Bilateral Occipital Lobe Hemorrhages Presenting as Denial of Blindness in Posterior Reversible Encephalopathy Syndrome- A Rare Combination of Anton Syndrome and Encephalopathy

A neuropsychiatric case of delayed post-hypoxic leukoencephalopathy from opioid intoxication resulting in Anton-Babinski syndrome and quadriplegia

This is the case of a 26-year-old male who developed Anton Babinski syndrome (ABS), quadriplegia, and delayed post-hypoxic leukoencephalopathy (DPHL) after an opioid overdose. He exhibited cortical blindness, visual anosognosia, and confabulation upon awakening. Several days later, he experienced acute psychosis and agitation. T2-FSE MRI revealed extensive supratentorial leukoencephalopathy involving both cerebral hemispheres, extending to the posterior corpus callosum due to cerebral anoxia. This case report will discuss different types of encephalopathy from opioid abuse, ABS, visual anosognosia, and confabulation's pathogenic mechanisms. It underscores the necessity of researching substance-induced neuropsychiatric disorders and their pathogenic mechanisms for effective treatments.

Clinical characteristics and outcomes of patients admitted to hospitals for posterior reversible encephalopathy syndrome: a retrospective cohort study

Background

Posterior reversible encephalopathy syndrome (PRES) is usually a benign, yet underdiagnosed clinical condition associated with subacute to acute neurological manifestations primarily affecting white matter. PRES is reversible when recognized promptly and treated early by removal of the insulting factor; however, can lead to irreversible and life-threatening complications such as cerebral hemorrhage, cerebellar herniation, and refractory status epilepticus.

Methods

We utilized the National Inpatient Sample database provided by the Healthcare Cost and Utilization Project (HCUP-NIS) 2017 to investigate the demographic variables (age, sex, and race) for patients with PRES, concomitant comorbidities and conditions, inpatient complications, inpatient mortality, length of stay (LOS), and disposition.

Results

A total of 635 admissions for patients aged 18 years or older with PRES were identified. The mean age was 57.2 ± 0.6 years old with most encounters for female patients (71.7%, n = 455) and white as the most prevalent race. Half the patients in our study presented with seizures (50.1%, n = 318), sixty-three patients (9.9%) presented with vision loss, and sixty-four patients (10.1%) had speech difficulty. In addition, 45.5% of patients had hypertensive crisis (n = 289). 2.2% of hospitalizations had death as the outcome (n = 14). The mean LOS was 8.2 (±0.3) days, and the mean total charges were $92,503 (±$5758). Inpatient mortality differed between males and females (1.7% vs. 2.4%) and by race (3.6% in black vs. 1.8% in white) but was ultimately determined to be not statistically significant. Most patients who present with vision disturbance have a high risk of intracranial hemorrhage. Furthermore, end-stage renal disease, atrial fibrillation, and malignancy seemed to be linked with a very high risk of mortality.

Conclusion

PRES, formerly known as reversible posterior leukoencephalopathy, is a neurological disorder with variable presenting symptoms. Although it is generally a reversible condition, some patients suffer significant morbidity and even mortality. To the best of our knowledge, this is the largest retrospective cohort of PRES admissions that raises clinician awareness of clinical characteristics and outcomes of this syndrome.

Anton's syndrome: a rare and unusual form of blindness

Anton syndrome is characterised by visual anosognosia. It results from damage to both occipital lobes, while the anterior visual pathways remain intact. We describe four cases of Anton's syndrome. First case is that of a 73-year-old woman, who presented with two separate events of intraparenchymal brain haemorrhage, 4 years apart. Her first stroke affected the left and second affected the right occipital lobe. Bilateral occipital lobe damage resulted in cortical blindness. Second case is an 88-year-old man, who suffered from two ischaemic strokes, 2 days apart. Each stroke involved one posterior cerebral artery. This resulted in bilateral occipital and temporal lobe infarcts. Third case is a 64-year-old woman with chronic renal failure, who suffered bilateral occipital lobe infarction after haemodialysis, due to posterior reversible encephalopathy syndrome. Last case is that of an 80-year-old woman who suffered a basilar artery stroke, resulting in bilateral thalamic, temporal and occipital lobe infarction.