Midodrine‐Associated Posterior Reversible Encephalopathy Syndrome Following Medullary and Cervical Spinal Cord Infarction in a Child

ABSTRACT Introduction Posterior reversible encephalopathy syndrome (PRES) is a clinico‐radiological syndrome driven by disrupted cerebral autoregulation, typically in the setting of acute hypertension, toxic drug exposure, or endothelial injury. Midodrine, an alpha‐1 adrenergic agonist widely prescribed for neurogenic orthostatic hypotension, can generate paradoxical supine hypertension of sufficient magnitude to overwhelm cerebrovascular autoregulatory capacity; its role as a precipitant of PRES, mediated indirectly through this hemodynamic effect rather than through direct cerebral toxicity, remains under‐recognized. Case Presentation We report a 13‐year‐old male who developed radiologically confirmed PRES within five days of commencing midodrine for autonomic dysfunction following a combined medullary and anterior cervical spinal cord infarction. Discontinuation of midodrine was followed by clinical resolution within seven days and near‐complete radiological resolution on follow‐up imaging after 6 weeks. Conclusion To our knowledge, this is among the first reported pediatric cases of PRES temporally associated with midodrine therapy. We contextualize it within the existing literature of autonomic dysfunction and midodrine‐associated PRES and discuss implications for pediatric prescribing and monitoring.