Acute Reversible Posterior Encephalopathy Triggered by Sheath Removal Pain After Coronary Angiography: A Case Report

Abstract Background When acute neurological symptoms appear after coronary angiography, contrast-induced encephalopathy (CIE) and posterior reversible encephalopathy syndrome (PRES) are key differential diagnoses. Yet the role of acute peri-procedural pain as a potential trigger has received little attention. Case presentation A 77-year-old man with hypertension and stage 3 chronic kidney disease developed severe pain during radial sheath removal three hours after coronary angiography. Within seconds, he lost consciousness and had generalized tonic-clonic seizures. Blood pressure rose from 136/70 mmHg to 160/90 mmHg. CT perfusion imaging showed hypoperfusion in the left temporal and bilateral occipital lobes, with relatively preserved cerebral blood volume and cerebral blood flow, and prolonged mean transit time and time-to-peak. A second seizure occurred later that evening, without a clear pain trigger, suggesting a persistent process with a tendency for spontaneous recurrence. The patient recovered completely within four days with conservative management and remained symptom-free at six-month follow-up. CIE and PRES could not be definitively diagnosed because MRI and EEG were not performed. Conclusions This case suggests that acute peri-procedural pain may trigger acute reversible posterior encephalopathy. The temporal association—measured in seconds—between pain and neurological symptom onset is exceptionally rare. Clinicians should recognize the potential value of peri-procedural pain management in preventing such complications.