title: Asymmetric posterior reversible encephalopathy syndrome complicating hemodynamic augmentation for subarachnoid hemorrhage-associated cerebral vasospasm.
abstract: BACKGROUND
  Posterior reversible encephalopathy syndrome (PRES) is a rare complication of hemodynamic augmentation for subarachnoid hemorrhage (SAH)-associated vasospasm. The roles of hyperperfusion and hypoperfusion in the genesis of PRES remain uncertain.
  
  
  METHODS
  Case report.
  
  
  RESULTS
  We admitted a 35-year-old woman with Hunt & Hess grade II SAH secondary to rupture of a right middle cerebral artery (MCA) aneurysm. This was surgically clipped. Beginning on hospital day 3, she developed recurrent symptomatic vasospasm of the right MCA despite hemodynamic augmentation to a MAP as high as 130 mmHg and endovascular therapy. On hospital day 7, after 36 h of sustained MAP 120-130 mmHg, her level of arousal progressively declined, culminating in stupor and two generalized tonic-clonic seizures. MRI showed widespread, yet markedly asymmetric changes consistent with PRES largely sparing the right MCA territory. After the MAP was decreased to 85-100 mmHg, she had no further seizures. 2 days later she was fully alert with mild left hemiparesis.
  
  
  CONCLUSIONS
  PRES is a rare complication of hemodynamic augmentation that should be considered in the differential diagnosis of delayed neurological decline in patients with aneurysmal SAH-associated cerebral vasospasm. The markedly asymmetric distribution of PRES lesions with sparing of the territory affected by vasospasm supports the hypothesis that hyperperfusion underlies the pathophysiology of this disorder.
authors.affiliation: Department of Neurology, Lahey Clinic Medical Center, Tufts University School of Medicine, Burlington, MA, USA.
authors.forename: Barbara
authors.initials: B
authors.lastname: Voetsch
authors.forename: Nicholas
authors.initials: N
authors.lastname: Tarlov
authors.forename: Thanh N
authors.initials: TN
authors.lastname: Nguyen
authors.forename: Christina
authors.initials: C
authors.lastname: DeFusco
authors.forename: Glenn D
authors.initials: GD
authors.lastname: Barest
authors.forename: Alexander
authors.initials: A
authors.lastname: Norbash
authors.forename: Deborah M
authors.initials: DM
authors.lastname: Green
authors.forename: Joseph D
authors.initials: JD
authors.lastname: Burns
mesh_terms: D000328:Adult; D001794:Blood Pressure / Q000502:physiology; D002533:Cerebral Angiography; D038524:Diffusion Magnetic Resonance Imaging; D004292:Dominance, Cerebral / Q000502:physiology; D004830:Epilepsy, Tonic-Clonic / Q000150:complications / Q000503:physiopathology; D005260:Female; D006439:Hemodynamics / Q000502:physiology*; D006801:Humans; D007090:Image Interpretation, Computer-Assisted; D021621:Imaging, Three-Dimensional; D002532:Intracranial Aneurysm / Q000150:complications* / Q000503:physiopathology*; D008279:Magnetic Resonance Imaging; D020768:Middle Cerebral Artery / Q000503:physiopathology; D009460:Neurologic Examination; D010291:Paresis / Q000150:complications / Q000503:physiopathology; D054038:Posterior Leukoencephalopathy Syndrome / Q000150:complications* / Q000503:physiopathology*; D012008:Recurrence; D012039:Regional Blood Flow / Q000502:physiology; D013345:Subarachnoid Hemorrhage / Q000150:complications* / Q000503:physiopathology*; D014057:Tomography, X-Ray Computed; D020301:Vasospasm, Intracranial / Q000150:complications* / Q000503:physiopathology*