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Posterior Reversible Encephalopathy Syndrome: Incidence of Atypical Regions of Involvement and Imaging Findings

¹ Department of Radiology and Neuroradiology, University of Minnesota Medical Center, Minneapolis, MN.
² Department of Radiology, Hennepin County Medical Center, 701 Park Ave. S, Minneapolis, MN 55415.

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —Mild posterior reversible encephalopathy syndrome (PRES) in 12-year-old girl with seizures who was undergoing immunosuppressive therapy for lung transplantation. 3-T MR image shows bilateral parietooccipital cortical and subcortical edema on fat-suppressed FLAIR images (A) with avid leptomeningeal or cortical contrast enhancement on T1-weighted image (B) but no diffusion abnormalities (not shown). Tacrolimus was considered causative and was discontinued, and symptoms subsided.

View larger version (111K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —Mild posterior reversible encephalopathy syndrome (PRES) in 12-year-old girl with seizures who was undergoing immunosuppressive therapy for lung transplantation. 3-T MR image shows bilateral parietooccipital cortical and subcortical edema on fat-suppressed FLAIR images (A) with avid leptomeningeal or cortical contrast enhancement on T1-weighted image (B) but no diffusion abnormalities (not shown). Tacrolimus was considered causative and was discontinued, and symptoms subsided.

View larger version (126K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —Mild posterior reversible encephalopathy syndrome (PRES) in 12-year-old girl with seizures who was undergoing immunosuppressive therapy for lung transplantation. Edema has resolved on FLAIR image 1 month later.

View larger version (126K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —Moderate posterior reversible encephalopathy syndrome (PRES) with restriction on diffusion-weighted imaging (DWI). A 51-year-old woman with acute alcohol withdrawal (after 8 days of binge drinking) presented with acute loss of vision. MR image shows edema in cortical, subcortical, and deep white matter and in cerebellum and thalami (not shown).

View larger version (98K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —Moderate posterior reversible encephalopathy syndrome (PRES) with restriction on diffusion-weighted imaging (DWI). A 51-year-old woman with acute alcohol withdrawal (after 8 days of binge drinking) presented with acute loss of vision. DWI (upper image) and apparent diffusion coefficient map (lower image) confirmed moderately restricted diffusion focally (arrows) in right parietooccipital vasogenic edema (62.3 vs 85–100 x 10-3 mm2/s in other normal cortical and subcortical white matter locations). Symptoms improved markedly after a few days.

View larger version (117K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C —Moderate posterior reversible encephalopathy syndrome (PRES) with restriction on diffusion-weighted imaging (DWI). A 51-year-old woman with acute alcohol withdrawal (after 8 days of binge drinking) presented with acute loss of vision. Follow-up imaging at 2 months shows subtle focal right parietooccipital atrophy in location of previously restricted diffusion, even though follow-up imaging at 5 days (not shown) showed improvement.

View larger version (100K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —Two patients with severe posterior reversible encephalopathy syndrome (PRES), both related to hypertension. Both cases involved cerebellum. Repeat MRI after several weeks (not shown) showed marked improvement in both patients, with no ensuing encephalomalacia. Bilateral edema is present on FLAIR MR image in 54-year-old woman, involving brainstem and cerebellum (A) and diffusely involving basal ganglia (B). Diffuse sulcal hyperintensity is presumed to be hemorrhage.

View larger version (111K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —Two patients with severe posterior reversible encephalopathy syndrome (PRES), both related to hypertension. Both cases involved cerebellum. Repeat MRI after several weeks (not shown) showed marked improvement in both patients, with no ensuing encephalomalacia. Bilateral edema is present on FLAIR MR image in 54-year-old woman, involving brainstem and cerebellum (A) and diffusely involving basal ganglia (B). Diffuse sulcal hyperintensity is presumed to be hemorrhage.

View larger version (97K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C —Two patients with severe posterior reversible encephalopathy syndrome (PRES), both related to hypertension. Both cases involved cerebellum. Repeat MRI after several weeks (not shown) showed marked improvement in both patients, with no ensuing encephalomalacia. In another pateint, a 25-year-old woman, bilateral diffuse edema extends from cortex to ventricular margin on FLAIR MR image.

View larger version (8K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4 —Bar graph shows regional involvement by posterior reversible encephalopathy syndrome (PRES) in 76 patients. Number of patients in each region are listed in or above each bar.

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —Tumefactive posterior reversible encephalopathy syndrome (PRES) in 57-year-old woman with lymphoma who is taking cyclosporine after bone marrow transplant. FLAIR MR image shows unilateral left temporal edema and mass effect. No contrast enhancement (not shown) or diffusion restriction was seen, suggesting primary brain tumor.

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —Tumefactive posterior reversible encephalopathy syndrome (PRES) in 57-year-old woman with lymphoma who is taking cyclosporine after bone marrow transplant. One month after cyclosporine cessation, symptoms and imaging are vastly improved.

View larger version (109K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —Two patients with hemorrhagic posterior reversible encephalopathy syndrome (PRES). 34-year-old man taking cyclosporine for seizures after bone marrow transplantation has mild edema with small subarachnoid hemorrhage. Initial brain MR image shows small amount of sulcal FLAIR hyperintensity (arrows, A) and mild cortical edema in high frontal and parietal lobes (B). Gradient-echo image confirms small amount of sulcal hemorrhage (arrow, C).

View larger version (99K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —Two patients with hemorrhagic posterior reversible encephalopathy syndrome (PRES). 34-year-old man taking cyclosporine for seizures after bone marrow transplantation has mild edema with small subarachnoid hemorrhage. Initial brain MR image shows small amount of sulcal FLAIR hyperintensity (arrows, A) and mild cortical edema in high frontal and parietal lobes (B). Gradient-echo image confirms small amount of sulcal hemorrhage (arrow, C).

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6C —Two patients with hemorrhagic posterior reversible encephalopathy syndrome (PRES). 34-year-old man taking cyclosporine for seizures after bone marrow transplantation has mild edema with small subarachnoid hemorrhage. Initial brain MR image shows small amount of sulcal FLAIR hyperintensity (arrows, A) and mild cortical edema in high frontal and parietal lobes (B). Gradient-echo image confirms small amount of sulcal hemorrhage (arrow, C).

View larger version (102K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6D —Two patients with hemorrhagic posterior reversible encephalopathy syndrome (PRES). In 44-year-old woman taking cyclosporine, large cerebellar parenchymal hematoma with bilateral edema is seen on CT (D) and gradient-echo MRI (E), with only mild edema on FLAIR image (F) of parietooccipital region.

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6E —Two patients with hemorrhagic posterior reversible encephalopathy syndrome (PRES). In 44-year-old woman taking cyclosporine, large cerebellar parenchymal hematoma with bilateral edema is seen on CT (D) and gradient-echo MRI (E), with only mild edema on FLAIR image (F) of parietooccipital region.

View larger version (136K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6F —Two patients with hemorrhagic posterior reversible encephalopathy syndrome (PRES). In 44-year-old woman taking cyclosporine, large cerebellar parenchymal hematoma with bilateral edema is seen on CT (D) and gradient-echo MRI (E), with only mild edema on FLAIR image (F) of parietooccipital region.

View larger version (140K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —How to discern posterior reversible encephalopathy syndrome (PRES) in setting of underlying leukodystrophy. 16-year-old girl with metachromatic leukodystrophy underwent MRI with FLAIR imaging (A) just before bone marrow transplantation. Ten days later, mild PRES was noted in frontal and parietooccipital cortical and subcortical white matter related to cyclosporine (arrows, B). Cyclosporine was discontinued, and resolution of PRES was seen on MRI 1 month later (not shown).

View larger version (126K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —How to discern posterior reversible encephalopathy syndrome (PRES) in setting of underlying leukodystrophy. 16-year-old girl with metachromatic leukodystrophy underwent MRI with FLAIR imaging (A) just before bone marrow transplantation. Ten days later, mild PRES was noted in frontal and parietooccipital cortical and subcortical white matter related to cyclosporine (arrows, B). Cyclosporine was discontinued, and resolution of PRES was seen on MRI 1 month later (not shown).

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