An acutely confused young woman.

摘要

In September, 2009, a 20-year-old previously healthy woman presented to our emergency department with altered mental status, right arm tingling and numbness, and a bilateral pulsating frontotemporal headache. Her symptoms had started several hours earlier with transient loss of consciousness. On examination, she was alert, with reduced concentration, incoherent thoughts, and poor recall for recent events. There was no evidence of localising neurological signs or neck stiffness. Her temperature, blood pressure, and vital signs were normal. Abuse of alcohol or illicit substances was denied by a friend who accompanied the patient. Her personal and family history was negative for seizure disorders, migraine, and vascular risk factors. CT of the brain and haematological, biochemical, and cerebrospinal fluid examination were normal. MRI of the brain, 20 h after the onset of her symptoms, showed multiple confluent areas of abnormal high signal intensity on T2-weighted scans, symmetrically involving juxtacortical white matter of the frontal, parietal, occipital, and temporal lobes. In these areas, diffusion coefficient maps, generated by diffusion-weighted imaging, showed an elevated diffusion suggestive of vasogenic oedema (figure A, C, and web-appendix). A diagnosis of posterior reversible encephal-opathy syndrome (PRES) was suspected, and confirmed by the almost complete disappearance of MRI abnormalities a week later.