Korean J Radiol.  2013 Oct;14(5):849-853. 10.3348/kjr.2013.14.5.849.

Severe Posterior Reversible Encephalopathy in Pheochromocytoma: Importance of Susceptibility-Weighted MRI

• Serter A
• Alkan A
• Aralasmak
• Kocakoc E

• KMID: 1711446
• DOI: http://doi.org/10.3348/kjr.2013.14.5.849

Abstract

Pheochromocytoma is a rare cause of hypertension in children. Hypertension is one of the common reasons of posterior reversible encephalopathy. Intracerebral hemorrhage is a serious and unexpected complication of hypertensive encephalopathy due to pheochromocytoma, and very rarely seen in the childhood. Intracerebral hemorrhages should be searched if there are hypertensive reversible signal changes on the brain. Susceptibility weighted imaging (SWI) is a more sensitive method than conventional MRI when demonstrating cerebral microhemorrhagic foci. This is the first report of SWI findings on intracerebral hemorrhages in basal ganglia, brain stem and periventricular white matter due to hypertensive encephalopathy in a child with pheochromocytoma.

Keyword

Pheochromocytoma; Intracerebral hemorrhage; Susceptibility weighted imaging; Hypertension

MeSH Terms

Adolescent
Adrenal Gland Neoplasms/*complications/diagnosis
Brain/*pathology
Diagnosis, Differential
Female
Humans
Hypertensive Encephalopathy/*diagnosis/etiology
Magnetic Resonance Imaging/*methods
Pheochromocytoma/*complications/diagnosis

Figure

• 

  Fig. 1 MR appearance of hypertensive encephalopathy before treatment in patient with left surrenal pheochromocytoma. A. Axial contrast enhanced T1-weighted MRI shows large heterogeneous enhancing mass with central cystic necrotic area on left adrenal gland (arrow). B-E. Axial FLAIR (B), T2-weighted (C), and coronal FLAIR (D) and T1-weighted (E) MRI images before anti-hypertensive therapy. Axial FLAIR image shows abnormal hyperintense signals indicating edema in periventricular and deep white matter and basal ganglia, more so, on right side (arrow) (B). Cerebral edema is observed as hyperintense signal on T2-weighted image in bilateral caudate and lentiform nuclei (black arrow) (C). Coronal FLAIR image shows hyperintense signal changes in dentate nuclei (arrows) (D). Also T2-weighted MRI shows two hyperintense lesions with peripheral hemosiderin rim; chronic hematoma is hypointense on T1-weighted images and hyperintense on T2-weighted images in right external capsule (white arrow), subacute hematoma in right globus pallidus is hyperintense on T1 and T2-weighted images (arrowhead) (E). FLAIR = fluid attenuated inversion recovery F-H. On tenth day of anti-hypertensive therapy; axial FLAIR image (F) demonstrates remarkable regression of high signal intensities in periventricular and deep white matter, axial T2-weighted (G) and coronal FLAIR (H) images show complete losses of high signal intensities in caudate, lentiform and dentate nuclei due to regressions of vasogenic edema. I. On susceptibility weighted imaging, there are millimetric signal losses in bilateral basal ganglia which are compatible with hemorrhagic foci. These were not seen on conventional MRI. FLAIR = fluid attenuated inversion recovery

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