Unilateral Posterior Reversible Encephalopathy Syndrome after Ventriculo-Peritoneal Shunt for Normal Pressure Hydrocephalus Following Subarachnoid Hemorrhage:A Case Report Hiroyuki SATO 1 , Takayuki KOIZUMI 1 , Daisuke SATO 1 , Shin ENDO 1 , Syunichi KATO 1 1Department of Neurosurgery, Takeda General Hospital Keyword: posterior reversible encephalopathy syndrome , unilateral , hydrocephalus , shunt complication , intracranial hypotension pp.507-515
Published Date 2016/6/10
DOI https://doi.org/10.11477/mf.1436203320
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 The patient, a 79-year-old man, experienced a Hunt & Kosnik grade Ⅳ subarachnoid hemorrhage, presenting with sudden-onset coma and severe left hemiplegia. We performed cranial clipping surgery for a ruptured aneurysm on the right middle cerebral artery the same day. Post-operative recovery proceeded smoothly, with gradual improvements in disturbed consciousness and left hemiplegia. Three weeks post-operation, CT revealed low-density areas in the right frontal and temporal lobe, believed to be due to subarachnoid hemorrhage, as well as hydrocephaly. We then performed a lumbo-peritoneal(L-P)shunt for the hydrocephaly. Two months later, the patient experienced shunt occlusion, and we performed a ventriculo-peritoneal(V-P)shunt revision(pressure:6cm H2O). Headaches, severe decline in cognitive function, and worsened left hemiplegia were observed seven weeks post-shunt revision. Cranial CT revealed widespread low-density areas in right posterior cerebral white matter. We suspected unilateral posterior reversible encephalopathy syndrome(PRES)after performing cranial MRI and cerebral angiography. Increasing the set pressure of the shunt improved the symptoms and radiographic findings.

 PRES is typically bilateral, and unilateral incidents are rare. This is the first report of unilateral PRES secondary to shunt operation. Its unilaterality appears to have been caused by unilateral brain damage or adhesions to the brain surface from the subarachnoid cerebral hemorrhage. Overdrainage post-shunt can also induce PRES. Diagnosis of PRES is more difficult in unilateral cases;practitioners must keep PRES in mind as a rare complication post-shunt operation.

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