Recognize uncommon presentations of PRES. 

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A 60-year-old man was found unresponsive in his car. On arrival to the ED, he was agitated and his blood pressure was 210/153mmHg. He was intubated and started on propofol. Neurological exam was unremarkable except for disconjugate gaze with intact vestibulo-ocular reflex. Urine toxicology was positive for cocaine. Head CT and MRI are shown (Figure 1). EEG and CSF were unremarkable. He improved with supportive care and blood pressure control, with no residual deficits and improvement of MRI changes (Figure 2). Based on the reversible deficits and improving MRI changes, a diagnosis of posterior reversible encephalopathy syndrome (PRES) was made. Isolated brainstem involvement in is unusual but should be considered in the appropriate clinical context.