DesCripTionA 38-year-old man with hypertension presented with sudden-onset headache and vomiting. He was irritable and had a blood pressure of 180/120 mm Hg. There were no meningeal signs or focal neurological deficits. His optic fundi were normal. Initial evaluation with CT of the brain showed subarachnoid haemorrhage (SAH) in the right parasagittal sulcal region ( figure 1A) and the left perimesencephalic cistern (figure 1B). A CT angiogram (CTA) followed by a digital subtraction angiogram (DSA) ruled out aneurysms ( figure 1C-F). The venous phase of DSA ( figure 1G) and magnetic resonance (MR) venogram (figure 1H,I) were normal. MRI of the brain (figure 2) showed hyperintense lesions in the bilateral parieto-occipital regions and the basal ganglia suggesting posterior reversible encephalopathy syndrome (PRES). He was managed with antihypertensives and made a gradual and complete recovery.Our patient presented with non-traumatic SAH on an emergent head CT scan. It showed simultaneous presence of blood in two interesting locations. The first is the perimesencephalic region, where the majority of cases are negative for aneurysms and is considered due to venous rupture.
Bilateral independent periodic lateralised epileptiform discharges (BIPLEDs) in electroencephalograms (EEGs) are commonly caused by anoxic encephalopathy and central nervous system infections. They are associated with coma and high mortality and are thus markers of poor prognosis. We present a case of encephalitis who presented with BIPLEDs in EEG. Though the clinical, EEG and MRI features closely resembled herpes simplex encephalitis, further investigations proved it to be Epstein-Barr virus (EBV) encephalitis. Despite the presence of BIPLEDs in the EEG, the patient had a rapid clinical response to therapy with acyclovir. We emphasise that BIPLEDs may not always indicate poor prognosis especially in the setting of EBV encephalitis.
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