Which MRI findings are characteristic of posterior reversible encephalopathy syndrome (PRES) in the workup of acute stroke?

Answer

Posterior reversible encephalopathy syndrome (PRES) presents clinically with acute/subacute onset headache, seizures, visual changes, altered mental status, and occasionally focal neurologic signs. MRI typically shows symmetrically distributed areas of vasogenic edema predominantly within the territories of the posterior circulation. The abnormalities affect primarily the white matter, but cortex is also involved. The diffusion weighted abnormality is associated with normal or high ADC value, differentiating the vasogenic edema induced by hypertension from cytoxic edema induced by ischemia.^[6]

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Alsop DC, Detre JA, Golay X, Günther M, Hendrikse J, Hernandez-Garcia L, et al. Recommended implementation of arterial spin-labeled perfusion MRI for clinical applications: A consensus of the ISMRM perfusion study group and the European consortium for ASL in dementia. Magn Reson Med. 2014 Apr 8. [Medline].
Duong TQ, Fisher M. Applications of diffusion/perfusion magnetic resonance imaging in experimental and clinical aspects of stroke. Curr Atheroscler Rep. 2004 Jul. 6(4):267-73. [Medline].
Davis SM, Donnan GA, Parsons MW, Levi C, Butcher KS, Peeters A, et al. Effects of alteplase beyond 3 h after stroke in the Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET): a placebo-controlled randomised trial. Lancet Neurol. 2008 Apr. 7(4):299-309. [Medline].
Geisler BS, Brandhoff F, Fiehler J, et al. Blood-oxygen-level-dependent MRI allows metabolic description of tissue at risk in acute stroke patients. Stroke. 2006 Jul. 37(7):1778-84. [Medline].
Herath P, Hanayik T, Krebs K, Dennis L, Rorden C, et al. Resting State Functional Connectivity and Thrombolysis Mediated. J Neurol Disord. 2015. 3:228.
Covarrubias DJ, Luetmer PH, Campeau NG. Posterior reversible encephalopathy syndrome: prognostic utility of quantitative diffusion-weighted MR images. AJNR Am J Neuroradiol. 2002 Jun-Jul. 23 (6):1038-48. [Medline].
Mishra NK, Albers GW, Davis SM, Donnan GA, Furlan AJ, Hacke W, et al. Mismatch-based delayed thrombolysis: a meta-analysis. Stroke. 2010 Jan. 41(1):e25-33. [Medline].
Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008 Sep 25. 359(13):1317-29. [Medline].
Kidwell CS, Jahan R, Gornbein J, et al. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med. 2013 Mar 7. 368(10):914-23. [Medline].
Hermier M, Nighoghossian N. Contribution of susceptibility-weighted imaging to acute stroke assessment. Stroke. 2004 Aug. 35(8):1989-94. [Medline].
Souvik S. and Oppenheimer S.M. Bedside Assessment of Stroke and Stroke Mimics. Ann Indian Acad Neurol. 2008. 11:S4-S11.
Paolini S, Burdine J, Verenes M, Webster J, Faber T, Graham CB, et al. Rapid Short MRI Sequence Useful in Eliminating Stroke Mimics Among Acute Stroke Patients Considered for Intravenous Thrombolysis. J Neurol Disord. 2013 Oct 24. 1:137. [Medline].
[Guideline] Jauch EC, Saver JL, Adams HP Jr, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013 Mar. 44(3):870-947. [Medline].
Purroy F, Jiménez-Caballero PE, Mauri-Capdevila G, et al. Predictive value of brain and vascular imaging including intracranial vessels in transient ischaemic attack patients: external validation of the ABCD3-I score. Eur J Neurol. 2013 Mar 26. [Medline].
Kidwell CS, Saver JL, Villablanca JP, et al. Magnetic resonance imaging detection of microbleeds before thrombolysis: an emerging application. Stroke. 2002 Jan. 33(1):95-8. [Medline].
Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013 Mar. 44 (3):870-947. [Medline].
[Guideline] Lersy F, Boulouis G, Clement O, et al. Consensus Guidelines of the French Society of Neuroradiology (SFNR) on the use of Gadolinium-Based Contrast agents (GBCAs) and related MRI protocols in Neuroradiology. J Neuroradiol. 2020 Nov. 47 (6):441-449. [Medline]. [Full Text].
Davis SM, Donnan GA, Butcher KS, Parsons M. Selection of thrombolytic therapy beyond 3 h using magnetic resonance imaging. Curr Opin Neurol. 2005 Feb. 18(1):47-52. [Medline].
Hacke W, Furlan AJ, Al-Rawi Y, Davalos A, Fiebach JB, Gruber F. Intravenous desmoteplase in patients with acute ischaemic stroke selected by MRI perfusion-diffusion weighted imaging or perfusion CT (DIAS-2): a prospective, randomised, double-blind, placebo-controlled study. Lancet Neurol. 2008 Dec 17. [Medline]. [Full Text].

Media Gallery

Magnetic resonance imaging in acute stroke. Left: Diffusion-weighted MRI in acute ischemic stroke performed 35 minutes after symptom onset. Right: Apparent diffusion coefficient (ADC) map obtained from the same patient at the same time.
Magnetic resonance imaging in acute stroke. Left: Perfusion-weighted MRI of a patient who presented 1 hour after onset of stroke symptoms. Right: Mean transfer time (MTT) map of the same patient.
Magnetic resonance imaging in acute stroke. Diffusion-perfusion mismatch in acute ischemic stroke. The perfusion abnormality (right) is larger than the diffusion abnormality (left), indicating the ischemic penumbra, which is at risk of infarction.
The diffusion-weighted MRI reveals a region of hypointensity in the distribution of the right middle cerebral artery. Flanking the anterior and posterior regions of this abnormality are regions of hyperintensities, which represent regions of new infarct. The contiguity of these regions suggests that they are extensions of the old infarct.

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Author

Souvik Sen, MD, MPH, MS, FAHA Professor and Chair, Department of Neurology, University of South Carolina School of Medicine

Souvik Sen, MD, MPH, MS, FAHA is a member of the following medical societies: American Academy of Neurology, Association for Patient-Oriented Research, American Heart Association

Disclosure: Nothing to disclose.

Coauthor(s)

Amar Anand, MD Resident Physician, Department of Neurology, Palmetto Health, Medical University of South Carolina College of Medicine

Amar Anand, MD is a member of the following medical societies: American Medical Student Association/Foundation, American College of Physicians, American Academy of Neurology

Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD Professor and Vice Chair, Department of Neurology, Oregon Health and Science University School of Medicine; Associate Director, OHSU Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology, American Stroke Association

Disclosure: Medscape Neurology Editorial Advisory Board for: Stroke Adjudication Committee, CREST2; Physician Advisory Board for Coherex Medical; National Leader and Steering Committee Clinical Trial, Bristol Myers Squibb; Abbott Laboratories, advisory group.

Acknowledgements

Draga Jichici, MD, FRCP, FAHA Associate Clinical Professor, Department of Neurology and Critical Care Medicine, McMaster University School of Medicine, Canada

Draga Jichici, MD, FRCP, FAHA is a member of the following medical societies: American Academy of Neurology, Canadian Congress of Neurological Sciences, Canadian Congress of Neurological Sciences, Canadian Congress of Neurological Sciences, Canadian Critical Care Society, Canadian Medical Protective Association, Canadian Neurocritical Care Society, Neurocritical Care Society, Royal College of Physicians and Surgeons of Canada, and Society of Critical Care Medicine (USA)

Disclosure: Nothing to disclose.

Howard S Kirshner, MD Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center

Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neurorehabilitation, National Stroke Association, Phi Beta Kappa, and Tennessee Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Which MRI findings are characteristic of posterior reversible encephalopathy syndrome (PRES) in the workup of acute stroke?

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