A Case of Posterior Reversible Encephalopathy Syndrome Complicating a Thoracic Spinal Subdural Hematoma

TL;DR

A 68-year-old man with a spinal hematoma developed PRES, a rare neurological condition, likely triggered by severe hypertension and pain.

Contribution

This case highlights the rare association between spinal hematoma and PRES, emphasizing the importance of monitoring for PRES in similar clinical scenarios.

Findings

The patient's PRES was likely triggered by hypertension and pain from a thoracic spinal hematoma.

Neurological symptoms resolved with controlled blood pressure and appropriate sedation.

PRES should be considered in spinal hematoma patients with new neurological symptoms and hypertension.

Abstract

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological syndrome characterized by acute neurological symptoms such as headache, seizures, altered consciousness, and visual disturbances, along with neuroimaging findings that typically demonstrate vasogenic edema predominantly involving the parieto-occipital regions. Common precipitants include hypertension, renal dysfunction, hypertensive disorders of pregnancy, immunosuppressive agents, and perioperative factors; however, PRES in association with spinal hematoma has rarely been reported.

A 68-year-old man developed acute back pain while stretching and presented to the emergency department. On initial evaluation, no focal neurological deficits were evident, and he was discharged after adequate analgesia. The following day, he returned with recurrent back pain. Thoracic spine magnetic resonance imaging (MRI) demonstrated findings suggestive of a spinal subdural hematoma at T3/4-T5/6, necessitating further inpatient evaluation. After admission, he experienced persistent intense pain accompanied by marked hypertension, with a peak blood pressure of 230/140 mmHg. He subsequently developed generalized seizures associated with headache and visual disturbances. Brain MRI revealed hyperintensity on T2-weighted and fluid-attenuated inversion recovery (FLAIR) images predominantly in the bilateral parieto-occipital regions, consistent with PRES. In the intensive care unit, blood pressure was controlled with continuous nicardipine infusion, targeting a systolic blood pressure of ≤160 mmHg and carefully titrating the infusion to avoid a decrease of >50 mmHg within the first hour, and analgesia/sedation was provided with fentanyl and dexmedetomidine, with subsequent resolution of neurological symptoms. He was later transitioned to oral antihypertensive and analgesic medications, with improvement on follow-up imaging. Although PRES complicating spinal hematoma is uncommon, several potential PRES triggers may be involved, including pain-related blood pressure fluctuations, sustained hypertension, renal and fluid balance disturbances, autonomic influences, perioperative factors, cerebrospinal fluid leakage, and cerebral vasospasm. When hypertension and new neurological symptoms, such as headache, visual disturbances, or seizures, occur during the clinical course of spinal hematoma, PRES may be considered, and prompt blood pressure control with brain MRI evaluation may be warranted.

Figures