Posterior Reversible Encephalopathy Syndrome Presenting as Balint Syndrome

Balint syndrome is a disorder of inaccurate visually guided saccades, optic ataxia, and simultanagnosia that typically results from bilateral parieto-occipital lesions. Visual perception disturbances in the posterior reversible encephalopathy syndrome (PRES) include hemianopia, visual neglect, and cerebral blindness, but Balint syndrome had not been recognized. We report Balint syndrome associated with PRES in a 37-year-old woman with acute hypertension and systemic lupus erythematosus. Balint syndrome can be an initial presentation of PRES.

Posterior Reversible Encephalopathy Syndrome Presenting as Balint Syndrome Sunil Kumar, FRCS, MS, Archana Abhayambika, MS, Arun N. E. Sundaram, MD, FRCPC, James A. Sharpe, MD, FRCPC Abstract: Balint syndrome is a disorder of inaccurate visually guided saccades, optic ataxia, and simulta-nagnosia that typically results from bilateral parieto-occipital lesions. Visual perception disturbances in the posterior reversible encephalopathy syndrome (PRES) include hemianopia, visual neglect, and cerebral blind-ness, but Balint syndrome had not been recognized. We report Balint syndrome associated with PRES in a 37-year-old woman with acute hypertension and systemic lupus erythematosus. Balint syndrome can be an initial pre-sentation of PRES. Journal of Neuro-Ophthalmology 2011;31:224-227 doi: 10.1097/WNO.0b013e31821b5f92 2011 by North American Neuro-Ophthalmology Society Posterior reversible encephalopathy syndrome (PRES) is characterized by seizures, headache, and visual symp-toms with hyperintense signals due to vasogenic edema predominantly involving the parieto-occipital region on T2 or FLAIR sequence of MRI (1,2). The central nervous system manifestations of systemic lupus erythematosus (SLE) are diverse (3). However, PRES associated with SLE has seldom been reported (4). Inaccuracy of visually guided saccades, optic ataxia, and simultanagnosia, the cardinal features of Balint syndrome, usually occurs with bilateral parieto-occipital lesions (5). We report Balint syndrome as the initial presentation of PRES in a patient with SLE. CASE REPORT A 37-year-old woman complained of abdominal pain, nausea, vomiting, alopecia, malar rash, and arthritis. Her serum was positive for anti-double-stranded DNA and an-ticardiolipin antibodies. SLE was diagnosed and treated with intravenous methylprednisolone. Her blood pressure was elevated, and lupus nephritis was presumed responsible, but serum creatinine was normal (64 mmol/L; normal range, 50-90 mmol/L), and renal biopsy was not performed. Two weeks after initial presentation, she rapidly devel-oped bilateral impairment of vision. Her medical history was unremarkable. Physical examination was remarkable for a blood pressure of 190/150 mm Hg. The mini mental status examination was normal. Her visual acuity was dif-ficult to assess because she made erroneous saccades toward optotypes but was at least 20/400 in each eye. She was able to count fingers in the left hemifield of each eye but per-ceived only hand movement in the right hemifields. Pupils were 3 mm and reacted normally to light. Ductions were full and pursuit was saccadic. Although the patient had full range of volitional saccades to directional commands, she could not make visually guided saccades to small or large objects in any direction. That is, saccades were generated in directions that grossly missed fixation of visual objects presented in portions of the visual fields where they could be seen. Hand movements were dysmetric when the patient attempted to grasp a viewed object but accurate toward her own body parts. She was unable to recognize more than 1 item at a time when presented with the Cookie Theft Picture (6). Dilated fundus examination was normal. Three days later, automated visual field testing showed a right inferior homonymous quadrantanopia. Visual evoked potentials were normal. Epileptiform changes emanating from the occipital lobes were recorded on electroencepha-logram. MRI on the day of admission to hospital showed extensive FLAIR hyperintensity within the parietal, occip-ital, and frontal lobes. Diffusion-weighted imaging (DWI) Division of Neurology and Department of Ophthalmology and Vision Sciences, University Health Network, University of Toronto, Toronto, Ontario, Canada. The authors report no conflicts of interest. Address correspondence to Sunil Kumar, FRCS, MS, University Health Network W5-815 TWH, 399 Bathurst Street, Toronto M5T 2S8, Canada; Email: [e-mail] 224 Kumar et al: J Neuro-Ophthalmol 2011; 31: 224-227 Original Contribution Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. and apparent diffusion coefficient (ADC) demonstrated restricted diffusion in some of the involved areas (Fig. 1). Magnetic resonance venography was normal. Hypertension was treated with angiotensin-converting enzyme inhibitors, and prednisone, mycophenolic acid, and hydroxychloroquine were given to treat SLE. Optic ataxia resolved 6 days after the initiation of treatment. Simulta-nagnosia and impaired visually guided saccades resolved at 3-month follow-up. Six months following initial pre-sentation, the patient's vision improved to 20/80 in each eye, and the right inferior homonymous quadrantanopia resolved. Brain MRI six months following initial pre-sentation showed a significant improvement. FLAIR hyperintense signals in the parietal lobes had resolved, while areas of increased signals in the occipital lobes were consistent with residual gliosis (Fig. 2). DISCUSSION The term Balint syndrome was proposed in 1954 (7) to denote the clinical features of a patient reported by Rudolf Balint in 1907 (8). These included inaccurate visually guided saccades, optic ataxia, and simultanagnosia. As in our case, visual field defects, though not an element of Balint syndrome, have also been reported (9). Bilateral parieto-occipital ischemia due to arterial occlusive disease (10,11) or acute hypotension (12) is the dominant cause of Balint syndrome (Table 1). Patients with Balint syndrome are unable to make accu-rate voluntary or reflexive saccades to visual targets, despite an unrestricted range of eye movements. These inaccurate sac-cades, described as ‘‘psychic paralysis of gaze'' by Balint are sometimes incorrectly referred to as ocular motor apraxia (17). Optic ataxia consisting of inaccurate visually guided limb movements, despite intact motor function, is a cardinal feature of Balint syndrome (18). Patients with Balint syn-drome exhibit defective perception of objects in the visual field, except for isolated objects of attention. If attention is FIG. 1. A. Axial brain MRI with FLAIR sequences demonstrates increased signal in parietal, occipital, and frontal lobes bilaterally. B. DWI shows increased signal in the parieto-occipital cortex bilaterally and in the left frontal subcortex. C. ADC map reveals areas of abnormality corresponding to DWI, consistent with restricted diffusion and cytotoxic damage. FIG. 2. Six months after the onset of symptoms increased FLAIR signal in occipital lobes, which is suggestive of residual gliosis. Kumar et al: J Neuro-Ophthalmol 2011; 31: 224-227 225 Original Contribution Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. shifted from the previously appreciated object, regardless of size, it is not perceived (18). Patients can describe only a series of single objects and are unable to describe an entire scene. Balint (8) described this focal attention as ‘‘fatigability of attention,'' which is now termed ‘‘simultanagnosia.'' Our patient exhibited all these features. Reversible white matter edema presenting with head-ache, decreased alertness, altered mental functioning, seiz-ures, and abnormalities of visual perception was reported as the reversible posterior leukoencephalopathy syndrome (RPLS) (1). It became apparent that RPLS was a misnomer as it is not always reversible, may extend beyond the pos-terior region of brain, and can involve both white and gray matter. Stott et al (19) proposed an alternate designation of PRES. Vision perception disturbances include hemianopia, visual neglect, and cerebral blindness (20), but Balint syndrome had not been recognized in PRES. PRES may occur in numerous clinical settings (Table 2), although severe hypertension is a major predisposing factor (27). Recurrence has been reported in 4% of patients (28). Cerebral edema in PRES predominates in the parieto-occipital region but is often more widespread involving the frontal lobe, temporo-occipital junction, and cerebellum (29). Isolated edema of the brainstem or basal ganglia has been reported in atypical PRES (29). This edema com-monly involves the border zone of cerebral arterial terri-tories. Bilateral symmetrical edema mainly involving the subcortical white matter is a typical MRI finding. In-creased apparent diffusion coefficients (ADCs) accompa-nied by anisotropy loss in the involved regions on DWI and diffusion-tensor sequences suggest reversible vasogenic edema as an underlying pathophysiology (30). The absence of abnormalities on DWI predicts a favorable outcome. Most often DWI and ADC changes are consistent with vasogenic edema, which is also associated with a favorable prognosis. However, increased signal on DWI accompa-nied by a reduced ADC signal indicates cytotoxicity and cell loss from ischemic necrosis (4). Focal areas of restricted diffusion representing infarction or tissue injury with cy-totoxic edema are uncommon (11%-26%) in PRES (31). Such tissue injury may lead to gliosis and result in per-manent hyperintense signal alterations on FLAIR (32). Nevertheless, DWI, even with ADC maps, is limited in precisely predicting the clinical course of PRES (33). Possible mechanisms of PRES are controversial. A hyper-tension- hyperperfusion theory holds that hypertension over-whelms the autoregulatory capability of brain vasculature leading to capillary bed injury, vasogenic edema, and hyper-perfusion (34). This theory does not explain PRES in nor-motensive patients, the negative correlation between severity of hypertension and PRES, or drug-induced PRES. Second theory deals with activation of T cells, considered to play an important role in the development of PRES in association with toxemia of pregnancy, allogenic bone marrow transplant, solid organ transplant, infection, autoimmune diseases, and che-motherapy. Cytokines released by activated T cells trigger activation, augmented surface marker expression, and diffuse injury of endothelial cells. Cytokine-induced leukocytes ad-herence and tissue migration (trafficking) causes microcircu-latory dysfunction. Endothelial damage and leukocyte trafficking seem to play an important role in cerebral hypo-perfusion and vasogenic brain edema in PRES. Depletion of endothelium-derived nitric oxide, leading to platelets aggre-gation and vasoconstriction, is postulated to play an important role in pathophysiology of PRES (35). Biopsy obtained during the acute stage of PRES demonstrates vasogenic edema, re-active astrocytes, and microglia and evidence of endothelial activation (36). The role of SLE in the pathogenesis of PRES is often unclear. Often multiple factors associated with PRES are found in the SLE patient population, including hyperten-sion, nephritis, and immunosuppressive drugs. In our TABLE 1. Medical conditions associated with Balint syndrome (6,13-16) Arterial occlusive disease Acute hypotension Alzheimer disease Corticobasal degeneration Posterior cortical atrophy Creutzfeldt-Jakob disease Progressive multifocal leukoencephalopathy Head trauma Subacute HIV encephalitis Cerebral toxoplasmosis Brain metastasis TABLE 2. Medical conditions and drugs associated with PRES (21-26) Hypertension Eclampsia Acute glomerulonephritis Systemic lupus erythematosus Allogenic bone marrow transplant Solid organ transplants Thrombotic thrombocytopenic purpura Hemolytic uremic syndrome Severe infection or sepsis Guillain-Barre syndrome Porphyria Multisystem mitochondrial disorder Hypercalcemia Cyclosporine Tacrolimus Sunitinib Bevacizumab Infliximab Cisplatin Intravenous immunoglobulin Methotrexate Dexamethasone Erythropoietin 226 Kumar et al: J Neuro-Ophthalmol 2011; 31: 224-227 Original Contribution Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. patient, the relative roles of acute hypertension and cerebral SLE in the pathogenesis are not known. Either of both may have been responsible. The MRI appearance of PRES in SLE does not differ from PRES due to other causes (37). To our knowledge, Balint syndrome has not been pre-viously described in association with PRES. Fortunately, the outcome of this syndrome is typically favorable (38), as illustrated by the rapid resolution of Balint syndrome in our patient. REFERENCES 1. Hinchey J, Chaves C, Appignani B, Breen J, Pao L, Wang A, Pessin MS, Lamy C, Mas JL, Caplan LR. A reversible posterior leukoencephalopathy syndrome. N Engl J Med. 1996;334:494-500. 2. Bartynski WS, Boardman JF. Distinct imaging patterns and lesion distribution in posterior reversible encephalopathy syndrome. AJNR Am J Neuroradiol. 2007;28:1320-1327. 3. Jennekens FG, Kater L. The central nervous system in systemic lupus erythematosus. Part 1. Clinical syndromes: a literature investigation. Rheumatology (Oxford). 2002;41: 605-618. 4. Ishimori ML, Pressman BD, Wallace DJ, Weisman MH. Posterior reversible encephalopathy syndrome: another manifestation of CNS SLE? Lupus. 2007;16:436-443. 5. Rizzo M, Vecera SP. Psychoanatomical substrates of Balint's syndrome. J Neurol Neurosurg Psychiatry. 2002;72:162-178. 6. Mendez MF. Corticobasal ganglionic degeneration with Balint's syndrome. J Neuropsychiatry Clin Neurosci. 2000; 12:273-275. 7. Hecaen H, De Ajuriaguerra J. Balint's syndrome (psychic paralysis of visual fixation) and its minor forms. Brain. 1954; 77:373-400. 8. Balint R. Seenlenla¨hmung des ‘‘Schauens,'' optische ataxie, ra¨umliche Sto¨rung der Aufmerksamkeit. Monatsschr Psychiatr Neurol. 1909;25:51-81. 9. Gurjinder PS, Dhand UK, Chopra JS. Balint's syndrome following eclampsia. Clin Neurol Neurosurg. 1989;91:161-165. 10. Hijdra A, Meerwaldt JD. Balint's syndrome in a man with border-zone infarcts caused by atrial fibrillation. Clin Neurol Neurosurg. 1984;86:51-54. 11. Montero J, Pena J, Genis D, Rubio F, Peres-Serra J, Barraquer-Bordas L. Balint's syndrome. Report of four cases with watershed parieto-occipital lesions from vertebrobasilar ischemia or systemic hypotension. Acta Neurol Belg. 1982;82:270-280. 12. Mejia NI, Park S, Ning M, Buonanno FS. Pearls and Oy-sters: reversible iatrogenic Balint syndrome. Neurology. 2008;70: e97-e98. 13. Mendez MF, Cherrier MM. The evolution of alexia and simultanagnosia in posterior cortical atrophy. Neuropsychiatry Neuropsychol Behav Neurol. 1998;11:76-82. 14. Uyama E, Uchino M, Ando M. Balint's syndrome. Neurology. 1995;45:2118-2119. 15. Kertesz A. Visual agnosia: the dual deficit of perception and recognition. Cortex. 1979;15:403-419. 16. Schnider A, Landis T, Regard M. Balint's syndrome in subacute HIV encephalitis. J Neurol Neurosurg Psychiatry. 1991;54:822-825. 17. Sharpe J, Johnston JL. Ocular motor apraxia versus paresis. Ann Neurol. 1989;25:209. 18. Moreaud O. Balint syndrome. Arch Neurol. 2003;60: 1329-1331. 19. Stott VL, Hurrell MA, Anderson TJ. Reversible posterior leukoencephalopathy syndrome: a misnomer reviewed. Intern Med J. 2005;35:83-90. 20. Nguyen-Lam J, Kiernan MC. Acute cortical blindness due to posterior reversible encephalopathy. J Clin Neurosci. 2008; 15:1182-1185. 21. da Silva FMDRS, Pego PMB, Vendrell MCH, Farias MJDABFDS, Timoteo ACR, da Costa MCM, Cravo IMMBM, Gomes FMR. Posterior reversible encephalopathy syndrome and anti-angiogenic agents: a case report. J Neuroophthalmol. 2011;35:32-37. 22. Amagada JO, Kondagunta H, Afshan N, Watermeyer S, Jones R. Posterior reversible encephalopathy syndrome secondary to eclampsia. J Obstet Gynaecol. 2008;28: 646-647. 23. Siegal D, Keller A, Xu W, Bhuta S, Kim DH, Kuruvilla J, Lipton JH, Messner H, Gupta V. Central nervous system complications after allogeneic hematopoietic stem cell transplantation: incidence, manifestations, and clinical significance. Biol Blood Marrow Transplant. 2007;13: 1369-1379. 24. Burrus TM, Mandrekar J, Wijdicks EFM, Rabinstein AA. Renal failure and posterior reversible encephalopathy syndrome in patients with thrombotic thrombocytopenic purpura. Arch Neurol. 2010;67:831-834. 25. Bennett B, Booth T, Quan A. Late onset seizures, hemiparesis and blindness in hemolytic uremic syndrome. Clin Nephrol. 2003;59:196-200. 26. Bartynski WS, Boardman JF, Zeigler ZR, Shadduck RK, Lister J. Posterior reversible encephalopathy syndrome in infection, sepsis, and shock. AJNR Am J Neuroradiol. 2006; 27:2179-2190. 27. Everett CM, Turner B, Lobo M. Posterior reversible encephalopathy syndrome in (low renin) essential hypertension. J R Soc Med. 2007;100:522-523. 28. Sweany JM, Bartynski WS, Boardman JF. ‘‘Recurrent'' posterior reversible encephalopathy syndrome: report of 3 cases-PRES can strike twice! J Comput Assist Tomogr. 2007;31:148-156. 29. McKinney AM, Short J, Truwit CL, McKinney ZJ, Kozak OS, SantaCruz KS, Teksam M. Posterior reversible encephalopathy syndrome: incidence of atypical regions of involvement and imaging findings. Am J Roentgenol. 2007; 189:904-912. 30. Mukherjee P, McKinstry RC. Reversible posterior leukoencephalopathy syndrome: evaluation with diffusion-tensor MR imaging. Radiology. 2001;219:756-765. 31. Bartynski WS. Posterior reversible encephalopathy syndrome, part 1: fundamental imaging and clinical features. AJNR Am J Neuroradiol. 2008;29:1036-1042. 32. Doelken M, Lanz S, Rennert J, Alibek S, Richter G, Doerfler A. Differentiation of cytotoxic and vasogenic edema in a patient with reversible posterior leukoencephalopathy syndrome using diffusion-weighted MRI. Diagn Interv Radiol. 2007;3:125-128. 33. Pande AR, Ando K, Ishikura R, Nagami Y, Takada Y, Wada A, Watanabe Y, Miki Y, Uchino A, Nakao N. Clinicoradiological factors influencing the reversibility of posterior reversible encephalopathy syndrome: a multicenter study. Radiat Med. 2006;24:659-668. 34. Bartynski WS. Posterior reversible encephalopathy syndrome, part 2: controversies surrounding pathophysiology of vasogenic edema. AJNR Am J Neuroradiol. 2008;29:1043-1049. 35. Jecko T. A clue to the pathophysiology of posterior reversible encephalopathy syndrome. Arch Neurol. 2010;67:1536. 36. Horbinski C, Bartynski WS, Carson-Walter E, Hamilton RL, Tan HP, Cheng S. Reversible encephalopathy after cardiac transplantation: histologic evidence of endothelial activation, T-cell specific trafficking, and vascular endothelial growth factor expression. AJNR Am J Neuroradiol. 2009;30:588-590. 37. Mueller-Mang C, Mang T, Pirker A, Klein K, Prchla C, Prayer D. Posterior reversible encephalopathy syndrome: do predisposing risk factors make a difference in MRI appearance? Neuroradiology. 2009;51:373-383. 38. Roth C, Ferbert A. Posterior reversible encephalopathy syndrome: long-term follow-up. J Neurol Neurosurg Psychiatry. 2010;81:773-777. Kumar et al: J Neuro-Ophthalmol 2011; 31: 224-227 227 Original Contribution Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.