Introduction: Posterior reversible encephalopathy syndrome [PRES] is known as a disorder of reversible subcortical vasogenic brain edema in patients with acute neurological symptoms. Clinical features are seizures, disturbed vision,headache, and altered mental state. Brain imaging of the PRES usually reveals vasogenic edemain the parieto-occipital regions which is almost bilaterally symmetrical to the cerebral hemispheres. PRES is generally reversible and has favorable prognosis radiologically and clinically. However, there is no report about a long term-follow up of cognitive function after PRES.
Case presentation: Fifty eight year old man was consulted to our department because of longstanding cognitive impairment after PRES. The patient’s cognition was impaired with a mini-mental status examination scoreof 26, and Montreal cognitive assessment score of 26. Previous medical history showed that he was injured multiple organs and its vessels compressed by a pallet fork lift truck 80 days ago. On arrival to the trauma center of our hospital, he immediately have received damage control surgery of massive abdominal bleeding.The patient's kidney on the right side was removed due to dissection of renal artery. His acute renal injury required continuous renal replacement therapy for 15 days. Physical examinations for his early admission times showed that he was confused and agitated. On the 25th day of the onset, the patient developed generalized tonic-clonic seizure for few minutes. Before the onset of seizure, he was found to have fluctuate blood pressure for seven days as follows : 220/121 to 178/108. The rest of the vital signs, and laboratory test results were within normal ranges, an exception of leukocytosis (WBC, 16.24 K). CT findings of onset showed multifocal low density lesions in bilateral parieto-occipital lobes and cerebellum [Figure 1-A]. It suggested brain edema on the posterior regions of the brain. The characterstic CT findings led us to a diagnosis of PRES, which is associated with his clinical signs and symptoms. For a more detailed evaluation of cognition, we performed a neuropsychological test [Table 1]. There was no abnormal finding on axial view magnetic resonance imaging (MRI) of T2-weighted and T2- gradient echo showed only focal hemosiderin deposition in the left occipital lobe, which was suggested a sequelae of hemorrhage [Figure 1-B].
Using diffusion tensor tractography(DTT) , we reconstructed Papez' circuit,which is responsible for cognition.The DTT showed that both thalamocinuglate tracts could not be recontructed . In addition, the the right mamillothalamic tract was also not be able to reconstructed [Figure 1-C]. Conclusion: Our study using DTT suggests that may integrity of the Papez’s circuit reflect memory function in patient with PRES. Thus, pay to attention the cognitive function in patients after PRES will be needed for the therapeutics.
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