1. Reversible posterior leukoencephalopathy
Int 林君賢

2. Brief case present
49y/o female with L’t breast cancer in 93/9 s/p C/T Taxotere + Epirubicin
Underlying HTN,no DM
C.C: Incoherent speech then convulsion of right limb with consciousness change on 8/10 night

3. Brief history speak incoherently on 8/10 night.
Later in this early morning(about 1AM) convulsion of right limbs was noted accompanied by eye deviation to right side.
Mild fever at ER. AED was given
brain CT, CSF were done for survey the etiology. No evidence of ICH was impressed. Emperic A/B was given for suspected CNS infection.

4. CT on 8/11
Leukoencephalopathies involving the bilateral occipital lobes.
Leukoencephalopathies involving the bilateral occipital lobes.

5. 8/21 MRI

6. DWI

7. Hypertensive encephalopathy

8. Many names Hypertensive encephalopathy,
reversible occipitoparietal encephalopathy
reversible posterior leukoencephalopathy
Hypertensive encephalopathy, reversible occipitoparietal encephalopathy, or reversible posterior leukoencephalopathy: three names for an old syndrome J Child Neurol May;14(5):277-81

9. History 1928, Oppenheimer and Fishberg
s/s: headaches, confusion, drowsiness, blurring of vision, occasional seizures, and infrequent focal signs
DBP: > 140mmHg
D/D: stroke, systemic dz(ex: uremia,e- imbalance )

10. Cause Postgrad. Med. J. 2001;77;24-
Some suggest RPLS a predicator of eclampsia even if there is no other HELLP
Malignant hypertension is not necessary for the RPLS
Postgrad. Med. J. 2001;77;24-

11. Immunosuppresive agent
Postgrad. Med. J. 2001;77;24-

12. Symptom and sign H/A,N/V
Visual disturbance, cortical blindness(Anton’s syndrome)
Altered mental status(less coma and stupor)
Seziure: most seen GTC, preciptated by V/H,usually multiple attack

13. NE findings
CN II; intact, but maybe with hemianopia, neglect,anton’s syndrome,papilledema
DTR: increased and babinski sign may positive
May have muscle weakness and nild incoordination

14. Lab CSF: protein > 100mg/dl and pressure elevated
BUN mild elevation except in renal failure

15. Radiologic finding Reduced density on CT
Increased intensity bilateral white matter on T2WI, usually in occipital-parietal lobe,May not involved calcarine fissure asymmetrical not unusal
Advanced in brainstem, basal ganglion, frontal lobe,cerebellum
Often misinterpretated as large area infarction or demyelination
But reversible within weeks

16. Radiologic finding
unlike the edema in trauma, neoplasm, or stroke—there is little or no mass effect and the water does not tend to course along white matter tracts such as the corpus callosum
scattered cortical lesions occur in a watershed distribution and probably correspond to small infarctions

17. DWI & ADC maps

18. Typical image finding

19. TOB image

20. attack
remission

21. Image D/D
Top of basilar syndrome
Cerebral venous thrombosis

22. Pathophysiology
Vasospasm? Angio proved but not correlated with treatment improved image
Vasodilatation ? Image proved
Why post involved most?
Carotid system innerved by sympathetic sysmtem better than vertebro-basilar system

23. Treatment Nitroprusside: 0.5-0.8ug/kg/min
Lebetalol :20-40mg IV then 2mg/min
Then f/u with long acting ACEI or CCB
Only 15-20% MBP decreased but above 125 mmHg must be controlled, otherwise watershed infarction would be complicated.

24. Reference Adam 6th edition Merrit 8th edition
Postgrad. Med. J. 2001;77;24-
Magnetic resonance imaging in Posterior Reversible EncephalopathySyndrome: report of three cases and review of literature Arch Gynecol Obstet (2005) 271: 79–85