Perimesencephalic and sulcal subarachnoid haemorrhage: an interesting presentation of posterior reversible encephalopathy syndrome

A 38-year-old man with hypertension presented with sudden-onset headache and vomiting. He was irritable and had a blood pressure of 180/120 mm Hg. There were no meningeal signs or focal neurological deficits. His optic fundi were normal. Initial evaluation with CT of the brain showed subarachnoid haemorrhage (SAH) in the right parasagittal sulcal region (figure 1A) and the left perimesencephalic cistern (figure 1B). A CT angiogram (CTA) followed by a digital subtraction angiogram (DSA) ruled out aneurysms (figure 1C–F). The venous phase of DSA (figure 1G) and magnetic resonance (MR) venogram (figure 1H,I) were normal. MRI of the brain (figure 2) showed hyperintense lesions in the bilateral parieto-occipital regions and the basal ganglia suggesting posterior reversible encephalopathy syndrome (PRES). He was managed with antihypertensives and made a gradual and complete recovery. Figure 1 CT of the brain showing right parasagittal sulcal (A, arrow) and left perimesencephalic subarachnoid haemorrhage (B, arrow). CT angiography (C) was negative for aneurysms. Digital subtraction angiography …