[Medical Human Story – Episode 73]-Part II: The Invisible Enemy—When the Brain's Blood Vessels Began to Fail

 

[MHS: Medical Human Story]-Episode 73

     Prologue | Part 1 | Part 2 | Part 3 | Part 4 & Epilogue

Part II: The Invisible Enemy—When the Brain's Blood Vessels Began to Fail

Night Always Begins at Its Quietest Moment


The lights in the intensive care unit were not dim.

Yet every face seemed burdened by the weight of the night.

I had just lifted a cup of coffee in the on-call room

when my phone rang.

"Professor."

The resident's voice was trembling.

"Ms. Yoon-Hee Kim..."

"...has started having seizures."

I quietly set the cup back down.

Steam was still rising from the coffee,

but I never managed to take a single sip that night.

Rushing to the Patient's Room


As soon as the door opened,

the intensive care unit was already filled with tension.

A nurse was securing the oxygen mask.

A resident was preparing an anticonvulsant.

The patient's arm was trembling.

Her eyes had deviated to one side.

On the monitor,

her heart rate was climbing rapidly.

"Prepare Levetiracetam."

"Blood pressure?"

"One hundred ninety-eight over one hundred sixteen."

"Continue the Nicardipine infusion."

"Oxygen saturation?"

"Ninety-four percent."

Even within those brief exchanges,

every member of the medical team was thinking the same thing.

Is the brain swelling again?

Has the hemorrhage expanded?

Has this progressed to cerebral infarction?

Approximately half of patients with Posterior Reversible Encephalopathy Syndrome (PRES) experience seizures, and a subset may progress to status epilepticus. Prompt administration of antiepileptic medication, aggressive blood pressure control, and intensive care monitoring are therefore strongly recommended.


[Insert Figure]


Her Memories Were Beginning to Fade


After the seizure subsided,

she slowly opened her eyes.

"...Where..."

"...am I?"

I gently called her name.

"Ms. Yoon-Hee Kim."

"...Can you hear my voice?"

She looked at me.

But there was no recognition in her eyes.

"I'm sorry..."

"...who are you?"

For a moment,

the entire room fell silent.

Her husband struggled to hold back his tears.

I smiled reassuringly.

"It's alright."

"Your memory may be a little confused right now."

The truth, however,

was that my own heart was unsettled.

PRES is considered a reversible disease—

but it is not always reversible.

If diagnosis is delayed,

if blood pressure cannot be adequately controlled,

or if hemorrhage progresses,

the chances of recovery diminish with every passing hour.

Doctors Feel Fear Too


Many people believe

that doctors do not experience fear.

But that is simply not true.

We live with fear every day.

Fear that we might overlook a single CT image.

Fear that we might misinterpret one MRI slice.

Because an entire lifetime

can depend on a single clinical judgment.

I reopened the MRI study.

FLAIR.

DWI.

ADC.

GRE.

Images I had reviewed countless times before.

Yet this time,

I asked myself a different question.

"What if..."

"...we've missed something?"

When evaluating Posterior Reversible Encephalopathy Syndrome (PRES), radiologists assess far more than the mere presence of abnormalities. Careful attention is paid to bilateral involvement, posterior-predominant distribution, white matter localization, the absence of diffusion restriction on DWI, and the presence or absence of associated hemorrhage.


[Insert Figure]


[Medical Insight]


The Husband's Confession


Two o'clock in the morning.

Her husband quietly asked me to step into the hallway.

"Professor..."

"...this is my fault."

I remained silent.

He stared at the wall.

"I knew her blood pressure was high."

"...She had medication."

"...But..."

"...she kept saying she was fine."

"...that she only needed to rest."

"...I never insisted that she go to the hospital."

He buried his face in his hands.

"...Did I..."

"...cause this?"

I gently placed my hand on his shoulder.

"No."

"Hypertension often remains completely silent for years."

"And then, without warning, it can suddenly become a neurological emergency."

"What matters most now..."

"...is not the past."

"It's what we do from this moment forward."

He wept quietly.

A physician

must treat not only disease,

but also the guilt carried by those who love the patient.

The Predawn Conference


Neurology.

Critical Care Medicine.

Radiology.

Neurosurgery.

Four o'clock in the morning.

An emergency multidisciplinary conference convened.

"An aneurysm?"

"None on CT angiography."

"Vasculitis?"

"Unlikely."

"Reversible cerebral vasoconstriction syndrome?"

"The imaging findings don't fit."

"Cerebral infarction?"

"DWI is negative."

Silence settled over the conference room.

Finally,

the neurologist spoke.

"The most likely diagnosis..."

"...is hemorrhagic PRES."

I quietly nodded.

The images were telling us the story.

And

we chose to trust what they were saying.

The differential diagnosis of PRES includes posterior circulation infarction, multiple sclerosis, hypoxic-ischemic encephalopathy, cerebral amyloid angiopathy, and other neurological disorders. Accurate diagnosis requires careful integration of both imaging findings and the patient's clinical presentation.

[Insert Figure]


A Letter Left by the Patient's Daughter


As dawn slowly approached,

her daughter placed a small handwritten note beside the bed.

Mom,

We still haven't taken that trip together.

You still haven't met your grandchildren.

So...

Please hold on a little longer.

I still need my mom.

After reading the letter,

I closed my eyes for a moment.

Physicians

read countless scientific papers.

Yet sometimes,

a single letter written by a family member

has greater healing power

than any medical textbook ever published.

[Medical Recommendation]


Part I:  The Strom Arrived Without a Single Warning☜ Previous Chapter  

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