Cocaine-induced PRES in a previously normotensive patient: a case report and review of literature

Abstract Background Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological condition characterized by acute neurological manifestations and vasogenic cerebral oedema, typically affecting the parieto-occipital regions. Although acute hypertension is the most identified precipitating factor, the role of illicit substances such as cocaine is increasingly recognized yet remains underreported. Case presentation We describe a case of a 30-year-old white female admitted with generalized tonic-clonic seizure associated with a hypertensive crisis (210/130 mmHg), followed by acute visual disturbance. Initial non-contrast computed tomography of the brain raised concern for bilateral occipital infarction; however, subsequent magnetic resonance imaging revealed bilateral symmetrical vasogenic oedema without diffusion restriction, consistent with a diagnosis of PRES. Urine toxicology screening was positive for cocaine metabolites. The patient achieved complete neurological and visual recovery following prompt blood pressure control and initiation of antiepileptic therapy. A follow up MRI showed near complete resolution of previously noted hyperintensities. Conclusion This case underscores cocaine-induced PRES as an important differential diagnosis in young patients presenting with seizures, severe hypertension, and posterior circulation imaging abnormalities. Early recognition is crucial to prevent misdiagnosis as acute ischemic stroke and to avoid potentially irreversible neurological sequelae.