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<front>
<journal-meta>
<journal-id journal-id-type="publisher-id">JNC</journal-id>
<journal-title-group>
<journal-title>Journal of Neurocritical Care</journal-title><abbrev-journal-title>J Neurocrit Care</abbrev-journal-title></journal-title-group>
<issn pub-type="ppub">2005-0348</issn>
<issn pub-type="epub">2508-1349</issn>
<publisher>
<publisher-name>Korean Neurocritical Care Society</publisher-name></publisher></journal-meta>
<article-meta>
<article-id pub-id-type="doi">10.18700/jnc.210027</article-id>
<article-id pub-id-type="publisher-id">jnc-210027</article-id>
<article-categories>
<subj-group>
<subject>Images in Neurocritical Care</subject></subj-group></article-categories>
<title-group>
<article-title>Posterior reversible encephalopathy syndrome as delayed neurological sequelae after carbon monoxide intoxication</article-title>
<alt-title alt-title-type="right-running-head">PRES after carbon monoxide</alt-title>
</title-group>
<contrib-group>
<contrib contrib-type="author">
<contrib-id contrib-id-type="orcid">http://orcid.org/0000-0002-3141-9205</contrib-id>
<name><surname>Lee</surname><given-names>Hyesun</given-names></name>
<degrees>MD</degrees>
<xref ref-type="aff" rid="af1-jnc-210027"/>
</contrib>
<contrib contrib-type="author">
<contrib-id contrib-id-type="orcid">http://orcid.org/0000-0001-6581-5831</contrib-id>
<name><surname>Park</surname><given-names>Jinseok</given-names></name>
<degrees>MD</degrees><degrees>PhD</degrees>
<xref ref-type="corresp" rid="c1-jnc-210027"/>
<xref ref-type="aff" rid="af1-jnc-210027"/>
</contrib>
<aff id="af1-jnc-210027">
Department of Neurology, Hanyang University College of Medicine, Seoul, <country>Korea</country></aff>
</contrib-group>
<author-notes>
<corresp id="c1-jnc-210027">Corresponding Author: Jinseok Park, MD, PhD Department of Neurology, Hanyang University College of Medicine, 222-1 Wangsimni-ro, Seongdong-gu, Seoul 04763, Korea Tel: +82-2-2290-8367 Fax: +82-2- 2296-8370 E-mail: <email>jinspark@hanyang.ac.kr</email></corresp>
</author-notes>
<pub-date pub-type="ppub">
<month>12</month>
<year>2021</year></pub-date>
<pub-date pub-type="epub">
<day>28</day>
<month>12</month>
<year>2021</year></pub-date>
<volume>14</volume>
<issue>2</issue>
<fpage>121</fpage>
<lpage>122</lpage>
<history>
<date date-type="received">
<day>14</day>
<month>10</month>
<year>2021</year></date>
<date date-type="rev-recd">
<day>8</day>
<month>12</month>
<year>2021</year></date>
<date date-type="accepted">
<day>13</day>
<month>12</month>
<year>2021</year></date>
</history>
<permissions>
<copyright-statement>Copyright &#x000A9; 2021 The Korean Neurocritical Care Society</copyright-statement>
<copyright-year>2021</copyright-year>
<license>
<license-p>This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc/4.0">http://creativecommons.org/licenses/by-nc/4.0</ext-link>) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p></license></permissions>
</article-meta></front>
<body>
<p>A 27-year-old woman attempted suicide and was diagnosed with acute carbon monoxide (CO) poisoning. Neurological examinations were normal except for confusion. Initial brain images showed no acute lesions (<xref rid="f1-jnc-210027" ref-type="fig">Fig. 1A</xref>) on the next day of admission. Twelve days after CO intoxication, severe headache, choreic movement of both upper extremities, and impaired visual acuity with optic ataxia, oculomotor apraxia, and simultanagnosia were observed. Cerebrospinal fluid findings showed pleocytosis (white blood cell, 135/mm<sup>3</sup>) with elevated protein level (134.8 mg/dL). From the follow-up brain magnetic resonance imaging, she was diagnosed with posterior reversible encephalopathy syndrome (PRES) as delayed neurologic sequelae (DNS) after CO intoxication (<xref rid="f1-jnc-210027" ref-type="fig">Fig. 1B</xref>). With steroid pulse therapy, she had clinical improvement (<xref rid="f1-jnc-210027" ref-type="fig">Fig. 1C</xref>). During the acute phase of CO poisoning, brain MRI shows signal changes in the bilateral globus pallidus (GP) with cytotoxic edema &#x0005b;<xref ref-type="bibr" rid="b1-jnc-210027">1</xref>&#x0005d;. PRES shows distinctive MRI findings of the parieto-occipital lesions with either vasogenic or cytotoxic edema or both &#x0005b;<xref ref-type="bibr" rid="b2-jnc-210027">2</xref>&#x0005d;. A patient with DNS with PRES was reported without GP involvement &#x0005b;<xref ref-type="bibr" rid="b3-jnc-210027">3</xref>&#x0005d;. However, in this case, DNS after CO intoxication affected not only the basal ganglia but also the parieto-occipital regions as PRES. Therefore, it is the reason that the patient presented with both chorea and Balint&#x02019;s syndrome simultaneously.</p>
</body>
<back>
<fn-group>
<fn><p><bold>Ethics statement</bold></p><p>This case was reviewed and approved by the Institutional Review Board of Hanyang University Hospital (IRB No. 2021-10-012). The need for informed consent from a patient was waived by the IRB.</p></fn>
<fn fn-type="conflict"><p><bold>Conflict of interest</bold></p><p>No potential conflict of interest relevant to this article.</p></fn>
<fn fn-type="financial-disclosure"><p><bold>Funding</bold></p>
<p>This research was supported by the research fund of Hanyang University (HY-202100000001136).</p></fn>
<fn fn-type="participating-researchers"><p><bold>Author contributions</bold></p>
<p>Conceptualization: JP. Data curation: all authors. Formal analysis: all authors. Funding acquisition: JP. Investigation: all authors. Project administration: all authors. Visualization: all authors. Writing–original draft: all authors. Writing–review &amp; editing: all authors.</p></fn>
</fn-group>
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<sec sec-type="display-objects">
<title>Figure</title>
<fig id="f1-jnc-210027" position="float">
<label>Fig. 1.</label><caption><p>Brain magnetic resonance imaging. (A) The day of carbon monoxide (CO) poisoning, fluid-attenuated inversion recovery (FLAIR) images showed no abnormal high signal intensity. (B) Twelve days from CO intoxication, FLAIR images showed high signal intensities in bilateral globus pallidus (red box) and both parieto-occipital cortex (yellow arrows), suggesting posterior reversible encephalopathy syndrome. (C) Twenty-five days after CO intoxication, follow-up FLAIR image was obtained from the outpatient visit, and it showed interval decrease of signal and volume in bilateral globus pallidus (green box) and temporo-parieto-occipital cortex (blue arrows).</p></caption>
<graphic xlink:href="jnc-210027f1.tif"/>
</fig>
</sec>
</back></article>