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Abstract Details

Atypical Posterior Reversible Encephalopathy Syndrome with Obstructive Hydrocephalus and Impending Tonsillar Herniation.
Cerebrovascular Disease and Interventional Neurology
P6 - Poster Session 6 (5:30 PM-6:30 PM)
CASE DESCRIPTION: A 33-year-old male with uncontrolled hypertension and CKD Stage IV presented to hospital with occipital headache and vomiting.  His BP was 230/160. He was treated with Nicardipine infusion. CT head showed cerebellar vasogenic edema and mild tonsillar herniation with partial effacement of the fourth ventricle. MRI confirmed these findings, there was disproportionate dilatation of the lateral and third ventricles with periventricular T2 hyperintense signal consistent with transependymal CSF flow. The headache and neck pain were persistent. The patient was upgraded to Neurocritical Care Unit for monitoring and continued IV BP treatment. Given concerns for incipient tonsillar herniation, Mannitol and Hemodialysis [HD] were added to his medical treatment. After these interventions, his headache and blood pressure management improved. Two days later, CT showed significant interval improvement of hydrocephalus, cerebral edema and posterior fossa crowding.  
OBJECTIVE AND IMPORTANCE: Rhombencephalic edema with hydrocephalus has rarely been described as a manifestation of hypertensive emergency. We present an unusual case of brain edema with hydrocephalus secondary to hypertensive emergency. 
DISCUSSION: This was an unusual case of extension of PRES to the posterior fossa, leading to hydrocephalus and a vicious cycle of worsening rise in intracranial pressure, leading to worsening refractory systemic hypertension, end organ damage, need for hemodialysis, impending tonsillar herniation and risk of death.   
CONCLUSION: This presentation and improvement were compatible with the final diagnosis of an atypical presentation of Posterior Reversible Encephalopathy Syndrome. In this case, reduction of blood pressure, hyperosmolar therapy and dialysis resulted in improvement of the symptoms as well as radiological resolution of hydrocephalus. Aggressive medical treatment was the best approach in this case, but neurosurgical intervention would have been necessary if the patient had not responded to these measures. 
Juan Solano, MD (Einstein Medical Center)
Dr. Solano has nothing to disclose.
Saman Zafar, MD (Einstein Medical Center Philadelphia) Dr. Zafar has nothing to disclose.
George C. Newman, MD, PhD (Einstein Medical Center) Dr. Newman has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for Clyde Bergstresser, LLC. Dr. Newman has received personal compensation in the range of $500-$4,999 for serving as an Expert Witness for Maria Rubio LLC. The institution of Dr. Newman has received research support from Albert Einstein Society.