Extreme hypertension is a known precipitant of posterior reversible encephalopathy syndrome (PRES). This syndrome results from failed cerebrovascular auto-regulation and development of vasogenic edema. PRES with spinal cord involvement (PRES-SCI) is a rarely described phenomenon involving development of vasogenic edema in the spinal cord. We present a case of PRES-SCI with the additional finding of optic nerve edema related to eclampsia.

An 18-year-old woman with history of asthma was admitted with headache, blurred vision and new onset seizure. She was found to be 26 weeks pregnant and was ultimately diagnosed with eclampsia with systolic blood pressures peaking at 290 mmHg. Seizures persisted despite medical management and she underwent emergent caesarian section. Initial CT head without contrast demonstrated multiple hypodensities concerning for ischemia or edema. MRI brain and cervical spine both demonstrated T2 hyperintensities consistent with vasogenic edema. Cerebral vasogenic edema was primarily posteriorly located while spinal cord edema ranged from C2-C5. Neurologic examination did not reveal any clinical signs of spinal cord pathology. Patient had ongoing blurred vision and refractory elevation in blood pressures. Ophthalmologic exam revealed bilateral optic disc edema. With better blood pressure control, patient improved clinically. One month later, repeat MRIs of the brain and cervical spine showed significant decrease in T2 hyperintensities.

Our case is notable as it underscores the susceptibility of all central nervous system structures, including the brain, spinal cord, and optic nerve to hyperperfusion injury secondary to malignant hypertension. PRES-SCI is likely an underrecognized entity because the spinal cord is not typically imaged in patients with cerebral PRES. Optic nerve edema is also not frequently identified as ophthalmologic exams are rarely sought. As PRES is not necessarily always reversible, rapid identification and treatment of CNS tissue hyperperfusion injury can help improve outcomes.