High Blood Pressure and the Reversible Posterior Leukoencephalopathy Syndrome

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Updated December 30, 2014.

By definition, the reversible posterior leukoencephalopathy syndrome, or RPLS for short, is a stroke-like condition caused by swelling in the brain, usually in the setting of an episode of extremely high blood pressure. However, the syndrome is full of surprises. So, to fully understand the syndrome, it is helpful to delve into the role played by each word in the RPLS acronym.

The letter R stands for the word reversible, which implies that this condition is only temporary and that its symptoms and MRI findings are transient.

The letter P stands for the word posterior, which indicates that the brain areas affected by high blood pressure in this syndrome are located in the back of the brain. The letter L stands for the word leukoencephalopathy, which is defined as a clouding of consciousness, confusion, or an altered mental state due to a condition that effects the white matter of the brain. The letter S stands for syndrome, which is the constellation of symptoms of a disease.

RPLS is a syndrome in which an episode of high blood pressure causes reversible swelling in the white matter of the back areas of the brain, thus leading to a transient altered mental state. Or is it?

As it turns out, the symptoms observed with this condition are not as clearly defined as its acronym implies, as RPLS has been shown to cause a variety of symptoms, all of which have a wide spectrum of severity, and duration. The most common of these, as reported by one study, include encephalopathy (92%) seizures (87%), headaches (54%) and visual problems (39%).

But not all cases of RPLS are reversible, posterior, or related to swelling in the white matter. So almost any area of the brain can be affected by RPLS, and other stroke symptoms might also be present.

How is it diagnosed?

The diagnosis of RPLS is made from several sources of information including an MRI of the brain, the symptoms experienced by the patient, and the presence of high blood pressure around the time of its onset. One study, however, shows that some people might suffer RPLS even in the presence of a normal blood pressure, especially in conditions such as eclampsia. It can also occur in people who use certain medications.
Typically, the MRI of the head of patients with RPLS shows swelling in the white matter of both sides of the back of the brain. However, in some cases, RPLS can affect areas in the front or other areas of the brain, and even in the gray matter. Furthermore, many cases of RPLS have left people with permanent damage, although in most cases a resolution of the swelling does occur and can be confirmed by a follow-up MRI of the head.

How is it treated?

The treatment for RPLS consists mostly of controlling blood pressure, and treating possible seizures and headaches with appropriate medicines.

What is the prognosis?

Typically patients symptoms disappear days to weeks after the onset of RPLS. However, as stated above, there might be mild or even severe leftover symptoms from any unresolved brain lesions.

Vivien H. Lee, MD; Eelco F. M. Wijdicks, MD; Edward M. Manno, MD; Alejandro A. Rabinstein, MD; Clinical Spectrum of Reversible Posterior Leukoencephalopathy Syndrome; Arch Neurol. 2008;65(2):205-210.

J. P. Mohr, Dennis W. Choi, James C. Grotta, Bryce Weir, Phillip A. Wolf Stroke: Pathophysiology, Diagnosis, and Management Churchill Livingstone; 4th edition (2004)..
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