Reversal of white matter edema in hypertensive encephalopathy.

A 42-year-old man was admitted to the hospital because of increasing difficulty with gait and recent loss of vision. Examination revealed a blood pressure of 250/150 mm Hg, normal mental status , and severe hypertensive retinopathy bilaterally. There was no papilledema, and the fundi were pale. Cranial nerve, motor, and sensory examinations were normal. Plantar reflexes were extensor bilaterally. Gait was wide-based and unstable. There was no dysmetria on fingerto-nose testing. Electrolytes were remarkable for a potassium of 2.6 , a blood urea nitrogen of 75, and a creatinine of 3.8. CT showed obliteration of the fourth ventricle and marked narrowing of the prepontine cistern; patchy periventricular hypodensity was present supratentorially. A subsequent MR study (Figs. 1 A and 1 C) suggested diffuse white matter edema, particularly in the posterior fossa. The patient 's gait improved dramatically, and his plantar responses became flexor after vigorous treatment of his hypertension. Repeat CT scan at 1 week showed resolution of mass effect in the posterior fossa. Four days later, a follow-up MR study also showed improvement (Figs. 1 B and 1 D).