Case Presentation:

A 35–year–old man presented with new onset seizures. He reported progressively worsening bilateral occipital headache that suddenly resulted in a “white–out” of his vision. He lost consciousness, and was taken to an outside hospital where he had a seizure. His blood pressure was 240/125 mmHg, was started on a nicardipine drip and transferred to our facility. He denied palpitations or chest pain, dyspnea, illicit drug use, head trauma, or prior similar episodes. On admission he had a temperature of 100.1°F, a heart rate of 89 bt/min, and a blood pressure of 184/133 mmHg. He was lethargic and confused, but his neurologic exam revealed no focal deficits; his headache had resolved. Laboratory studies revealed an elevated creatinine consistent with his baseline, normal glucose, normal cardiac enzymes and moderate left ventricular hypertrophy on EKG. Head CT revealed no evidence of bleed. He was stabilized and admitted to the ICU on a nicardipine drip. His blood pressure reduced safely, his altered mental status resolved and he became symptom–free within a few hours. As his mental status improved, he noted that he had ran out of his medications two weeks earlier. The next day, a head MRI revealed diffuse hyper–intensities in the posterior occipital lobes on T2 and T2 FLAIR consistent with vasogenic edema from posterior reversible encephalopathy syndrome (PRES). An EEG showed nonspecific diffuse slowing.

Discussion:

Hypertensive urgencies are commonly encountered by the hospitalist. Typically, the management is focused on the lowering of the blood pressure, with re–institution of long–term anti–hypertensive therapy upon discharge. Hypertensive urgencies can present with symptoms referable to the end–organ damage of the hypertension, as was the case with our patient’s syncope and seizure presentation. Posterior reversible encephalopathy syndrome (PRES) is a clinical constellation of symptoms that consists of headache, visual changes, altered mental status and seizures. Headaches usually begin insidiously, and vision changes vary in severity. Changes in mental status range from mild somnolence to coma, but focal neurological deficits are usually absent. Seizures often occur multiple times, begin focally and can progress to generalized convulsions or status epilepticus. MRI is the neuroimaging gold standard and usually shows increased signal intensity on T2–weighted images, most commonly in the parieto–occipital regions.

Conclusions:

The prognosis for patients with PRES is usually excellent and most have reversal of symptoms within days to weeks if treatment is initiated promptly. Anti–epileptic agents should be tapered once seizures resolve, as the likelihood of seizure recurrence is minimal contingent upon good blood pressure control. Significant morbidity and mortality have been reported due to status epilepticus, intracranial hemorrhages and large cerebral infarctions; in these cases, early intervention can often prevent serious long–term neurologic sequelae.