Background: Posterior Reversible Encephalopathy Syndrome (PRES) is a clinical-radiological phenomenon that occurs due to a disruption in the autoregulation of the cerebral blood flow resulting in vasogenic edema. It is seen most often in settings of acute hypertension and is often associated with eclampsia. Symptoms that PRES patients commonly present with include seizures, visual disturbances, headache, and altered mental status. Case: We present a patient and review select cases cited in the literature that cocaine, a common drug of abuse, can precipitate hypertension with PRES. Our patient initially presented with severe headache, acute renal failure, hypertension, profound somnolence, and a widespread vasogenic edema after relapsing and using cocaine. Within 24 hours and with control of her blood pressure, her symptoms resolved and she was alert, cognitively intact and free from any identifiable residual effects. Conclusion: We suggest that this rapid sequence of clinical and neuroimaging abnormalities following cocaine ingestion may not be a rare phenomenon. As has been previously described, the magnitude of PRES related vasogenic edema is not well correlated with either symptom severity or ultimate clinical outcome.

Injury to the vascular system in the cervical mediastinal area can cause delayed neurologic symptoms. In this article, the authors describe a patient in whom pseudoaneurysm formation after a gunshot wound eventually led to weakness in the shoulder and arm.

We present a case of a 62-year-old Caucasian male with laryngeal cancer and Ramsay Hunt Syndrome otherwise known as herpes zoster oticus due to reactivation of the varicella zoster virus. Classic findings include the triad of ipsilateral facial paralysis, otic pain, and herpetic lesions in the sensory supply of the facial nerve. e common pathogenesis is associated with anterograde axonal reactivation of the varicella zoster virus in the geniculate ganglion. Unique features of our case include retrograde transaxonal spread of the varicella-zoster virus from the geniculate ganglion into the brainstem and cerebellum including involvement of the abducens nucleus, facial nucleus, middle cerebral peduncle, and inferior cerebellar peduncle. is presented as left facial paralysis, left sixth nerve palsy, horizontal diplopia to the left lateral gaze, profound truncal ataxia, and left-sided dysmetria. Clinical awareness that Ramsay Hunt syndrome may also involve the brainstem and cerebellum is critical in evaluating the clinical neurologic findings and expanding the diagnostic workup to include brain magnetic resonance imaging and cerebrospinal fluid analysis, including varicella zoster polymerase chain reaction. Encephalitis requires longer duration administration of high-dose intravenous acyclovir in conjunction with steroids. Delays in treatment are often associated with unsatisfactory outcomes with extensive residual deficits.

The artery of Percheron (AOP) is a relatively rare anatomic variant in which a solitary arterial trunk branches from the proximal segment of the posterior cerebral artery and provides arterial supply to the paramedian region of the thalami bilaterally and often to the rostral part of the midbrain. Occlusion of the artery of Percheron results in bilateral paramedian thalamic infarcts with and without midbrain involvement. Recognition of this condition as an acute stroke may be challenging due to various nonlocalized clinical presentations, given the wide range of neurological functions subserved by the thalamus. Prompt neuroimaging, preferably with magnetic resonance imaging (MRI), in conjunction with familiarity with this relatively rare vascular variation can facilitate initiation of appropriate time contingent thrombolytic treatment and improved long-term prognosis. We present a case of a 56-year-old African American female with a bilateral thalamic infarct secondary to the artery of Percheron thromboembolism. This patient presented unresponsive without focal neurologic findings but with an initial Glasgow Coma Score (GCS) of 7, and subsequent computed tomographic (CT) head revealed bilateral thalamic hypodensities. Confirmatory MRI exhibited bilateral subacute thalamic infarcts, which were thought to be embolic with the source from the left ventricular thrombus as the patient had at least three distinct clots. Unfortunately, the patient’s mental status did not improve significantly, and she was discharged to a nursing facility for extended care. AOP infarction may be missed on vascular imaging utilizing CT, MRI, and even catheter angiography. Clinical recognition that the AOP is one of the only single artery occlusions that can affect bilateral structures and frequently present solely as altered mental status without focal neurologic deficits is crucial to the diagnosis.

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