Posterior Reversible Encephalopathy Syndrome (PRES) is a clinico-radiological diagnosis first described by Hinchey et al. in 1996. (Hinchey et al., 1996) The classic presentation includes headache, encephalopathy, seizures, and visual disturbances.(Fischer and Schmutzhard, 2017; Hinduja, 2020) Radiologically, it typically shows vasogenic edema in the posterior cerebral white matter. (Hinduja, 2020)However, atypical distributions are common and well recognized. (McKinney et al., 2007) The primary mechanisms are believed to be impaired cerebral autoregulation and endothelial dysfunction. (Fugate and Rabinstein, 2015)These lead to hyperperfusion, vasogenic edema, and capillary leakage. (Fugate and Rabinstein, 2015)

Common precipitants include severe hypertension, eclampsia, renal disease, and immunosuppressive therapy.(Fischer and Schmutzhard, 2017) While often reversible, complications like intracerebral hemorrhage (ICH) or ischemia can worsen the prognosis. (McKinney et al., 2007) We present a complex case of a young male with untreated hypertension. He developed PRES with intraventricular hemorrhage, illustrating a management challenge and the importance of a multidisciplinary approach.

This case exemplifies a severe and complicated presentation of PRES. The patient's untreated hypertension led to a fatal breach of cerebral autoregulation, resulting in the classic vasogenic edema of PRES.(Fischer and Schmutzhard, 2017) However, whether the extreme blood pressure caused vascular rupture, leading to the massive IVH or not, is still undefined. (Robles and Volovici, 2022) This combination of hemorrhage and PRES is a recognized and serious complication that significantly complicates management and is associated with a poorer prognosis. (Covarrubias, Luetmer and Campeau, 2002; McKinney et al., 2007; Chen et al., 2018) The diagnosis of PRES was confirmed on MRI, which is the imaging modality of choice for identifying characteristic vasogenic edema patterns, even in atypical distributions. (McKinney et al., 2007; Fugate and Rabinstein, 2015)

Blood pressure management in this patient required a delicate balance. On one hand, aggressive reduction was necessary to halt hyperperfusion driving PRES-related vasogenic edema and to prevent rebleeding or extension of the IVH. (Hemphill et al>, 2015; Fischer and Schmutzhard, 2017) On the other hand, excessive reduction risked compromising cerebral perfusion in PRES-affected regions, potentially converting vasogenic edema to ischemia. (Hawkes, Hajeb and Rabinstein, 2023). Following current hemorrhagic stroke guidelines, we adopted a cautious strategy of targeting a systolic BP of 140 using intravenous agents for precise titration, while acknowledging that optimal targets in cases combining PRES and hemorrhage remain undefined and require individualized monitoring. (Marra et al., 2014; Hemphill et al., 2015). The IVH necessitated invasive neurosurgical intervention with an EVD, which carried a risk of infection, experienced by the patient. (Dey et al>, 2012) The development of classic parieto-occipital vasogenic edema confirmed PRES as the primary process, with the hemorrhage being a severe complication. The patient's eventual recovery, with only mild residual hemiparesis, underscores the brain's resilience and the importance of sustained, multidisciplinary critical care support. (Roth and Ferbert, 2011)

A limitation of this report is its nature as a single case, which cannot establish causation or be generalized to all PRES presentations. The patient’s significant alcohol use is a confounding factor that may have influenced the disease severity and course.

This case highlights the severe consequences of uncontrolled hypertension and its potential for dramatic clinical presentation. PRES should be included in the differential diagnoses for patients with encephalopathy and severe hypertension, even when intracranial hemorrhage predominates. Early diagnosis using MRI, careful blood pressure management, and a multidisciplinary approach involving neurology, neurosurgery, intensive care, and cardiology are essential for optimal outcomes in high-risk patients. Evidence-based interventions such as patient education, digital adherence reminders, and regular counseling sessions are critical for maintaining compliance with antihypertensive therapy.