Answer for BIR CoW 10 Sep 2023
Central Variant of Atypical Posterior Reversible Encephalopathy Syndrome
Findings
T2/FLAIR hyperintensity noted in bilateral lentiform nucleus showing restricted diffusion with low ADC values and internal gradient blooming with surrounding dema. T2/FLAIR hyperintensity noted in the bilateral caudate nucleus ,posterior limb of edema bilateral internal capsule, bilateral cortical spinal tract, pons with no restricted diffusion.
Discussion
Posterior reversible encephalopathy syndrome (PRES) is a condition clinically characterized by headache, altered mental status, seizures, and visual loss and may be associated with systemic hypertension, preeclampsia/eclampsia, chemotherapy, immunosuppressive therapies in the setting of organ transplantation, and uremic encephalopathy. While brain imaging in patients with PRES typically reveals symmetric vasogenic edema within the parietal and occipital lobes, PRES may present with atypical imaging findings such as central brainstem and deep gray involvement without subcortical edema, and even spinal cord involvement. Additionally, PRES may be complicated in some cases by the presence of cytotoxic edema and hemorrhage. PRES most commonly manifests on imaging as subcortical/cortical edema within the cerebral hemispheres with a parietaloccipital predominance and some variable involvement of deep structures as well as the posterior fossa, it may occur in an atypical fashion with isolated involvement of deep gray nuclei, brainstem/cerebellar hemispheres, and exceptionally the spinal cord without cerebral hemispheric involvement.These findings may lead to a diagnostic dilemma, with a delay in diagnosis and reversal of the offending condition potentially leading to a poor patient outcome. I maging findings of a “central variant” PRES, revealing brainstem or deep gray nuclei involvement without involvement of the cerebral hemispheres . PRES may be complicated by the presence of hemorrhage. Vasogenic edema predominates in PRES, however cases may be complicated by the development of cytotoxic edema as indicated by diffusion restriction.
REFERENCES:
• Saad AF, Chaudhari R, Wintermark Reversible Encephalopathy Syndrome. Front Neurol. 2019 Sep 4;10:964. M. Imaging of Atypical and Complicated Posterior doi 10.3389/fneur.2019.00964. PMID: 31551919; PMCID: PMC6738024. • H inchey J, Chaves C, Appignani : B, Breen J, Pao L, Wang A, et al. . A reversible posterior leukoencephalopathy syndrome. N Engl 10.1056/NEJM199602223340803
Findings
T2/FLAIR hyperintensity noted in bilateral lentiform nucleus showing restricted diffusion with low ADC values and internal gradient blooming with surrounding dema. T2/FLAIR hyperintensity noted in the bilateral caudate nucleus ,posterior limb of edema bilateral internal capsule, bilateral cortical spinal tract, pons with no restricted diffusion.
Discussion
Posterior reversible encephalopathy syndrome (PRES) is a condition clinically characterized by headache, altered mental status, seizures, and visual loss and may be associated with systemic hypertension, preeclampsia/eclampsia, chemotherapy, immunosuppressive therapies in the setting of organ transplantation, and uremic encephalopathy. While brain imaging in patients with PRES typically reveals symmetric vasogenic edema within the parietal and occipital lobes, PRES may present with atypical imaging findings such as central brainstem and deep gray involvement without subcortical edema, and even spinal cord involvement. Additionally, PRES may be complicated in some cases by the presence of cytotoxic edema and hemorrhage. PRES most commonly manifests on imaging as subcortical/cortical edema within the cerebral hemispheres with a parietaloccipital predominance and some variable involvement of deep structures as well as the posterior fossa, it may occur in an atypical fashion with isolated involvement of deep gray nuclei, brainstem/cerebellar hemispheres, and exceptionally the spinal cord without cerebral hemispheric involvement.These findings may lead to a diagnostic dilemma, with a delay in diagnosis and reversal of the offending condition potentially leading to a poor patient outcome. I maging findings of a “central variant” PRES, revealing brainstem or deep gray nuclei involvement without involvement of the cerebral hemispheres . PRES may be complicated by the presence of hemorrhage. Vasogenic edema predominates in PRES, however cases may be complicated by the development of cytotoxic edema as indicated by diffusion restriction.
REFERENCES:
• Saad AF, Chaudhari R, Wintermark Reversible Encephalopathy Syndrome. Front Neurol. 2019 Sep 4;10:964. M. Imaging of Atypical and Complicated Posterior doi 10.3389/fneur.2019.00964. PMID: 31551919; PMCID: PMC6738024. • H inchey J, Chaves C, Appignani : B, Breen J, Pao L, Wang A, et al. . A reversible posterior leukoencephalopathy syndrome. N Engl 10.1056/NEJM199602223340803
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!