(Kiosk 4) The Rare Hemorrhagic Subtype of Posterior Reversible Encephalopathy Syndrome: A Case Report

Case Diagnosis: Posterior Reversible Encephalopathy Syndrome, Hemorrhagic Subtype

Case Description or Program Description: 46 year old female with history of headaches, hypertension, depression and anxiety presented to the ED for sudden severe headache and vomiting. Blood pressure at home prior to presentation was 197/123, reduced to 150/104 upon arrival to ED. Admission head CT was unremarkable. Initial headache treatment included triptans and analgesics, but recurred with progression to include nausea, R arm paresthesias and visual impairment. Repeat CT head showed bilateral posterior cerebral edema with notable areas of hemorrhage, suspicious for PRES, confirmed on MRI. This prompted ICU transfer for monitoring with valproate and ketamine drip for headaches.

Setting: Inpatient Rehabilitation Facility (IRF)

Assessment/Results: Presentation at IRF included severe headaches, visual deficits, and functional decline. She manifested severe disequilibrium, requiring moderate assistance in transfers and walking, and total assistance for stairs. Severe visual limitations impacted BADLs, which required minimum to maximal assistance. She experienced a rapid recovery trajectory. One week later, she progressed to independence in all mobility tasks and most BADLs. Most visual symptoms resolved concurrently.

Discussion (relevance): First described in 1996, PRES is a clinic-radiological syndrome characterized by headache, altered mental status, and visual impairment. It predominantly affects the posterior occipital and parietal white matter. This patient exhibited the rare hemorrhagic subtype of PRES, which comprises 5-30% of cases. She manifested classic symptoms of PRES and improved rapidly during her rehabilitation course. While the exact etiology is unknown, PRES has a generally favorable prognosis. The hemorrhagic subtype, however, is associated with increased morbidity and even death.

Conclusions: We describe the presentation and rapid functional recovery of a patient with symptoms and imaging findings consistent with the rare hemorrhagic subtype of PRES. This case demonstrates the generally favorable prognosis of PRES, with this particular patient illustrating the prominent role of visual symptom resolution on functional outcome.