Korean J Radiol.  2015 Oct;16(5):1104-1108. 10.3348/kjr.2015.16.5.1104.

Atypical Unilateral Posterior Reversible Encephalopathy Syndrome Mimicking a Middle Cerebral Artery Infarction

• Camlidag I
• Cho YJ
• Park M
• Lee SK

• KMID: 2160778
• DOI: http://doi.org/10.3348/kjr.2015.16.5.1104

Abstract

Posterior reversible encephalopathy syndrome (PRES) is usually a reversible clinical and radiological entity associated with typical features on brain MR or CT imaging. However, the not-so-uncommon atypical radiological presentations of the condition are also present and they may go unrecognised as they are confused with other conditions. Here, we report a very rare case of atypical, unilateral PRES in a 49-year-old uremic, post-transplant female patient who presented with seizures. Initial MRI showed high-grade occlusion of the left middle cerebral artery (MCA) and lesions suggestive of subacute infarction in the ipsilateral frontotemporoparietal lobe. Patient symptoms had resolved a day after the onset without any specific treatment but early follow-up CT findings suggested hemorrhagic transformation. Follow-up MRI performed 2 years later showed complete disappearence of the lesions and persisting MCA occlusion.

Keyword

Posterior reversible encephalopathy syndrome; Atypical; Unilateral; Infarction

MeSH Terms

Acute Kidney Injury/complications
Brain/radiography
Diagnosis, Differential
Female
Humans
Infarction, Middle Cerebral Artery/diagnosis/radiography
Lung Transplantation
Magnetic Resonance Imaging
Middle Aged
Posterior Leukoencephalopathy Syndrome/complications/*diagnosis
Tomography, X-Ray Computed

Figure

• 

  Fig. 1 Unilateral posterior reversible encephalopathy syndrome in 49-year-old woman with acute renal failure who had history of lung transplantation and of taking tacrolimus. A. Axial fluid attenuation inversion recovery images show extensive hyperintense lesions mainly in left frontotemporoparietal region predominantly involving subcortical and deep white matter including splenium of corpus callosum, and striatum (short arrows). Subtle hyperintensity is also noted in right external capsule (long arrow). B. Diffusion weighted images show that lesions are iso to hyperintense (arrows). C. Apparent diffusion coefficient maps show that lesions are hyperintense suggesting vasogenic edema (arrows). D. Post-contrast axial three-dimensional (3D)-T1 weighted images show patchy enhancement of lesions (arrows). E. 3D-time-of-flight image reveals high-grade occlusion of left middle cerebral artery (arrows). F. Follow-up CT examination of patient performed 5 days later. Axial image shows newly developed small intraparenchymal hematoma in left temporal lobe (asterisk). Right frontal subdural widening and small subarachnoid hemorrhage along right side of anterior interhemispheric fissure were also noted (arrow). Follow-up MRI performed at two years after first examination. G. Axial fluid attenuation inversion recovery images show complete disappearance of lesions and old hemorrhagic focus in left temporal lobe (arrow). H. Three-dimensional time-of-flight image shows stable left middle cerebral artery occlusion (arrows).

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