A 33 year-old woman with history of obstructive sleep apnea, obesity, and severe hypertension, was hospitalized for symptoms of headache, shortness of breath, blurry vision, and generalized fatigue. She had hypertensive urgency (SBP 260s/150s), with non-ST elevation MI, and pulmonary edema due to acute renal failure necessitating hemodialysis. Brain MRI revealed significant cerebellar edema leading to mild obstructive hydrocephalus as well as edema of the medulla and pons, consistent with central variant of PRES. Also noted was a partially empty sella turcica. Blood pressure normalized with anti-hypertensives. Repeat MRI showed resolution of edema and hydrocephalus.

She returned 3 weeks from initial presentation with worsening vision and headache, vomiting, and pulsatile tinnitus. Ophthalmologic exam revealed papilledema with grade 4-5 disc edema with hemorrhages and exudates, with severe visual impairment (20/200 OD, finger counting OS). Repeat brain MRI demonstrated continued resolution of edema and hydrocephalus, with partially empty sella turcica and indentation of the posterior globes. MRV showed left>right, severe transverse sinus stenosis without thrombosis. Opening pressure on lumbar puncture was 65 cm H2O.  She underwent urgent stenting of the left transverse sinus and was started on acetazolamide. Vision improved to 20/100 OD (20/30 with pinhole) and 20/200 OS (same with pinhole) with improvement in headache and tinnitus.

We present a patient with central variant of PRES who responded well to control of blood pressure with improvement in clinical and imaging findings. She subsequently developed findings suggestive of IIH with worsening vision which responded to stenting of a stenotic transverse sinus.  We suggest evaluating for transverse sinus stenosis in patients with central PRES.