Summary: Purpose: Reversible posterior leukoencephalopathy syndrome (RPLS) is an increasingly recognized brain disorder most commonly associated with malignant hypertension, toxemia of pregnancy, or the use of immunosuppressive agents. When associated with acute hypertension, RPLS typically occurs concurrently with the fulminant clinical syndrome of hypertensive encephalopathy. We describe occipital lobe seizures, in the setting of only moderate elevations of blood pressure, as the major clinical manifestation of RPLS. Methods: Two patients from the Dent Neurologic Institute are presented with clinical and magnetic resonance imaging(MRI) correlation. Results: New onset secondarily generalized occipital seizures were noted, with MRI findings consistent with RPLS. Both of the patients had chronic renal failure and a moderate acute exacerbation of chronic hypertension. Other features of hypertensive encephalopathy were lacking, such as headache, nausea, papilledema, and an altered sensorium. Magnetic resonance imaging (MRI) showed edematous lesions primarily involving the posterior supratentorial white matter and corticomedullary junction, consistent with RPLS. With lowered blood pressure, the MRI lesions resolved and the patients became seizure‐free without requiring chronic anticonvulsant therapy. Conclusions: Occipital seizures may represent the only major neurologic manifestation of RPLS due to acute hypertension, especially in patients with renal failure. Other evidence of hypertensive encephalopathy, such as cerebral signs and symptoms, need not be present. Blood pressure elevations may be only moderate. Early recognition of this readily treatable cause of occipital seizures may obviate the need for extensive, invasive investigations. Despite the impressive lesions on MRI, prompt treatment of this disorder carries a favorable prognosis.
Nuclear magnetic resonance (NMR) imaging was superior to CT for imaging the brain lesions of 27 patients with MS. The incidence of abnormal examinations was 78% by NMR and 63% by CT. In cases in which both studies were abnormal, NMR usually demonstrated many more lesions and more extensive involvement than CT. The appearance and locations of lesions identified by NMR were similar to those of autopsy studies of MS and may be relatively specific for this disease. Some lesions identified by CT disappeared during serial examinations, but lesions identified by NMR did not resolve over time. Seventy-five percent of the lesions were clinically "silent"; only 5% were definitely related to the clinical symptoms and signs. All of those lesions were located in the brainstem or cerebellar peduncles and were identified by NMR, but missed by CT.
Acquired paroxysmal choreoathetosis may result from various structural and metabolic disorders.1We report on a diabetic patient in whom choreoathetosis was a manifestation of hypoglycemia.
REPORT OF A CASE
A 45-year-old woman with long-standing insulin-dependent diabetes mellitus appeared at the emergency room with a severe headache, nausea, and emesis. She was given an injection of 0.5 mL of hydromorphone hydrochloride and after 1½ hours she suddenly became stuporous. Fifteen minutes later she was more awake but very confused. She suddenly manifested vigorous choreoathetosis of all four extremities, opisthotonus, and facial grimacing. There was hypotonia of the extremities, but no evidence of weakness. Deep tendon reflexes were absent in the lower extremities. There was no diaphoresis, tremor, or tachycardia. The remainder of the neurologic examination results were normal. The patient had no history of drug ingestion, specifically haloperidol or phenothiazines, and there was no family history of neurologic disorder.
Abstract Ring formation with contrast infusion in computerized tomography has been described with various entities. The current report demonstrates its appearance in three postoperative patients from whom cerebral tumors had been removed. These examples of postoperative ring formation are compared with the ring formation in the scan of an unoperated patient with an intracerebral hematoma.
