International Journal of Clinical & Medical Images

Introduction: Reversible posterior Leukoencehalopathy syndrome (RPLS) or PRES (Posterior Reversible Encephalopathy Syndrome) is a clinical radiographic syndrome of heterogeneous etiologies. A 46 year old female with past medical history of chronic pain, chronic pancreatitis, hypertension, anxiety, fibromyalgia and migraines with multiple admissions in the last 3 months for acute migraine attacks presented with headache. It started 3 days ago with typical involvement of frontal region along with nausea and non-bloody emesis.

Headache was accompanied by diffuse abdominal pain 10/10 with no diarrhea or fever. She was unable to take her medications due to persistent vomiting episodes. She denied any focal weakness, tingling, numbness or vision problems. At presentation in emergency room, her systolic blood pressure was >200 and heart rate of 120. She was given intravenous hydralazine along with intravenous dialudid. She was about to be transferred to medical floor when she had blurry vision and later was unable to seen anything. Later she developed generalized tonic clonic seizures lasting less than 30 sec, responded well to intravenous valium. Her initial labs were normal in ER. An urgent MRI Brain showed interval development of non-enhancing bihemispheric and bilateral cerebellar hyper intense foci likely reflective of posterior reversible encephalopathy syndrome with no evidence of acute cerebral infarction or intracranial brain lesions (Figure 1a and 1b).

The patient was started on patient controlled analgesia for control of migraine headaches and abdominal pain was attributed to opioid withdrawal given her normal labs. She did very well with control of blood pressure and outpatient MRI few weeks later showed reversal of MRI changes. PRES syndrome is a well-known condition which is under diagnosed and can be easily missed in presence of other conditions like Migraine and is really easy to miss. Early recognition and removal of precipitating factors is key to treat and prevent neurological compromise