Reversible bilateral pyramidal tract lesions after hypertensive crisis and cerebral seizures

This is a rare case of reversible high signal-intensity changes along the pyramidal tracts in a patient with reversible posterior leukoencephalopathy syndrome (RPLS). A 38-year-old man was admitted to hospital for loss of consciousness and generalized seizures. His systolic blood pressure was 220 mmHg. Neurological examination revealed bilateral pyramidal-tract signs, and paresis of the right arm. Initial MRI showed increased signal intensities on T2-weighted, FLAIR and diffusion-weighted imaging in the following regions: bilateral temporo-occipital white matter and cortex, dorsal parts of the lentiform nuclei, bilateral caudate nuclei and external capsule. High signal intensities were observed in the pyramidal tracts as well. On patient follow-up, MRI signal abnormalities and clinical symptoms were completely resolved after antihypertensive treatment.