SHM Converge Scientific Abstract ePoster Gallery-Posterior Reversible Encephalopathy Syndrome ,Brainstem and CKD : A Clinical Vignette and Call for Rapid Diagnosis With Brain Magnetic Resonance Imaging

Posterior Reversible Encephalopathy Syndrome ,Brainstem and CKD : A Clinical Vignette and Call for Rapid Diagnosis With Brain Magnetic Resonance Imaging

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This clinical vignette describes a 32-year-old man with severe hypertension and stage IV chronic kidney disease who was found unresponsive and brought to the emergency department. He had marked hypertension (266/166 mm Hg), altered mental status, and intermittent right gaze deviation, but no clear seizures. Initial CT head and CTA were negative for hemorrhage or large vessel occlusion, making stroke less likely. Because of elevated troponins and EKG changes, demand ischemia from hypertensive emergency was considered.<br /><br />He was admitted to the ICU with acute-on-chronic kidney injury requiring emergent dialysis. EEG showed no epileptiform activity. Brain MRI without contrast revealed a well-circumscribed expansile T2/FLAIR hyperintense lesion in the pons, initially concerning for a brainstem mass. A follow-up MRI with contrast still showed diffuse pontine T2 hyperintensity, and an infiltrative mass could not be excluded. However, after blood pressure control with nicardipine, a repeat MRI 8 days later showed partial resolution of the pontine abnormalities, confirming atypical posterior reversible encephalopathy syndrome (PRES).<br /><br />The report highlights that PRES is a clinical-radiologic syndrome caused by reversible vasogenic edema, usually in parieto-occipital regions but occasionally involving the brainstem alone. It is associated with severe hypertension, renal dysfunction, and autoimmune disease. Symptoms may include altered consciousness, headache, visual changes, and seizures.<br /><br />The authors emphasize that MRI is the preferred and often only imaging modality that can diagnose PRES. In patients with hypertension and renal dysfunction who present with encephalopathy, PRES should be considered early to avoid unnecessary invasive workup for suspected brainstem mass. Repeat MRI can help confirm interval improvement and support the diagnosis.

Asset Subtitle

Liliana Guevara

Meta Tag

Author List Aurangzeb Memon, Liliana Guevara, Mary Ann K. Hall

Category Clinical Vignettes

Concept Posterior Reversible Encephalopathy Syndrome

Concept Magnetic Resonance Imaging

Concept Severe Hypertension

Concept Vasogenic Edema

Concept Blood Pressure Control

Distinguished Non-Finalist

Presenter Organization Emory School of Medicine/ Division of Hospital Medicine

Presenting Author Liliana Guevara

Track Adult

Keywords

posterior reversible encephalopathy syndrome

PRES

brainstem lesion

pontine hyperintensity

severe hypertension

chronic kidney disease

hypertensive emergency

altered mental status

MRI brain

vasogenic edema

Posterior Reversible Encephalopathy Syndrome

Magnetic Resonance Imaging

Severe Hypertension

Vasogenic Edema

Blood Pressure Control