写在前面：
瑞英第一期给大家介绍了RESLES ， 大白老师提到了“三大可逆”RESLES、RCVS、PRES ， 存在“个性”和“共性”辩证统一 。 本期以Neuroimages的形式为大家展示PRES的少见并发症 。
Teaching NeuroImages: Convexal subarachnoid hemorrhage caused by posterior reversible encephalopathy syndrome.
A 57-year-old woman was admitted to our hospital for oppression in chest and headache for 7 days. The patient self-reported that her blood pressure fluctuated during this period. On admission, her blood pressure was 190/105 mmHg without any motor or sensory deficit and no neck stiffness. No significant personal or family history was present. The brain computerized topography (CT) showed convexal subarachnoid hemorrhage (cSAH) in the right temporal lobe (Fig. 1). Routine laboratory tests, including evaluations for inflammation, coagulation parameters, neoplastic markers, EKG, EEG and chest CT results were all unremarkable. Brain magnetic resonance image (MRI) revealed “vasogenic” edema typical of posterior reversible encephalopathy syndrome (PRES) with diffuse brain edema over the bilateral cerebellar hemispheres (Fig. 2A-C). Her symptoms were relieved after antihypertensive therapy. Follow-up MRI conducted 1 month later showed resolution of the edema (Fig. 2D).
PRES is a clinical entity with a wide spectrum of symptoms ranging from headache, mental status change, or seizure. Criteria for confirmation of PRES included complete or partial expression of the typical PRES pattern, reversibility on follow-up imaging, and a presentation consistent with a clinical syndrome. Common aetiologies of PRES include hypertensive encephalopathy, eclampsia, and also solid organ transplantation typically associated with calcineurin inhibitors used for immunosuppression. The usual MR pattern of PRES reveals widespread vasogenic subcortical oedema, predominantly in the parietal and occipital lobes. Atypical manifestations include the location of lesions in the cerebellum, basal ganglia and brainstem.1Intracranial haemorrhage (ICH) has been reported to occur in PRES with a variable incidence with an incidence ranging from 9 to 33%. As for the types of intracranial hemorrhage, SAH is relatively less common than intraparenchymal hemorrhage.2
cSAH accounts for about 5% to 7.5% of spontaneous SAH, the main clinical manifestations are headache or focal neurological deficits. The etiology of cSAH are diverse and often secondary to cerebral amyloid angiopathy (CAA) and reversible cerebral vascular contraction syndrome
syndrome (RCVS).3, 4
cSAH is a rare complication of PRES. In the present case and neuroimage, we described a rare case of PRES-related cSAH. This case provides us with information regarding the diagnosis, treatment, and prognosis of this kind of patients.
References
1.Bartynski WS. Posterior reversible encephalopathy syndrome, part 1: fundamental imaging and clinical features. AJNR Am J Neuroradiol 2008;29:1036-1042.
【edema|瑞英青年疑难病例分析第二季 | 第五集】2.Hefzy HM, Bartynski WS, Boardman JF, Lacomis D. Hemorrhage in posterior reversible encephalopathy syndrome: imaging and clinical features. AJNR Am J Neuroradiol 2009;30:1371-1379.

稿源：(上海瑞金医院神经内科)

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标题：edema|瑞英青年疑难病例分析第二季 | 第五集