1 case of atypical reversible rear encephalopathy syndrome

Patients, male, 33 years old, acute illness, short course, the previous history of hypertension, the highest blood pressure 180/120 mmHg, usually not oral antihypertensive drugs, mainly manifested as dizziness, dizziness, ignoring the rotation of objects, no tinnitus and hearing loss, and head and position changes, symptoms persist: No nervous system-positive signs, dynamic blood pressure monitoring blood pressure fluctuations in 140 to 178/90 to 120 mmHgBiochemical examination: high blood lipids (triglycerides 2.15 mmol/L), high blood homocysteine (34 smol/L), slightly high uric acid (489 smol/L)Imaging performance: skull CT: left frontal leaf patch-shaped low density shadow, CT value is about 15 HU, slightly blurred edge (Figure 1A, 1B)Figure1A to B: Head CT;skull MRI: left frontal plaque flake long T1, long T2 signal shadow, FLAIR high signal, diffusion weighted imaging (imaging, DWI) such signal, apparent diffusion coefficient (apparent diffusion, ADC) chart is high signal, magnetically weighted imaging is a high signal3D arterial spin marker (3D-arterial spin labeling, 3D-ASL): The left frontal lobe visible in a similar shape to a high perfusion area, with a significantly higher brain blood flow value than the right sideMagnetic resonance spectrum (magnetic resonance spectroscopy, MRS): The left frontal lobe lesions area N-acetyltinateic acid (NAA) peak slightly reduced, choline (Choline, Cho) and other peaks did not see a clear abnormality, enhanced scanning lesions with visible strip mild reinforcement, intracranial arteries did not see clear abnormalities (Figure 1C-1L)Diagnosis: Left frontal glioma may beFigure 1C-L: head MRI;were admitted to hospital for treatment, giving patients nutritional nerves, benette leveling depresso, oral simvatadin delipidation; Patients 10 d after discharge, discharge diagnosis: intracranial occupancy may, hypertension 3 (very high risk), hyperlipidemia, high homocysteine; March 20, 2018 in our hospital review: dizziness, head smouldering symptoms significantly improved, blood pressure 140/90 mmgHead MRI: The cranial brain did not see clear lesions, the left frontal lobe disease completely disappeared (Figure 1M to 1R)Atypical reversible later encephalopathy syndrome was diagnosed according to the patient's clinical performance, imaging performance and review resultsFigure 1 M-R: Patients review MRIDiscussedWith the development of medical imaging technology, the concept of reversible posterior reversible encephalo syndrome (PRES) has been gradually redefined, currently mainly refers to the short course of the disease, symptoms to headache, seizures, confusion, vision loss, etc , imaging examination lesions are located in the end of the brain, the disease reversible clinical imaging syndrome PRES is more frequently followed by a sharp increase in blood pressure, such as hypertension in brain disease patients and pregnant women with pre-eclampsia or eclampsia, PRES can also be a complication of the application of anti-rejection drugs (e.g cyclosporine A), such as organ transplant patients, PRES can also be followed by uremia, hemolytic urethra syndrome, thrombosis platelet reduced cyanosis and chemotherapy after certain drug applications PreS-type preS can be found in acute sepsis The pathological mechanism of PRES is not fully clear At present, there are two main types of speculation, one is vascular spasms theory, that is, various reasons lead to small blood vessel spasms in the brain, blood flow reduction causes cerebral tissue ischemia; presimaging performance: typical PRES lesions are mainly located in the post-circulating blood supply area, polysacchious and the top pillow leaf symmetry of the lower cortical white matter, imaging performance is mostly symmetric CT shows a low density of lesions MRI: long T1, long T2 signal change, FLAIR sequence lesions are high signal DWI sequence lesions are more like-signaled, ADC diagram shows that the lesions are more than equal lysometric signals, which are characterized by typical signal changes of vascular-derived edema Some cases show dWI high signal, ADC graph signal slightly reduced, this situation suggests that the lesions local transformation into cytotoxic edema, and even progress to cerebral infarction, its prognosis is poor Contrast agent enhanced scanning most lesions are not strengthened, a small number of lesions can have a slight reinforcement of the spot-like, which may be related to the examination time Atypical PRES can also be tired of the base section, frontal lobe, but mostly due to symmetry, asymmetry is rare the routine differential diagnosis of PRES has the upper symon embolism, venous cerebral infarction, etc , magnetic resonance venous imaging (magnetic venogram, MRV) for its identification of the two has important value, the upper sinus thrombosis occurs, MRV can clearly show the embolism site and scope, and PRES easier identification However, when the limitations of PRES are limited to some parts of the skull, it is not easy to identify with intracranial prepositional lesions (such as low-level gliomas) in the skull, at which time it is necessary to synthesize the results of a variety of magnetic resonance sequence series and combine the patient's review to identify the two some brain function sequences can provide some help for the identification diagnosis of the two, such as 3D-ASL, MRS, PRES 3D-ASL performance shows high perfusion area that does not match the lesions, MRS is not significantly changed, and the high perfusion form of low-level glioma is more consistent with the lesions, MRS more prompt NAA peak decline and Cho peak increase The lesions of this case are limited to the left frontal lobe, not the typical pathogenesis of PRES, and the manifestation of vascular-derived edema, enhanced scanning lesions with spot-like mild reinforcement, 3D-ASL lesions have significant high perfusion areas, so the initial diagnosis misdiagnosed as glioma (low-level), but when the patient re-examined, the lesions completely disappeared review this case, the patient has a clear history of hypertension (maximum hypertension 180/120 mmHg), and the course is short, after the blood pressure is effectively controlled, the patient's symptoms improved; With the lesion sin form does not match, high perfusion area is only limited to the lesions and morphological rules, DWI lesions are such a signal, ADC map is high signal, MRS shows NAA peak did not see a clear reduction, Cho peak did not clearly increase, indicating that neurons were not destroyed; these performances are more similar to those reported by academics such as McKinney And the case of mild speckled reinforcement, there is a clear high perfusion area, indicating that local brain tissue over-perfusion, blood-brain barrier function is mildly impaired, all support preS 2 pathogenesis, but the lesions and the specific cause of the left frontal lobe is unknown, may be relatively lack of sympathetic nerve control of the patient's left frontal lobe, so that it can not effectively avoid the rise of intravascular pressure, abnormal blood pressure when the abnormal lyonofirma Because the lesions are limited to the left frontal lobe of the reversible encephalopathy syndrome is rare, when the lesions are vascular-derived edema, the blood-brain barrier function is mildly impaired, and local high perfusion, it is not easy to identify with some intracranial occupancy (low-level glioma), the usual clinical work needs more attention