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Postictal cortical visual impairment: A symptom of posterior reversible encephalopathy
Epilepsy & Behavior 17 (2010) 276–277
Contents lists available at ScienceDirect
Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Case Report
Postictal cortical visual impairment: A symptom of posterior reversible encephalopathy Andreas P. Lysandropoulos *, Andrea O. Rossetti Service de Neurologie, Centre Hospitalier Universitaire Vaudois and Université de Lausanne, Lausanne, Switzerland
a r t i c l e
i n f o
Article history: Received 5 November 2009 Revised 1 December 2009 Accepted 13 December 2009 Available online 12 January 2010
a b s t r a c t We describe a patient presenting with a first generalized convulsion after alcohol consumption, in whom the early postictal finding of a rapidly regressive cortical visual impairment suggested the presence of a posterior reversible encephalopathy. This was confirmed radiologically, and probably represented the key factor in the seizure etiology. Ó 2009 Elsevier Inc. All rights reserved.
Keywords: Seizure Posterior reversible encephalopathy syndrome
A 74-year-old woman with arterial hypertension, and under cyclosporine treatment after a kidney-transplantation 3 months before, was admitted to the emergency room after her first generalized tonic–clonic seizure. Etiology was first attributed to unusual alcohol consumption the day before, combined with a moderate serum hyponatremia (131 mmol/L) and her chronic renal impairment (creatinine 183 lmol/L). However, on neurological examination 3 hours after the event, a disturbance of the visual recognition of several objects and faces represented the only abnormality: the patient reported that the examiner was wearing eyeglasses and had a beard, but both were not true; furthermore, there was some impairment in the detailed description of complex images. These findings disappeared after a few hours. Her posterior cortical dysfunction, together with the systolic arterial blood pressure of 195 mm Hg on admission and the cyclosporine treatment, led us to postulate a posterior reversible encephalopathy syndrome (PRES) as the origin of the entire clinical constellation, including the seizure [1]. Indeed, brain MRI performed after 48 hours showed a vasogenic edema of parietal, occipital, and cerebellar regions (Fig. 1). The clinical evolution was spontaneously favorable after control of blood pressure. Six
* Corresponding author. Address: Service de Neurologie, CHUV-BH07, CH-1011 Lausanne, Switzerland. Fax: +41 21 314 1290. E-mail address: [email protected] (A.P. Lysandropoulos). 1525-5050/$ - see front matter Ó 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.yebeh.2009.12.006
weeks later, follow-up MRI showed complete resolution of the lesions (Fig. 1), thus confirming the clinical diagnosis. The rapid clinical resolution might suggest that the major etiological component of the transitory posterior cortical dysfunction was related to the seizure, as most postictal phenomena are very short-lived [2], and MRI performed after clinical normalization still showed a vasogenic edema. This case illustrates that even in the presence of seemingly clear-cut seizure-provoking factors (such as previous alcohol intake and hyponatremia), the finding of a definite focal brain impairment should always prompt a thorough search for an occult underlying etiology. References [1] Cosottini M, Lazzarotti G, Ceravolo R, Michelassi MC, Canapicchi R, Murri L. Cyclosporine-related posterior reversible encephalopathy syndrome (PRES) in non-transplant patient: a case report and literature review. Eur J Neurol 2003;10:461–2. [2] Gallmetzer P, Leutmezer F, Serles W, Assem-Hilger E, Spatt J, Baumgartner C. Postictal paresis in focal epilepsies: incidence, duration, and causes. Neurology 2004;62:2160–4.
A.P. Lysandropoulos, A.O. Rossetti / Epilepsy & Behavior 17 (2010) 276–277
277
Fig. 1. (a–c) T2-weighted MRI scan demonstrating hyperintense lesions in the cerebellar, parietal, and occipital lobes (arrows). (d) Diffusion-weighted MRI (ADC) scan demonstrating a vasogenic edema with increased diffusion (arrows). (e–g) T2-weighted MRI and (h) diffusion-weighted MRI (ADC) scans at follow-up showing resolution of the lesions.
Contents lists available at ScienceDirect
Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Case Report
Postictal cortical visual impairment: A symptom of posterior reversible encephalopathy Andreas P. Lysandropoulos *, Andrea O. Rossetti Service de Neurologie, Centre Hospitalier Universitaire Vaudois and Université de Lausanne, Lausanne, Switzerland
a r t i c l e
i n f o
Article history: Received 5 November 2009 Revised 1 December 2009 Accepted 13 December 2009 Available online 12 January 2010
a b s t r a c t We describe a patient presenting with a first generalized convulsion after alcohol consumption, in whom the early postictal finding of a rapidly regressive cortical visual impairment suggested the presence of a posterior reversible encephalopathy. This was confirmed radiologically, and probably represented the key factor in the seizure etiology. Ó 2009 Elsevier Inc. All rights reserved.
Keywords: Seizure Posterior reversible encephalopathy syndrome
A 74-year-old woman with arterial hypertension, and under cyclosporine treatment after a kidney-transplantation 3 months before, was admitted to the emergency room after her first generalized tonic–clonic seizure. Etiology was first attributed to unusual alcohol consumption the day before, combined with a moderate serum hyponatremia (131 mmol/L) and her chronic renal impairment (creatinine 183 lmol/L). However, on neurological examination 3 hours after the event, a disturbance of the visual recognition of several objects and faces represented the only abnormality: the patient reported that the examiner was wearing eyeglasses and had a beard, but both were not true; furthermore, there was some impairment in the detailed description of complex images. These findings disappeared after a few hours. Her posterior cortical dysfunction, together with the systolic arterial blood pressure of 195 mm Hg on admission and the cyclosporine treatment, led us to postulate a posterior reversible encephalopathy syndrome (PRES) as the origin of the entire clinical constellation, including the seizure [1]. Indeed, brain MRI performed after 48 hours showed a vasogenic edema of parietal, occipital, and cerebellar regions (Fig. 1). The clinical evolution was spontaneously favorable after control of blood pressure. Six
* Corresponding author. Address: Service de Neurologie, CHUV-BH07, CH-1011 Lausanne, Switzerland. Fax: +41 21 314 1290. E-mail address: [email protected] (A.P. Lysandropoulos). 1525-5050/$ - see front matter Ó 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.yebeh.2009.12.006
weeks later, follow-up MRI showed complete resolution of the lesions (Fig. 1), thus confirming the clinical diagnosis. The rapid clinical resolution might suggest that the major etiological component of the transitory posterior cortical dysfunction was related to the seizure, as most postictal phenomena are very short-lived [2], and MRI performed after clinical normalization still showed a vasogenic edema. This case illustrates that even in the presence of seemingly clear-cut seizure-provoking factors (such as previous alcohol intake and hyponatremia), the finding of a definite focal brain impairment should always prompt a thorough search for an occult underlying etiology. References [1] Cosottini M, Lazzarotti G, Ceravolo R, Michelassi MC, Canapicchi R, Murri L. Cyclosporine-related posterior reversible encephalopathy syndrome (PRES) in non-transplant patient: a case report and literature review. Eur J Neurol 2003;10:461–2. [2] Gallmetzer P, Leutmezer F, Serles W, Assem-Hilger E, Spatt J, Baumgartner C. Postictal paresis in focal epilepsies: incidence, duration, and causes. Neurology 2004;62:2160–4.
A.P. Lysandropoulos, A.O. Rossetti / Epilepsy & Behavior 17 (2010) 276–277
277
Fig. 1. (a–c) T2-weighted MRI scan demonstrating hyperintense lesions in the cerebellar, parietal, and occipital lobes (arrows). (d) Diffusion-weighted MRI (ADC) scan demonstrating a vasogenic edema with increased diffusion (arrows). (e–g) T2-weighted MRI and (h) diffusion-weighted MRI (ADC) scans at follow-up showing resolution of the lesions.