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Two Case Reports of Posterior Reversible Encephalopathy Syndrome (PRES) Involving the Spinal Cord 2014

Category General Spine Loren G. Longenecker
Lubdha M. Shah, MD
Purpose Although posterior reversible encephalopathy syndrome (PRES) is a well-known entity with a wide definition of the clinical and imaging findings, involvement of the spinal cord is not directly addressed by the established definition. Six patients have been described in the literature with a clinical and radiographic presentation consistent with PRES with spinal cord involvement by imaging with the most characteristic finding being central spinal cord T2 hyperintensity on MRI. We present two additional cases with a similar PRES-like entity affecting the spinal cord. Materials & Methods We present case reports of 2 patients with PRES of the spinal cord. Results Case 1: A 50 year-old male with untreated hypertension presented with six-weeks of headache, nausea and vomiting and one-week of progressive bilateral vision loss, confusion, increasing lower extremity weakness and urinary incontinence. The patient's initial blood pressure was 180/110 and his pertinent positive exam included papilledema, hypertensive retinopathy and bilateral lower extremity weakness. Case 2: A 25 year-old male with untreated hypertension secondary to membranoproliferative glomerulonephritis presented with two weeks of headache and progressive vision loss in left eye. His initial blood pressure was 225/160 and he had decreased vision in left eye and bilateral hypertensive retinopathy. Ophthalmologic exam revealed flame exudates and cotton wool spots. This patient had no cord-related symptoms. Both patients had abnormal T2 hyperintensity at the cervicomedullary junction on initial brain MRI and characteristic PRES findings of confluent T2 hyperintensity involving the subcortical white matter in bilateral posterior parietal lobes, occipital lobes and cerebellar hemispheres. Both patients had additional cervical and thoracic spine MRIs within two days of presentation. There were similar MR findings in both patients: slightly expansile, central spinal cord T2/STIR hyperintensity spanning over 4 spinal segments and originating at the cervicomedullary junction. The acute symptoms in both patients resolved after treatment of hypertension. The abnormal imaging findings in the spine and brain resolved on follow-up outpatient MRI. Conclusion PRES with involvement of the cervicomedullary junction extending into the spinal cord is a rare but increasingly recognized entity. It is important for radiologists to be familiar with this entity from an imaging perspective in order to help referring physicians consider this diagnosis. References Briganti et al. Asymptomatic Spinal Cord Involvement in Posterior Reversible Encephalopathy Syndrome. Neurology. 73:1507-1508, 2009. Lapuyade B. et al. Spinal Cord involvement in posterior reversible encephalopathy syndrome. J Neurol Neurosurg Psychiatry. 80(1):35, 2009. Milia et al. Spinal Cord involvement during hypertensive encephalopathy: clinical and radiolgical findings. 255: 142-143, 2008.