High Blood Pressure and Reversible Strokes

Brain MRI is used to diagnose RPLS
Photo: Adam Gault / Getty Images

A syndrome known as reversible posterior leukoencephalopathy syndrome, or RPLS, is a rare, stroke-like condition caused by swelling in the brain. Reversible posterior leukoencephalopathy is usually associated with an episode of extremely high blood pressure. However, the syndrome may develop in an unpredictable way before it resolves. And, because it is never guaranteed that a stroke or a stroke- like episide will eventually resolve, it is important to get medical attention for neurological symptoms.

If you have been told that you or a loved one has had reversible posterior leukoencephalopathy syndrome, you probably have a few questions about it.

One of the characteristics of RPLS is that it is reversible, which means that this condition is temporary and that its symptoms and MRI findings are transient. The regions of the brain affected by this syndrome  are located in the back of the brain. Leukoencephalopathy, is defined as a clouding of consciousness, confusion, or an altered mental state due to a condition that affects a large region of the brain. In the case of RPLS, it is the the white matter of the brain that is most predominantly affected. This condition is a syndrome. A syndrome is the constellation of symptoms of a disease that typically occur together whenever the disease worsens or 'acts up.'

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.

Variability of RPLS

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 through a careful medical workup which includes a careful history of the symptoms experienced by the patient, a neurological physical examination, an MRI of the brain, and the presence of high blood pressure around the time of the event. One research study, however, shows that some people might suffer from RPLS in the presence of a normal blood pressure. This may occur in a  condition called eclampsia, that most often is associated with late pregnancy or labor and delivery. Encepalopathy and leuokoencephalopathy can also occur in people who use certain medications.

Typically, the MRI of the brain of patients with RPLS shows an appearance of swelling in the white matter of the posterior region of the brain on both the left and right sides.

However, in some cases, RPLS can involve areas in the front of the brain or other regions of the brain, and it may even involve the gray matter. Furthermore, many cases of RPLS have left survivors with permanent brain damage, although in most cases a resolution of the swelling does occur. Improvement can typically be confirmed by a follow-up MRI of the brain.

How is it RPLS treated?

The treatment for RPLS consists is focused on closely controlling blood pressure and fluid levels in the body. Additionally,  preventing and treating seizures is an important component of the acute management of this condition. Closely watching symptoms such as headaches is an important component of determining urgent changes in the condition.

What is the prognosis?

Typically, symptoms resolve within a few days to weeks after the initial onset of RPLS. However, as with all episodes of stroke or mini stroke, there might be residual symptoms from brain damage.

Find out how a stroke causes brain damage.

Edited by Heidi Moawad MD


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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