A case of hypertensive encephalopathy with extensive spinal lesions on MRI

First case of neurofibromatosis with posterior reversible encephalopathy syndrome showing spinal cord involvement

Posterior reversible encephalopathy syndrome (PRES) is a well-documented pathology of the brain in systemic upsets. Majority of PRES cases present with edema in the cerebrum, most commonly in the territory of posterior circulation. It has been reported to show spinal cord involvement in a rare subgroup known as PRES with spinal cord involvement (PRES-SCI), with very limited existing literature even in adult patients. Our institution recently encountered a pediatric case with neurofibromatosis type I (NF 1) showing PRES with extensive reversible spinal cord changes. This case illustrates the features of this rare entity in the pediatric group of patients, and is the first reported case in NF 1 patients.

Posterior Reversible Encephalopathy Syndrome With Spinal Cord Involvement in Children

We characterized a cohort of patients with posterior reversible encephalopathy syndrome with spinal cord involvement. We encountered 2 children and identified an additional 19 patients from the internet databases. Of the 21 patients analyzed, 8 were children. The mean peak systolic blood pressure in adults was significantly higher than in children (221.8 ± 14.3 vs 191.4 ± 31.3 mm Hg; P < .01). Regardless of age, the most common clinical symptom was headache (90%) and the least common clinical symptom was seizures (28%). Atypical neuroimaging was more common in children (63%) than in adults (8%). Abnormal cerebrospinal fluid results were frequently found in children (83%). All children recovered uneventfully, but 3 adults had sequelae. A broader clinicoradiologic spectrum makes the diagnosis of children more complex than in adults. Awareness of the atypical features with a meticulous management of hypertension is imperative to avoid unnecessary invasive workups and to achieve an uneventful recovery.

Posterior reversible leukoencephalopathy syndrome with spinal cord involvement in a 9-year-old girl

We report the youngest pediatric case of posterior reversible leukoencephalopathy syndrome confined to brainstem and spinal cord. At presentation bicytopenia, renal derangement, visual disturbances, magnetic resonance imaging findings, increased protein content, IgG index and cell count in the cerebrospinal fluid led us to extensive search for myelitis. She received a short course of steroid treatment. The final diagnosis was hypertension due to reflux nephropathy. Severe hypertension that exceeds the range of autoregulation in anterior spinal territory may result in spinal posterior reversible leukoencephalopathy syndrome. Clinicians should be aware of spinal posterior reversible leukoencephalopathy syndrome when cases have extensive lesions in the brainstem and spinal cord with none or minimal clinical findings, so called "clinical radiologic dissociation".

Infectious and metabolic brain imaging

Central nervous system infectious and metabolic disease is a vast domain. We have chosen to focus particularly on five pathological conditions: brain abscess, herpes encephalitis, Creutzfeldt-Jacob disease, posterior reversible encephalopathy and central pontine myelinolysis. We will pay particular attention to MRI signs and the specific sequences to use in each condition, in addition to the conventional sequences, in order to avoid diagnostic traps. Once the MRI exploration is complete, the diagnosis still cannot be established without knowing the clinical and metabolic context.

Reversible brainstem edema due to hypertensive encephalopathy in an 8-year-old girl

The authors report an 8-year-old girl with refractory status epilepticus due to hypertensive encephalopathy, secondary to end-stage renal disease. Brain magnetic resonance imaging (MRI) in the acute phase showed striking hyperintensities in the brain stem and medial thalamus along with subtle cortical lesions. After successful control of hypertensive crisis and status epilepticus, the patient recovered to her baseline. Near total resolution of the lesions was noted on follow-up imaging performed 9 days later. Predominant brainstem involvement as a feature of posterior reversible encephalopathy syndrome due to hypertensive crisis is extremely rare in children and has not been well documented.

[Demyelinating disorders]

Leukoencephalopathies in adults are frequent and exhibit highly variable aetiology, including multiple acquired causes such as inflammatory, vascular or toxic diseases and neoplasias. In contrast leukodystrophies are genetically determined, chronic progressive myelin disorders with a variable pathogenetic background and a great diversity of clinical and paraclinical findings. Some diseases, namely those with an additional inborn error of metabolism, are treatable. Genetic counselling appears to be of major importance for patients and their families. In the light of numerous acquired adulthood leukoencephalopathies a clear delineation of late-onset genetic leukodystrophies is necessary. Clinical symptoms and MRI patterns of some of the major leukodystrophies are reported, including possibilities of biochemical and genetic testing.