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Figure?1. (A) MRI without contrast enhancement FLAIR signal showing hyperintensity in the right parietal lobe (white arrow), head of caudate nucleus (asterisk) and adjacent white matter. (B) Sequential image of series showing hyperintensity in the temporal lobe ... Figure?2. MRA without contrast enhancement using time-of-flight technique shows diminished flow in right MCA M1 (white arrow) and bilateral ACA A1 segments (black arrows). MRA, magnetic resonance angiography; MCA, middle cerebral artery; ACA, anterior cerebral ... Initial hospital course Over the next 96 h intravenous nicardipine (dose range of 2�C10 ?g/kg/min) and furosemide (0.1 mg/kg/h) were infused in an attempt to normalize BP to less than the 90th percentile for height (126/81 mmHg) (Figure?3). Her mental and neurological status returned Vemurafenib in vitro http://www.selleckchem.com/products/INCB18424.html to baseline without appreciable deficits and she was extubated. Over a 2-week hospital course she was transitioned to oral antihypertensive agents including amlodipine 5 mg twice daily, atenolol 50 mg daily, clonidine 0.1 mg twice daily, lisinopril 2.5 mg twice daily and furosemide 40 mg twice daily (Figure?3). Evaluation for autoimmune disease and vasculitis included ANA, ANCA, anti-GBM antibodies��all were negative. Complement levels: C3 and C4 were normal. ESR was elevated at 83 mm/h. Repeat MRI/MRA without contrast showed near complete resolution of previously seen T2/FLAIR hyperintensities although there was no flow in the right M1 and A1 segment. Even with this persistent MRA abnormality, her rapid return to normal without neurological deficit and near-complete resolution of FLAIR signal abnormalities was thought to be most consistent with PRES. Furthermore, kidney function remained compromised (creatinine peaked at 645.3 ?mol/L [7.3 mg/dL]; eGFR 10 mL/min/1.73 m2), and therefore we were reluctant to proceed with a conventional angiogram as it was likely to result in the need for dialysis due to contrast nephropathy. She was discharged Amiloride home on four antihypertensive agents and furosemide for a target BP at the 50th percentile for height with close follow up. Figure?3. Graphical representation of patient's blood pressure, target ranges and medications prescribed during initial hospitalization. Long-term management Over a 6-month period she remained on three or four antihypertensive medications which were adjusted to target a BP below 112/66 mmHg (50th percentile for height). In addition, she was started on epoetin alpha 2000 units2 weekly, calcitriol 0.25 ?g daily, sodium bicarbonate 1300 mg twice daily and calcium acetate 667 mg tab with food for chronic kidney disease (CKD) management. Kidney function improved (creatinine declined to 265.2 ?mol/L (3 mg/dL); eGFR 24 mL/min/1.73 m2), anemia was treated to a target of
