Posterior reversible encephalopathy syndrome (PRES) is characterised by acute neurological symptoms with vasogenic oedema typically in parieto-occipital lobes. PRES involving atypical locations is becoming increasingly recognised. Here we report two atypical cases.
An 83-year-old male with ureteric carcinoma presented with confusion, headache and high blood pressure (170/80). MRI revealed symmetrical temporal lobe T2-hyperintensities with no mass-effect or restricted diffusion. He was treated for presumed viral encephalitis. CSF was negative. Seizure was treated with Levetiracetam. Three weeks later MRI showed worsening of temporal lobe T2-hyperintensities with mild mass-effect and one small area of restricted diffusion. Despite no treatment for hypertension, six weeks later MRI showed significant improvement. Gradient echo demonstrated multiple microhaemorrhages consistent with hypertension.
A 69-year-old female presented with discitis, sepsis, fluctuating consciousness and high blood pressure (180/90). Patient reported hearing a song recurrently which could represent ‘musical hallucination’ associated with seizure. CSF was normal. She was treated with Levetiracetam. MRI showed symmetrical fronto-temporal lobe T2-hyperintensities with no mass-effect and small area of restricted diffusion. Although hypertension was not treated, one week later MRI improved significantly.
In summary, MRI appearances improved in both with minimal intervention. The underlying aetiology may remain elusive, but could these be atypical presentations of PRES?
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