Magnetic resonance imaging changes and clinical features of reversible posterior leukoencephalopathy syndrome / 中南大学学报(医学版)

OBJECTIVES@#Reversible posterior leukoencephalopathy syndrome (RPLS) is a rare clinical imaging syndrome. The causes of RPLS are complex and diverse, the pathogenesis is not yet clear. The onset is urgent and the onset age span is large, ranging from children to the elderly. The clinical symptoms of RPLS have no significant specificity, which can be manifested as headache, blurred vision, disturbance of consciousness or seizures. Clinicians have little knowledge on the disease, which may lead to misdiagnosis or missed diagnosis. This study aims to analyze and summarize the MRI changes and clinical characteristics regarding RPLS patients, so as to provide basis for rapid diagnosis and timely intervention for this disease.@*METHODS@#The clinical data and complete imaging data of 77 patients with RPLS diagnosed in Xiangya Hospital of Central South University from January 2012 to March 2021 were retrospectively collected. The main image data include T1 weighted imaging (T1WI), T2 weighted imaging (T2WI), T2 liquid attenuation inversion recovery (T2-FLAIR), diffusion weighted imaging (DWI) (b value=1 000×10-6 mm2/s), and apparent diffusion coefficient (ADC). The case group included 63 patients who underwent DWI examination, and 71 normal controls matched in age and sex. The characteristics of patients' magnetic resonance signals and the ADC value of 19 regions of interest (ROI) were analyzed. The differences in bilateral ADC value in the case group, the difference of ADC value between the case group and the normal control group, and the difference of ADC value in the case group before and after treatment were compared.@*RESULTS@#Compared with the normal control group, the ADC value of the right frontal lobe, bilateral parietal lobe, bilateral thalamus, bilateral head of caudate nucleus, left lenticular nucleus, right internal capsule, bilateral temporal lobe and pons in the case group were significantly higher (all P<0.01). There was no significant difference in ADC value of bilateral sides of the case group and before and after treatment in the case group (all P>0.01). The lesions of RPLS were widely distributed and multiple, usually high signal in the posterior parieto temporo occipital lobe or pons of the brain, and involved the cortex and subcortical white matter. Most of them were bilateral, but not completely symmetrical.@*CONCLUSIONS@#The imaging manifestations of RPLS and the occurrence and development of clinical symptoms are basically synchronous. The imaging manifestations are specific. Magnetic resonance imaging can show the range of involvement of RPLS. ADC value can provide information on the severity of the disease and predict the prognosis. There are few reversible diseases. It is very important to fully understand and timely diagnose the disease.

Síndrome da encefalopatia posterior reversível em paciente com COVID-19 submetida à oxigenação por membrana extracorpórea / Posterior reversible encephalopathy syndrome in a patient submitted to extracorporeal membrane oxygenation for COVID-19

RESUMO Uma mulher com 63 anos de idade compareceu ao pronto-socorro com história aguda de febre, prostração e dispneia. Recebeu diagnóstico de quadro grave da COVID-19 e síndrome do desconforto respiratório agudo. Apesar de suporte clínico intensivo, cumpriu os critérios para ser submetida à oxigenação venovenosa por membrana extracorpórea. No dia 34, após 7 dias de desmame da sedação com evolução positiva de seu quadro neurológico, apresentou uma crise tônico-clônica generalizada limitada, não relacionada com desequilíbrio hidroeletrolítico ou metabólico, que levou à necessidade de investigação diagnóstica. Seus exames de imagem cerebral revelaram síndrome da encefalopatia posterior reversível. Este caso enfatiza a questão das complicações neurológicas em pacientes com COVID-19 grave e a importância do diagnóstico e suporte precoces.

ABSTRACT A 63-year-old woman presented to the emergency department with an acute history of fever, prostration and dyspnea. She was diagnosed with severe COVID-19 acute respiratory distress syndrome and, despite optimized critical care support, met the indications for veno-venous extracorporeal membrane oxygenation. On day 34, after 7 days of wean sedation with a positive evolution of neurologic status, she presented a limited generalized tonic-clonic seizure not related to hydroelectrolytic or metabolic imbalance, which led to a diagnostic investigation; her brain imaging tests showed a posterior reversible encephalopathy syndrome. This case emphasizes the issue of neurological complications in patients with severe COVID-19 infection and the importance of early diagnosis and support.

Leucoencefalopatía posterior reversible en pacientes trasplantados. Presentación clínica, radiológica y evolución / Posterior reversible encephalopathy syndrome in transplanted patients. Clinical features and imaging follow up

Resumen El síndrome de leucoencefalopatía posterior reversible (PRES) es un desorden neurológico agudo caracterizado por cefalea, alteración de la conciencia, convulsiones y alteraciones visuales, con imágenes de edema vasogénico reversible en regiones cerebrales posteriores. Nos propusimos describir una serie de casos de pacientes trasplantados que desarrollaron PRES, caracterizando su presentación, evolución clínica, imágenes y terapéutica. Se analizaron historias clínicas informatizadas desde enero 2009 hasta enero 2019. Se recabaron datos demográficos, antecedentes clínicos, motivos y días de internación, tiempos desde el trasplante a la presentación clínica y diagnóstico. Se evaluó la mejoría/resolución en estudios por imágenes y la supervivencia anual. Se identificaron 27 pacientes con PRES; 22 trasplantados de órgano sólido de 1647 totales (1.3%) y 5 de médula ósea de 617 totales (0.8%). La media de edad fue de 38.2 años (DS 19.5), 62.9% de sexo femenino, 59.2% (16) antes del año del trasplante. Las comorbilidades más frecuentes enfermedad renal (14; 51%) e hipertensión arterial (11; 40%). Se realizó tomografía axial computarizada (TAC) a 23 pacientes (85.1%), siendo patológica en 11 (47.8%), y resonancia magnética nuclear (RMN) a 25 (92.6%), mostrando patrón característico en 17 (62.9%), con mejoría/resolución antes del año en 20 (74%). El tratamiento fue sintomático, modificando la inmunosupresión. Se registraron 5 óbitos durante la internación y otros 3 antes del año, con una supervivencia anual del 70.3% (19). La población de trasplantados, en crecimiento en nuestro medio, es particularmente susceptible al PRES. Tanto su presentación en estudios por imágenes, como su comorbilidad, difieren de otras poblaciones.

Abstract Posterior reversible encephalopathy syndrome (PRES) is an acute neurological disorder characterized by headache, encephalopathy, seizures and visual disturbances, with reversible vasogenic edema in posterior brain areas. The aim of this research was to describe a case series of transplanted patients who developed PRES, characterize their presentation, treatment, clinical and imaging evolution. Electronic medi cal records were analyzed from January 2009 to January 2019. Demographic data, clinical backgrounds, causes of admission, hospital length of stay and time from transplantation to PRES were collected. Image improvement/ resolution and annual survival were assessed. We identified 27 patients with PRES; 22 of 1647 total solid-organ transplant (1.3%) and 5 of 617 total bone marrow transplant (0.8%). The mean age at presentation was 38.2 years (SD 19.5), 62.9% female, 59.2% (16) before the year of transplantation. The most common comorbidities were kidney disease (14; 51%) and high blood pressure (11; 40%). Computed axial tomography (CT) was per formed in 23 patients (85.1%), with pathological findings in 11 (47.8%). Magnetic resonance imaging (MRI) of 25 (92.6%), showed a characteristic pattern in 17 (62.9%) with improvement/resolution before the year in 20 (74%). Treatment was symptomatic, modifying immunosuppression. Five deaths were recorded during hospital stay and another 3 before the year of admission, with an annual survival of 70.3% (19 patients). Organ transplant trend is growing in our region. These patients are particularly susceptible to PRES, with a different imaging presentation and comorbidities from other populations.

Reversible posterior encephalopathy syndrome in a 10-year-old child / Síndrome da encefalopatia reversível posterior em uma criança de 10 anos

Abstract Introduction: The posterior reversible encephalopathy (PRES) syndrome encompasses a set of clinical-radiological findings associated with severe systemic arterial hypertension. This case report proposes to discuss the identification, diagnosis, and management of PRES in the pediatric population. Case presentation: Female patient, 10 years old, admitted to the emergency room with complaint of oliguria and generalized edema. At the initial physical exam, the only alteration present was anasarca. The diagnostic investigation revealed nephrotic syndrome, and clinical treatment was started. She evolved on the 8th day of hospitalization with peak hypertension, sudden visual loss, reduced level of consciousness, nystagmus, and focal seizures requiring intubation. She was transferred to the Intensive Care Unit, with neurological improvement, after the established therapy. CT scan revealed a discrete hypodense area in the white matter of the occipital lobe and anteroposterior groove asymmetry, compatible with PRES. Discussion: PRES is due to vasogenic cerebral edema of acute or subacute installation. Symptoms include headache and altered consciousness, stupor, coma, neurological deficits, seizures and cortical blindness. Nephropathies are the main cause of PRES in pediatrics. Magnetic resonance imaging with diffusion of molecules is the gold standard for diagnosis. The initial treatment objectives are the reduction of blood pressure, antiepileptic therapy, correction of hydroelectrolytic and acid-base disorders and management of intracranial hypertension. Conclusion: PRES is associated with acute hypertension. Early diagnosis and proper management may determine a better prognosis and minimize the severity of the clinical course.

Resumo Introdução: A Síndrome de Encefalopatia Posterior Reversível (SEPR) engloba um conjunto de achados clínico-radiológicos, associados a hipertensão arterial sistêmica grave. Este relato de caso propõe discutir a identificação, o diagnóstico e o manejo de SEPR na população pediátrica. Apresentação do caso: Paciente do sexo feminino, 10 anos, admitida em pronto-atendimento com queixa de oligúria e edema generalizado. Ao exame físico inicial, a única alteração presente era anasarca. A investigação diagnóstica revelou síndrome nefrótica, iniciando-se tratamento clínico. Evoluiu no 8º dia de internação com pico hipertensivo, perda visual súbita, redução do nível de consciência, nistagmo e crises convulsivas focais, demandando intubação. Foi transferida para Unidade de Terapia Intensiva, com melhora neurológica, após a terapêutica instituída. Tomografia de crânio evidenciou área de hipodensidade discreta em substância branca do lobo occipital e assimetria anteroposterior de sulcos, compatível com SEPR. Discussão: A SEPR decorre de edema cerebral vasogênico de instalação aguda ou subaguda. Sintomas descritos incluem cefaleia e alteração de consciência, estupor, coma, déficits neurológicos, convulsões e cegueira cortical. As nefropatias constituem as principais causas de SEPR em pediatria. A ressonância magnética com difusão de moléculas é o padrão-ouro para o diagnóstico. Os objetivos iniciais são a redução dos níveis pressóricos, terapia antiepiléptica, correção de distúrbios hidroeletrolíticos e do equilíbrio ácido-básico, e manejo da hipertensão intracraniana. Conclusão: A SEPR ocorre associada à hipertensão aguda. O diagnóstico precoce e manejo adequado podem determinar melhor prognóstico e minimizar a gravidade do curso clínico.

Encefalopatía posterior reversible en el curso de una emergencia hipertensiva, serie de cuatro niños hospitalizados en el Centro Hospitalario Pereira Rossell / Posterior reversible encephalopathy during a hypertensive emergency in 4 children hospitalized at the Pereira Rossell Pediatric Hospital / Encefalopatia reversível durante uma emergência hipertensiva em 4 crianças hospitalizadas no Centro Hospitalar Pereira Rossell

Introducción: la encefalopatía posterior reversible (PRES) es un complejo sindromático caracterizado por cefaleas, crisis epilépticas, trastornos visuales y alteración del sensorio asociado a cambios en la sustancia blanca de lóbulos occipitales y parietales en la resonancia nuclear magnética. Se relaciona con diversas causas que provocan edema cerebral, entre las que se destaca la hipertensión arterial (HTA) y los tratamientos inmunosupresores. Descripción de casos: se incluyeron cuatro niños hospitalizados entre el 1 de enero de 2005 y el 31 de diciembre de 2015 en el Centro Hospitalario Pereira Rossell. La mediana de edad fue 11,5 años. La manifestación clínica inicial en tres de los cuatro pacientes fue disnea y edemas generalizados. Todos presentaron hipertensión endocraneana y convulsiones generalizadas. La tomografía computada fue la primera imagen solicitada en todos los pacientes, evidenciado lesiones hipodensas córtico-subcorticales occipitales, parietales y frontales. Se realizó resonancia magnética en tres casos con hallazgos característicos. Todos presentaron síndrome nefrítico con cifras de tensión arterial mayores al P99, insuficiencia renal reversible, disminución de C3 y aumento del antiestreptolisina O (AELO). El control de HTA requirió politerapia en unidad de cuidado crítico. Ninguno presentó secuelas neurológicas. Conclusiones: la PRES es una asociación o manifestación poco habitual de la emergencia hipertensiva. Es necesaria la sospecha e identificación por parte del pediatra con el fin de realizar un abordaje terapéutico adecuado y precoz.

Introduction: posterior reversible encephalopathy (PRES) is a complex syndrome characterized by headaches, epileptic seizures, visual disturbances and sensorial alterations associated to changes of white matter in parieto-occipital regions shown in magnetic nuclear resonance. It is linked to various causes that provoke cerebral edema including arterial hypertension (AH) and immunosuppressive treatments. Clinical cases: 4 children admitted between January 1st, 2005 and December 31st, 2015 at the Pereira Rossell Pediatric Hospital. Median age: 11.5 years. The initial clinical manifestation in 3 of 4 patients was dyspnea and generalized edema. All of them presented endocranial hypertension and generalized convulsions. CT was the first requested image to all patients, and it was clear that all of them had experienced occipital cortical-subcortical, parietal and frontal hypodense lesions. In three of the cases we performed a Magnetic Resonance that showed typical findings. All of them presented nephritic syndrome with arterial hypertension over P99, reversible renal failure, a decrease of C3 and an increase of Antistreptolysin O (AELO). HTA control required polytherapy at the critical care unit. None of them presented neurological sequelae. Conclusions: PRES is an association or unusual manifestation of hypertensive emergency. Early detection by pediatricians seems essential to provide an appropriate therapeutic approach.

Introdução: a encefalopatia posterior reversível (PRES) é uma síndrome complexa caracterizada por dores de cabeça, convulsões epilépticas, distúrbios visuais e alterações sensoriais associadas à mudança da substância branca nas regiões parieto-occipitais observadas na ressonância magnética nuclear. Está ligada a várias causas que provocam o edema cerebral, incluindo hipertensão arterial (HA) e tratamentos imunossupressores. Casos clínicos: 4 crianças internadas entre 1º de janeiro de 2005 e 31 de dezembro de 2015 no Hospital Pediátrico Pereira Rossell. Idade mediana: 11,5 anos. A manifestação clínica inicial em 3 dos 4 pacientes foi dispneia e edema generalizado. Todos apresentaram hipertensão endocraniana e convulsões generalizadas. A TC foi a primeira imagem solicitada e todos os pacientes mostraram lesões occipitais corticais-subcorticais, parietais e hipodensas frontais evidentes. Em três dos casos, a Ressonância Magnética mostrou achados típicos. Todos apresentaram síndrome nefrítica com hipertensão arterial acima de P99, insuficiência renal reversível, diminuição de C3 e aumento de antiestreptolisina O (AELO). O controle de HTA requereu politerapia na unidade de terapia intensiva. Nenhum dos pacientes apresentou sequelas neurológicas. Conclusões: A PRES é uma associação ou manifestação de emergência hipertensiva pouco comum. A detecção precoce do pediatra é essencial para fornecer uma abordagem terapêutica adequada.

Posterior reversible encephalopathy syndrome in systemic lupus erythematosus: a case report / 北京大学学报(医学版)

This case report concerns a 22-year-old woman who had been diagnosed with systemic lupus erythematosus (SLE). She had intermittent fever, butterfly erythema, photosensitivity, oral ulcers, and multiple arthralgia in the past seven years, but she did not adhere to regular treatments. The edema of the lower extremities and face aggravated in the recent two weeks, so she was admitted to our Department of Rheumatology and Clinical Immunology. Meanwhile, we found she had severe hypertension, the maximal blood pressure was 170/120 mmHg. The patient had high SLE disease activity (the disease activity index score was as high as 23) with blood involvement, acute renal insufficiency, multiple serous effusion and rash. After one week treatments of intravenous methylprednisolone 80 mg daily and other drugs, her conditions made some extent improvement. However, she suffered sudden epileptic attacks. No positive neuropathological signs were found, and the blood pressure was up to 190/130 mmHg before the onset of the seizures. Her cerebrospinal fluid (CSF) pressure was 330 mmH2O, the CSF protein level was normal value, and the white blood cell count was 0 cell/mm3, with no signs of infection. Cranial MRI showed vasogenic edema at bilateral parietal, occipito-parietal regions, and centrum ovale. We prescribed drugs of decreasing intracranial pressure, intravenous drugs of decreasing blood pressure and midazolam for sedation, without corticosteroid impulse therapy. She recovered consciousness in the next day, without epilepsy recurrence. We eventually diagnosed it as posterior reversible encephalopathy syndrome (PRES), according to the history, laboratory results, imaging featuresand clinical outcome. PRES is a disorder of reversible subcortical vasogenic brain edema in patients with acute neurological symptoms (eg, seizures, encephalopathy, headache, and visual disturbances). PRES is mainly caused by blood pressure changes or endothelial injury, which lead to breakdown of the blood-brain barrier and subsequent brain edema. Most patients have a favourable prognosis. SLE complicated with PRES is not rare, especially in patients with disease activity, hypertension, lupus nephritis and/or renal insufficiency, and use of cytotoxic drugs, early recognition and appropriate treatment remain important. Brainstem involvement, intracranial hemorrhage, renal insufficiency and high disease activity of lupus are risk factors for poor prognosis.

Encefalopatía reversible posterior en una niña con lupus eritematoso sistémico: Presentación de un caso / Posterior reversible encephalopathy in a girl with systemic lupus erythematosus: Report of a case

La encefalopatía posterior reversible es una patología de baja frecuencia en pediatría. Las manifestaciones clínicas características son cefaleas, convulsiones, trastornos visuales y de conciencia asociadas a imágenes típicas en la resonancia magnética del sistema nervioso. Por lo general, se manifiesta en pacientes con eclampsia, trasplante de órganos sólidos, enfermedades hematológicas, renales y autoinmunes, entre otras causas menos frecuentes, y suele desencadenarse luego de un cuadro de hipertensión arterial o el uso de drogas inmunosupresoras. Factores patogénicos menos habituales, como transfusión sanguínea, uso de inmunoglobulinas o una infección subyacente, pueden estar asociados. Se describe una paciente con lupus eritematoso sistémico, que desarrolló la encefalopatía al estar expuesta a múltiples factores etiopatogénicos.

Posterior reversible encephalopathy is a rare disease in children. Clinical manifestations include headache, seizures, visual disturbances and altered consciousness associated with typical magnetic resonance images of the nervous system. The syndrome usually manifests in patients with eclampsia, solid organ transplantation, haematologic, renal and autoimmune diseases among other less common causes and it is often triggered after a hypertensive crisis or use of immunosuppressive drugs. Less common pathogenic factors as blood transfusion, use of immunoglobulins or an underlying infection can be associated. In this case a girl with systemic lupus erythematosus and exposed to multiple etiopathogenic factors developed posterior reversible encephalopathy.

Clinical, imagiological and etiological spectrum of posterior reversible encephalopathy syndrome / Espectro clínico, imagiológico e etiológico da síndrome de encefalopatia posterior reversível

Objective Analyze the cases of posterior reversible encephalopathy syndrome (PRES) admitted in a Neurology Department during an 8-year period. Method Retrospective observational study in a central hospital in the north of Portugal. Results 14 patients were identified, mean age 52.3 years. Precipitating factors included: eclampsia, isolated arterial hypertension, spinal trauma and autonomic dysreflexia, Guillain-Barré syndrome, sepsis, sarcoidosis and pulmonary cryptococcosis and drugs. Most patients presented posterior-predominant vasogenic edema lesions, however 64.2% presented frontal lesions and in 42.8% cerebellum was involved. Four patients also had acute ischemic lesions and 1 had hemorrhagic lesions. During follow-up 10 patients recovered fully, 2 recovered partially, 1 suffered a recurrence and 2 died in hospital. Conclusion PRES has many etiological factors. The terms posterior and reversible should be revised because PRES frequently involves other brain regions and it is not always reversible. PRES patients may develop life-threatening complications and mortality is not negligible. .

Objetivo Análise dos casos de síndrome de encefalopatia posterior reversível (PRES) internados em um Serviço de Neurologia durante oito anos. Método Estudo restrospectivo observacional num hospital central do norte de Portugal. Resultados Identificaram-se 14 casos, idade média de 52,3 anos. Os factores precipitantes foram: eclâmpsia, hipertensão arterial isolada, traumatismos vertebro-medulares com disfunção autonómica, síndrome de Guillain-Barré, sépsis, sarcoidose e criptococose pulmonar e fármacos. A maioria dos doentes apresentou lesões edematosas de predomínio posterior, contudo 64,2% apresentaram lesões frontais e 42,8% apresentaram também lesões cerebelosas. Quatro doentes tinham lesões isquémicas agudas e um apresentou lesões hemorrágicas. Durante o seguimento, 10 doentes recuperaram totalmente, 2 recuperaram com sequelas, 1 teve recidiva e 2 faleceram durante o internamento. Conclusão A PRES apresenta muitos factores precipitantes. As designações posterior e reversível deverão ser reequacionadas dado que a PRES afecta outras zonas do cérebro e nem sempre é reversível, apresentado complicações e mortalidade não ...

Encefalopatía posterior reversible como primera manifestación del Síndrome de Guillain-Barré / Posterior reversible encephalopathy as the first manifestation of Guillain-Barré syndrome. Report of one case

Background: We report a 56year old male hypertensive, who presented with a posterior reversible encephalopathy syndrome (PRES) as an initial manifestation of Guillain-Barré syndrome (GBS). His first symptoms were right hemiparesis and hemihypoesthesia, followed by headache, dizziness, dysarthria and a general feeling of discomfort. On the third day, flaccid tetraparesis, impairment of consciousness, epileptic seizures and respiratory failure appeared, along with severe hypertension. Cerebral Magnetic Resonance Imaging showed the characteristic PRES lesions. Cerebrospinal fluid analyses revealed albumin-cytological dissociation and nerve conduction studies showed an axonal demyelinating polyradiculoneuropathy, which confirmed the diagnosis of GBS. Treatment with intravenous immunoglobulin was given together with antihypertensive therapy and mechanical ventilation, achieving an important clinical and imaging remission of PRES, but maintaining tetraparesis during the hospitalization. Twelve months after discharge and regular motor rehabilitation, the patient achieved complete autonomy on the activities of daily living. It has been postulated that the autonomic failure and the elevation of circulating pro-inflammatory cytokines in GBS may be the cause of a breach in the blood-brain barrier, thus causing PRES, that can completely remit with an adequate management.

Posterior Reversible Encephalopathy Syndrome.

PRES stands for Posterior Reversible Encephalopathy Syndrome. It is a proposed clinoneuroradiological entity that is characterized by headache, altered mental status, cortical blindness, seizure and other focal neurological signs and diagnostic magnetic resonance imaging picture. A variety of different etiologies have been reported like hypertension, preeclampsia, eclampsia, cyclosporine (and tacrolimus) neurotoxicity, uremia, sepsis, porphyria, SLE and interferon therapy. With early diagnosis and treatment the syndrome is usually fully reversible. A case of reversible encephalopathy is reported here in a 7-day postpartum female patient with marked elevation of blood pressure. Clinician and radiologist must be familiar with this clinically frightening, under diagnosed condition to assure timely diagnosis and treatment so as to prevent persistent defect.

Late postpartum preeclampsia with posterior reversible encephalopathy syndrome.

Posterior reversible encephalopathy syndrome is a reversible syndrome characterized by headache, seizures, altered mentation, and loss of vision associated with white matter changes on imaging. We report here a 27 year-old lady three weeks postpartum, presenting with posterior reversible encephalopathy syndrome. She was treated successfully with antihypertensives and showed dramatic improvement. This condition is important to recognize and needs to be treated promptly to prevent morbidity and mortality in pregnancy and postpartum.

Status epilepticus as a presenting sign of reversible posterior leukoencephalopathy syndrome in a liver transplant recipient

Reversible posterior leukoencephalopathy syndrome [RPLE] is an increasingly recognized disorder, most commonly associated with immunosuppressive and cytotoxic agent, malignant hypertension and toxemia of pregnancy. Neurological symptoms are headache, mental and visual disturbance, and seizures. Brain MRI findings are symmetrical bilateral hyper intense areas of occipital and parietal lobes in T2-weighted magnetic resonance [MR] images. This finding is reversible with prompt successful treatment which may take days to weeks for full reversal. We observed a case of status epilepticus which occurred 32 days after liver transplantation in a patient on regimen consisting of Tacrolimus [FK 506]. He had no history of neurologic disease or metabolic abnormalities. Typical findings of RPLE were present on brain MRI. The recurrence of seizures terminated after a few hours with adding Na-valproate to Phenytoin, Phenobarbital and Midazolam. The radiological finding of brain MRI gradually diminished after several weeks. A physician should be alert of seizures during early post transplant period of liver transplantation. He should bear in mind the diagnosis of RPLE and consider discontinuation of immunosuppressive drugs