Journal of Emergencies, Trauma, and Shock
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PICTORIAL EDUCATION  
Year : 2014  |  Volume : 7  |  Issue : 3  |  Page : 242-243
Recurrent posterior reversible encephalopathy syndrome of the brainstem in a hypertensive patient with end-stage renal disease


1 Department of Emergency and Critical Care Medicine, Mito Kyodo General Hospital, University of Tsukuba, Ibaraki, Japan
2 Department of Medicine, Mito Kyodo General Hospital, University of Tsukuba, Ibaraki, Japan

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Date of Submission23-Jul-2013
Date of Acceptance21-Nov-2013
Date of Web Publication16-Jul-2014
 

   Abstract 

A 59-year-old man with end-stage renal disease was brought to our emergency department with complaints of headache, nausea, dysarthria, tic, and weakness involving the bilateral arms and legs. He had the similar episode 4 month before, when he was treated elsewhere. The patient had received hemodialysis three times per week. His medications included for hypertension. On examination at his arrival, he was alert with reduced concentration and incoherent thoughts. The blood pressure was 181/87 mmHg and other vital signs were normal. Neurological findings showed slight dysarthria and slow movements but no other abnormalities. Laboratory data showed increased serum creatinine and potassium presumably for a session of periodical hemodialysis but normal sodium concentration. His cerebrospinal fluid examination was normal. We treated him by hemodialysis. Diagnosis of PRES was most likely because of the clinical features and the MRI findings. His symptoms had disappeared immediately and completely after we controlled high blood pressure. MRI on 13 days after admission showed the improvement of the abnormal findings. Although the pathophysiology of PRES is incompletely understood, renal failure was known as one of the risk factors. A relative lack of sympathetic innervation of posterior circulation could not protect the area when severe hypertension makes auto-regulatory control collapsed. However, PRES of the brainstem is uncommon although the posterior circulation involves it. Because control of his hypertension was not appropriate in the outpatient settings before this event, it could have contributed to the recurrence in this patient.

Keywords: Posterior reversible encephalopathy syndrome, brainstem, end-stage renal disease, hemodialysis

How to cite this article:
Abe T, Tokuda Y. Recurrent posterior reversible encephalopathy syndrome of the brainstem in a hypertensive patient with end-stage renal disease. J Emerg Trauma Shock 2014;7:242-3

How to cite this URL:
Abe T, Tokuda Y. Recurrent posterior reversible encephalopathy syndrome of the brainstem in a hypertensive patient with end-stage renal disease. J Emerg Trauma Shock [serial online] 2014 [cited 2020 Aug 12];7:242-3. Available from: http://www.onlinejets.org/text.asp?2014/7/3/242/136876


A 59-year-old man with end-stage renal disease was brought to our emergency department with the complaints of headache, nausea, dysarthria, tic and weakness involving the bilateral arms and legs. He had the similar episode 4 month before, when he was treated elsewhere. Patient had received hemodialysis 3 times/week. His medications included for hypertension.

On examination at his arrival, he was alert with reduced concentration and incoherent thoughts. The blood pressure was 181/87 mmHg and other vital signs were normal. Neurological findings showed slight dysarthria and slow movements, but no other abnormalities.

Laboratory data showed increased serum creatinine and potassium presumably for a session of periodical hemodialysis, but normal sodium concentration. His cerebrospinal fluid examination was normal. We treated him by hemodialysis after he received plain brain computed tomography [Figure 1] and magnetic resonance imaging (MRI) T2-weighted fluid attenuated inversion recovery [Figure 2]a. Diagnosis of posterior reversible encephalopathy syndrome (PRES) was most likely because of the clinical features and the MRI findings. His symptoms had disappeared immediately and completely after we controlled high blood pressure. Diagnosis of central pontine myelinolysis was unlikely due to the rapid disappearance of his symptoms only by controlling the blood pressure on the day of admission. MRI on 13 days after admission showed the improvement of the abnormal findings [Figure 2]b.
Figure 1: Brain computed tomography on arrival revealed hypodense lesions with surrounding vasogenic edema in the brain stem

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Figure 2:

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Although the pathophysiology of PRES is incompletely understood, hypertension-induced vasogenic edema [1],[2] is widely believed. Thus, it is overwhelming of cerebral autoregulation. Other mechanism is forced dilation of arterioles with leakage of serum through capillary walls into cerebral interstitium. Furthermore, unchecked vasogenic edema may lead to interstitial edema [3] Renal failure was also known as one of the risk factors related to them. [2] A relative lack of sympathetic innervation of posterior circulation could not protect the area when severe hypertension makes auto-regulatory control collapsed. [4] However, PRES of the brainstem is uncommon although the posterior circulation involves it. [5] Because control of his hypertension was not appropriate in the out-patient settings before this event, it could have contributed to the recurrence in this patient.

 
   References Top

1.Hinchey J, Chaves C, Appignani B, Breen J, Pao L, Wang A, et al. A reversible posterior leukoencephalopathy syndrome. N Engl J Med 1996;334:494-500.  Back to cited text no. 1
    
2.Garg RK. Posterior leukoencephalopathy syndrome. Postgrad Med J 2001;77:24-8.  Back to cited text no. 2
[PUBMED]    
3.Covarrubias DJ, Luetmer PH, Campeau NG. Posterior reversible encephalopathy syndrome: Prognostic utility of quantitative diffusion-weighted MR images. AJNR Am J Neuroradiol 2002;23:1038-48.  Back to cited text no. 3
    
4.Rangi PS, Partridge WJ, Newlands ES, Waldman AD. Posterior reversible encephalopathy syndrome: A possible late interaction between cytotoxic agents and general anaesthesia. Neuroradiology 2005;47:586-90.  Back to cited text no. 4
    
5.McKinney AM, Short J, Truwit CL, McKinney ZJ, Kozak OS, SantaCruz KS, et al. Posterior reversible encephalopathy syndrome: Incidence of atypical regions of involvement and imaging findings. AJR Am J Roentgenol 2007;189:904-12.  Back to cited text no. 5
    

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Correspondence Address:
Toshikazu Abe
Department of Emergency and Critical Care Medicine, Mito Kyodo General Hospital, University of Tsukuba, Ibaraki
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2700.136876

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