Posterior Reversible Encephalopathy Syndrome Presenting Atypically as a Non-Convulsive Seizure

Abstract

BACKGROUND Posterior reversible encephalopathy syndrome (PRES), also known as reversible posterior leukoencephalopathy, is a neurotoxic state with multiple etiologies characterized by altered mental state, headaches, visual abnormalities, and seizures. This clinico-radiological syndrome is rare, and a high index of suspicion is needed to diagnose, provide adequate treatment, and prevent irreversible neurological sequelae. CASE REPORT We present a case of a woman with end-stage renal disease (ESRD) who presented with acute confusion and non-convulsive seizures and was later diagnosed with PRES. In this case, altered mental status was initially thought to be secondary to uremic encephalopathy. A diagnosis of PRES was subsequently made after she had several sessions of HD without significant improvement in her mental state, prompting magnetic resonant imaging (MRI) for further evaluation. Specific risk factors for PRES, including blood pressure fluctuations, were targeted and she made significant clinical recovery but had residual functional impairment. CONCLUSIONS This case underscores the need for a high index of suspicion, especially in cases with atypical presentation, as delayed diagnosis can lead to suboptimal outcomes.

Figure 1.

Computed tomography (CT) scan of the head done on the day of admission, showing age-related diffuse cerebral and cerebral volume loss.

Figure 2.

Repeat computed tomography (CT) scan of the head 7 days later, showing no interval changes.

Figure 3.

EEG showing epileptiform discharges, synchronous and asynchronous, with amplitude predominance mainly in the frontal, central parietal, and occipital regions.

Figure 4.

MRI Brain on day 15 of admission showing abnormal FLAIR (A) and T2-weighted (B) signals of the parieto-occipital and high bilateral fronto-parietal lobes, predominantly in the white matter. The signal abnormality is largely bilateral and symmetrical. Findings are suggestive of posterior reversible encephalopathy syndrome (PRES).

Figure 5.

Fluctuating blood pressure measurements in the first few days of admission.

Figure 6.

Repeat MRI Brain on day 20 of admission, showing increased late subacute and chronic hemorrhage associated with PRES and areas of developing encephalomalacia.