Involvement of the cervical cord and medulla in posterior reversible encephalopathy syndrome

Abstract

The posterior reversible encephalopathy syndrome (PRES) is characterized by patchy cortical and subcortical lesions in the distribution of the posterior circulation. The lesions are classically reversible. This syndrome has multiple etiologies, most of which cause acute hypertension. We present a case of PRES with involvement of the medulla and cervical cord (apart from the typical parieto-occipital lesions)-an extremely rare imaging manifestation of PRES. It is important to recognize the imaging findings of PRES in spinal cord, and avoid misdiagnosis as myelitis by proper clinical correlation. Typically patients with myelitis have a profound neurodeficit, while patients with spinal manifestations of PRES are asymptomatic. Involvement of the cord in PRES has probably been an underrecognized entity as spinal imaging is not routinely performed in posterior reversible encephalopathy syndrome.

Neuroimaging features in posterior reversible encephalopathy syndrome: A pictorial review

“…16 On the other hand, Fugate et al demonstrated in a large clinical series (113 patients) that cerebellar involvement was significantly more frequent in patients with a history of autoimmunity compared with those without autoimmunity. 23 Nine cases of spinal cord involvement are reported in the literature [33][34][35][36][37][38][39] . All patients had confluent expansile central spinal cord T2 hyperintensity spanning at least 4 spinal segments, originating at the cervicomedullary junction.…”

PRES with asymptomatic spinal cord involvement. Is this scenario more common than we know?

“…1,8,13 There are a few cases in literature that report the involvement of the spinal cord in this syndrome. [14][15][16][17][18] The elevation of blood pressure was reported in the cases of spinal cord involvement in PRES. In the case described in this paper, the patient was exposed to many triggers for PRES: elevation of blood pressure, acute renal failure and chemotherapy.…”

“…In the case described in this paper, the patient was exposed to many triggers for PRES: elevation of blood pressure, acute renal failure and chemotherapy. [14][15][16][17][18] Another interesting topic is that PRES involves predominantly the white matter of the brain, and in the brain stem and spinal cord the lesions described affect the gray matter. Normally, patients with spinal cord lesion had alterations in neurological examination (sensitive and motor deficits).…”

“…There is only one case that describes a neurological signal (Babinski sign) in a patient with spinal cord involvement. [14][15][16][17] The prediction for posterior brain regions is not yet understood. Probably, the low sympathetic innervation in posterior circulation leads to the prediction for this topography.…”

Posterior reversible encephalopathy syndrome with spinal cord involvement (PRES-SCI): A case report

“…The syndrome commonly affects hypertensive patients, but may also occur in normotensive individuals in 20–30% cases. [ 1 2 ] PRES with spinal cord involvement (PRES-SCI) is an extremely rare entity which should be suspected when patients with PRES have neurologic signs clinicoradiologically located to spinal cord with severe hypertension or grade IV hypertensive retinopathy. [ 2 ] We describe PRES-SCI involving the cervical spinal cord in a known case of Henoch-Schönlein purpura (HSP) caused by hypertension and uremia.…”