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|Year : 2021 | Volume
| Issue : 6 | Page : 1621-1622
Asymmetric Posterior Reversible Encephalopathy Syndrome Mimicking Massive Cerebral Hemispheric Infarction after Cardiac Surgery
Jae Y An1, Yang H Lee2, Woojun Kim1
1 Department of Neurology, The Catholic University of Korea, College of Medicine, Seoul, South Korea
2 Department of Neurology, Yonsei University Medical College, Seoul, South Korea
|Date of Submission||31-May-2019|
|Date of Decision||28-Nov-2019|
|Date of Acceptance||15-May-2021|
|Date of Web Publication||23-Dec-2021|
Department of Neurology, The Catholic University of Korea, College of Medicine, 222 Banpo-daero, Seocho-gu, Seoul
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
An JY, Lee YH, Kim W. Asymmetric Posterior Reversible Encephalopathy Syndrome Mimicking Massive Cerebral Hemispheric Infarction after Cardiac Surgery. Neurol India 2021;69:1621-2
|How to cite this URL:|
An JY, Lee YH, Kim W. Asymmetric Posterior Reversible Encephalopathy Syndrome Mimicking Massive Cerebral Hemispheric Infarction after Cardiac Surgery. Neurol India [serial online] 2021 [cited 2022 Jan 19];69:1621-2. Available from: https://www.neurologyindia.com/text.asp?2021/69/6/1621/333490
A 29-year-old female with underlying aplastic anemia, who underwent peripheral blood stem cell transplantation and tacrolimus therapy six months ago, presented with fever. Sepsis with methicillin-resistant Staphylococcus epidermidis and endocarditis with vegetation of the tricuspid valve was diagnosed, and surgery for artificial tricuspid valve replacement was performed successfully. During and after surgery, blood pressure was maintained within a normal to the slightly upper-normal range. Six hours after the surgery, the patient became stuporous and showed right gaze preponderance with left visual field defect and left hemiparesis, suggesting massive cerebral infarction involving the right hemisphere. 2 h later, consecutive seizures occurred, which stopped after intravenous infusion of lorazepam and high-dose of fosphenytoin.
Routine blood tests revealed elevated urea nitrogen (77.8 mg/dL) and creatinine (2.37 mg/dL). Brain MRI showed vasogenic edema in the right cerebral hemisphere, which suggested posterior reversible encephalopathy syndrome (PRES) [Figure 1]a. CT angiography was normal [Figure 1]b. Electroencephalography performed the next day showed intermittent slow waves over the right hemisphere. Under conservative treatment, neurological deficits slowly resolved and became normal after 1 month. In the follow-up, MRI performed two months later, the edematous lesion on the right hemisphere had disappeared [Figure 1]c.
|Figure 1: (a) Axial fluid attenuation inversion recovery (FLAIR) (left), diffusion-weighted images (DWIs) (center), and apparent diffusion coefficient (ADC) images performed 6 h after symptom onset. High signal intensity lesions occupy almost the whole right cerebral hemisphere in the FLAIR and DWIs (arrows). Iso- or hyperintensities seen in the ADC images suggest vasogenic edema. The lesions are also seen in the left frontal cortex (arrowheads); (b) CT angiography reveals no significant abnormalities; (c) the follow-up MRI performed 2 months later shows the previous lesions have disappeared|
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Considering the clinical findings, including the history of immunosuppressant therapy, acute deterioration of mental status, seizures, and complete recovery, this case is compatible with PRES, although the initial symptoms possibly indicated massive cerebral infarction. Typically, PRES shows reversible, vasogenic edema, and the lesions are usually located in the bilateral parieto-occipital regions. However, there have been reports about atypical imaging findings,, like those seen in our case.
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