1. 55 year-old man with acute headache and dizziness Teaching NeuroImages Neurology Resident and Fellow Section
David Yen-Ting Chen, MD
Ying-Chi Tseng, MD
Hui-Ling Hsu, MD
Yen-Lin Huang, MD
Chi-Jen Chen, MD
Department of Medical Imaging, Taipei Medical University, Shuang-Ho Hospital, New Taipei City, Taiwan

2. Vignette
A 55 year-old gentleman presented with acute onset of headache and dizziness.
History of chronic hypertension.
Physical examination showed severe hypertension (blood pressure: 210/140mmHg).
No definite neurological sign was observed.
Chen et al.

3. Imaging Brain MRI one day after symptom onset Chen et al.
Figure 1. Brain MRI one day after symptom onset.
T2 weighted images showed diffuse hyperintensities over the brainstem, bilateral thalami, and bilateral cerebellar hemispheres.
Susceptibility weighted images showed multiple microbleeds at bilateral basal ganglia (arrows), suggestive of chronic hypertensive status.
Chen et al.

4. Imaging Brain MRI one month later. Chen et al.
Figure 2. Brain MRI one month later.
Brain MRI showed resolution of brain edema in the brainstem, cerebellum and thalami.
Chen et al.

5. “Central variant” of Posterior Reversible Encephalopathy Syndrome
Central PRES predominantly involving the brainstem and basal ganglion and relatively sparing the parieto-occipital lobe is rare.
Paucity of brainstem signs and symptoms despite extensive neuroimaging abnormalities in a case with severe hypertension support the diagnosis.
Reference
1. McKinney A, Short J, Truwit C, et al. Posterior reversible encephalopathy syndrome: Incidence of atypical region of involvement and imaging findings. American Journal of Radiology 2007;189:904–912
2. Cruz-Flores S, Gondim F, Leira C. Brainstem involvement in hypertensive encephalopathy: Clinical and radiological findings. Neurology 2004;62:1417–1419.
Chen et al.