Abstract
A woman with prior lung transplantation presented with headaches, seizure, and obtundation. Head MRI (figure) revealed obstructive hydrocephalus and hyperintensity on T2-weighted imaging in the bilateral thalami and brainstem. Management included antiepileptic medications, ventriculostomy placement, and cessation of tacrolimus for concern of atypical posterior reversible encephalopathy syndrome (PRES). Infectious and paraneoplastic etiologies were ruled out. An autoimmune process was unlikely due to immunosuppression. There was rapid clinical improvement with repeat MRI revealing resolution of hydrocephalus and T2 changes. Hydrocephalus is a rare but devastating complication, which should be considered in posterior fossa dominant PRES.1,2 Early recognition is critical to ensuring recovery.
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