Jornal de Oftalmologia Clínica e Experimental
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A Case of Posterior Reversible Encephalopathy Syndrome Presenting with Isolated Diplopia

Masayuki Hata, Akio Oishi, Yasuo Kurimoto, Shiro Yamamoto and Nobuo Kohara

Background: Posterior Reversible Encephalopathy Syndrome (PRES) is a clinical entity characterized by a unique pattern of vasogenic brain edema mainly caused by eclampsia, immune suppressing drugs, or severe hypertension. The disease typically affects parieto-occipital lobe as the nomenclature indicates. Here we report a man with isolated concomitant strabismus, who was initially suspected as having glioma but was finally diagnosed with PRES.
 
Methods: A 43-year-old man complained of horizontal double vision for a week. He had no other neurological symptom, including headache or confusion. He had a history of hypertension but had no medication. On examination, he showed 10 to 12 prism diopter of exotropia in all gaze directions without any restriction of eye movement. The sudden onset of the symptom and the history of hypertension urged us to take head MRI, which showed poorly-demarcated T2-high intensity area in extensive brainstem and bilateral cerebellum. The image suggested a plausible diagnosis of brainstem glioma.
 
Results: He was admitted for planning brain biopsy. Since his systolic blood pressure was over 240 mmHg, he was to undergo blood pressure control before the biopsy. As the pressure decreased to around 180 mmHg, his symptom improved gradually. The lesion diminished in 2 weeks. Finally, he was diagnosed with PRES due to hypertension judged from the clinical course.
 
Conclusions: PRES can affect any locations in central nervous system including brainstem as shown in the present case. And of note, the patients with brainstem variant of PRES may present only minimal symptoms such as diplopia in the present case. Differentiation from tumors or infarction is very important to avoid unnecessary and invasive interventions. One useful characteristic is the clinical radiologic dissociation. Once brainstem variant of PRES is diagnosed, to monitor and control blood pressure is important because it is often caused by severe secondary hypertension.