Teaching Neuroimages: Central Variant Of Posterior Reversible Encephalopathy Syndrome

A 55-year-old man with chronic hypertension presented with acute headache and dizziness. Physical examination showed severe hypertension (210/140 mm Hg) without any neurologic sign. Brain MRI showed diffuse brain edema over the brainstem, bilateral thalami, and cerebellar hemispheres with multiple microbleeds at bilateral basal ganglia (figure 1). His symptoms improved dramatically after antihypertensive therapy. Brain MRI 1 month later showed resolution of the edema (figure 2). Central variant of posterior reversible encephalopathy syndrome predominantly involving the brainstem and basal ganglia and relatively sparing the parieto-occipital lobe is rare.(1) Paucity of brainstem signs and symptoms despite extensive neuroimaging abnormalities supports the diagnosis.