Posterior reversible encephalopathy syndrome after bevacizumab therapy in a normotensive patient

Abstract

Posterior reversible encephalopathy syndrome (PRES) is a neurological disorder characterised by distinct radiological features. Common precipitants of this disorder include acute medical illness, hypertensive crisis, eclampsia, immunosuppressive therapy and chemotherapy. We present the case of a patient with advanced ovarian carcinoma who developed PRES shortly after receiving bevacizumab (Avastin), an inhibitor of vascular endothelial growth factor. The patient's medical history and clinical presentation both suggest bevacizumab as the precipitator for PRES. This agent has been often overlooked as a possible cause of this rare neurological syndrome.

Figure 1

Axial fluid attenuation inversion recovery (FLAIR) MRIs at the level of the centrum semiovale (A) and at the level of the cerebellum (B). The figure obtained after the patient sustained a tonic–clonic seizure showing symmetrical abnormal high FLAIR signal in the cortico-subcortical white matter of parieto-occipital lobes and cerebellum (figure 1A). There was also symmetrical abnormal signal in the frontal lobes, in the brain stem and pons (figure 1B).

Figure 2

Axial fluid attenuation inversion recovery (FLAIR) MRIs at the level of the centrum semiovale (A) and at the level of the cerebellum (B). A follow-up 6 days later (A and B) showing decrease and resolution of the symmetrical abnormal high FLAIR signal.

Figure 3

Axial T1-weighted MRIs with gadolinium at the level of the centrum semiovale. (A) Obtained after the patient sustained a tonic–clonic seizure showing punctuate foci of enhancement in the centrum semiovale. (B) Follow-up 6 days later showing persistence of punctuate foci of enhancement.