atypical MRI findings led us to reconsider the initial diagnosis and contemplate differential. Typically MRI findings of PRES, seen in almost 98% of cases, include symmetric and bilateral hyperintense foci in the parieto-occipital subcortical regions on FLAIR/T2-weighted images. The imaging findings in this case could be classified as a central variant PRES, in which lesions are predominantly observed in the basal ganglia and brainstem, sparing subcortical and cortical regions. Differential diagnosis need to be considered in this case and infarction, osmotic demyelination, autoimmune diseases, infectious encephalitis and metabolic encephalopathies were discarded because MRI pattern with normal laboratory findings and clinical full recovery without deficits using only antihypertensives.

Final considerations: PRES is a rare and dangerous condition in which rapid diagnosis and treatment are essential. The diagnosis of atypical PRES may be challenging then the condition could be mistaken for other pathologies because the symptoms are nonspecific and the radiologic findings are rare, especially when lesions are located in central or infratentorial regions.

Palavras Chave

PRES, hypertensive encephalopathy