Posterior reversible encephalopathy syndrome due to autonomic dysreflexia in medullary infarction

Abstract

The simultaneous occurrence of cervicocephalic arterial dissection and posterior reversible encephalopathy syndrome (PRES) is a rare entity. A healthy 33-year-old male with no known comorbidities had sudden onset pain in the neck, while he was doing strenuous physical labor. Over the next 2 days, he developed symptoms such as swaying to either side while walking, numbness on the left side of his body, painless progressive bilateral blurring of vision, and drooping of bilateral eyelids. On arrival at the emergency room, he was drowsy with a Glasgow Coma Score of 14 and complained of headache in addition to the preexisting symptoms. He also reported that his entire visual field was clouded and dark. On examination, he was detected to have a blood pressure of 220/120 mmHg with bilateral mild ptosis and nonreactive pupils. He had cortical blindness at the time of admission. He had significant gait and truncal ataxia but no other cerebellar signs. Motor system examination was unremarkable and plantars were flexor. No objective sensory deficit was demonstrable. Magnetic resonance imaging showed acute infarct in the vermis with vertebral artery dissection at V4 extending to the basilar artery. In addition, there were diffuse T2-hyperintensities in the bilateral occipital areas without restricted diffusion suggestive of posterior reversible encephalopathy syndrome [Figure 1]. He was admitted to the intensive care unit; the high blood pressure was treated aggressively with labetalol and hydralazine. Gradually, his vision improved over 48 h and back to normal acuity by 5 days. His magnetic resonance angiography with the neck vessels showed a dissection of the vertebral artery. His symptoms of medullary infarct persisted for a few weeks and then resolved completely. Young brainstem stroke with neck pain points to vertebral artery dissection. Concurrent worsening with autonomic fluctuation can be due to associated PRES and is to be considered as this situation is eminently treatable with good control of blood pressure at the earliest.