Bath salts contain 3,4-methylenedioxypyrovalerone, a substance similar to cocaine and amphetamines, and can lead to vasospasm by inhibiting dopamine and norepinephrine reuptake. PRES and stroke can be caused by hypertension, but its coexistence in a patient with bath salt inhalation has been not described. 

This is a case report of a 48-year-old female patient with a history of heroin abuse was found unresponsive. On arrival, was noted to have a systolic blood pressure over 200s and was seizing. On exam, she had expressive and receptive aphasia. Initial labs including a urine toxicology screen were unremarkable. CTA was concerning for vasospasm vs vasculitis. MRI Brain revealed multiple infarcts in bilateral hemisphere with extensive involvement of left posterior cerebral artery and T2 hyperintensities in the bilateral cerebellum and pons. Moreover, T2 FLAIR hyperintensities were noted in bilateral frontal and parietal white matter indicative of PRES. There was also injury to bilateral thalami and watershed vascular distributions suggestive of hypoxic insult. Extensive workup including TEE and LP failed to show an embolic source or vasculitis. 

Bath salt inhalation is shown to be associated with ischemic colitis and myocardial infarction, but no instances of stroke or PRES have been reported. The pathophysiological mechanisms between PRES and stroke differ, but may be secondary to vasospasm in the setting of bath salt inhalation.