Hemorrhagic posterior reversible encephalopathy syndrome with pontine infarction in early-onset eclampsia: An atypical MRI spectrum

Posterior reversible encephalopathy syndrome is a clinicoradiological condition characterized by reversible vasogenic edema predominantly involving the posterior cerebral regions. It is commonly associated with hypertensive emergencies and pregnancy-related hypertensive disorders such as eclampsia. Although the typical imaging pattern involves the parieto-occipital white matter, atypical manifestations including brainstem involvement, infarction, and hemorrhage have been increasingly recognized. A 26-year-old primigravida at 25 + 2 weeks of gestation presented with multiple generalized tonic-clonic seizures and severe hypertension (190/110 mmHg). Laboratory investigations revealed elevated lactate dehydrogenase levels, proteinuria, thrombocytopenia, and mild transaminase elevation, consistent with severe preeclampsia. MRI performed using a comprehensive MRI protocol demonstrated bilateral parieto-occipital vasogenic edema with additional frontal and capsuloganglionic involvement. Diffusion-weighted imaging revealed pontine and occipital infarcts, while susceptibility-weighted imaging demonstrated petechial hemorrhagic foci. MR venography excluded cerebral venous thrombosis. The patient required intensive care admission, mechanical ventilation, and subsequent termination of pregnancy following confirmation of intrauterine fetal death. She demonstrated gradual neurological recovery and was discharged in stable condition.