We searched the PUBMED database with MeSH terms “posterior leukoencephalopathy syndrome”, “hypertensive encephalopathy", “Hydrocephalus”, “hypertension(HTN)” and “Encephalopathy”. We then analyzed the clinical and radiological features of 10 other cases that were also treated with EVD.

We are reporting a case of 59-year-old female with a medical history of HTN and a prior ischemic stroke presented with symptoms of altered mental status, elevated blood pressure, and radiological features of PRES. Radiological obstructive hydrocephalus with involvement of the brainstem and obliteration of 4th ventricle was noted. Initial differential diagnosis included a space-occupying lesion, such as lymphoma or abscess. However, initial cerebrospinal fluid analysis and MR brain indicated PRES as the likely diagnosis. Given the presence of obstructive hydrocephalus with worsening symptoms, urgently required treatment with an external ventricular drain. After initial management of hydrocephalus and HTN in the ICU, the patient completely recovered over 4 to 5 days. Repeat MR brain showed a complete reversal of T2(FLAIR) hyperintensities, confirming the diagnosis of PRES. Ten more cases were found in the literature review, describing obstructive hydrocephalus related to hypertensive encephalopathy requiring extra ventricular drain placement. All patients recovered neurologically except one who died of sepsis.

It is crucial to consider the risk of obstructive hydrocephalus with PRES, as it can lead to morbidity. Aggressive management, including reducing hypertension and relieving symptoms with EVD, may be required in cases of obstructive hydrocephalus.