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Shortly after admission, his blood pressure increased to 248/150?mmHg. He became lethargic and suffered a second episode of seizure activity, which was successfully treated with Lorazepam followed by a loading dose of Phenobarbital. His blood pressure was titrated with a nicardipine infusion for a target range of 120�C140?mmHg systolic and 70�C80?mmHg Talazoparib concentration diastolic. Initial diagnosis A renal ultrasound revealed a smaller right kidney (length 6.4?cm) as compared to the left (length 7.6?cm). The right kidney when compared to the left had less cortical thickness and increased echogenicity suggestive of vascular insult. The vessels were not completely visualized via color Doppler. MRI of the brain without contrast demonstrated features consistent with PRES (Figure ?(Figure1).1). MRI of the abdomen with contrast showed a small right kidney and a high-grade proximal renal artery stenosis (Figures ?(Figures11 and ?and2A).2A). Upper pole hypointense lesions of the right kidney consistent with long-standing ischemic insults. Diagnostic angiography later confirmed a complete occlusion of his renal artery accompanied by a 20% narrowing of the perirenal aorta. Video EEG was performed which exhibited frequent, focal spikes and sharp waves in the left temporal region. Seizure activity was thought to emanate from accrued pathological alterations in the brain regions specified. Figure 1 Pre-angioplasty MRI image showing high-grade proximal renal artery stenosis (A) and hyperintense lesions binedaline Dabrafenib supplier of PRES (B). Figure 2 Angiography of right renal artery (A), pre-balloon dilation and stenting (B), balloon dilation (C) stenting (D), post-balloon dilation and stenting. Outcome The right renal artery was balloon dilated to 50% as shown in Figure ?Figure2B.2B. This was complicated by renal artery re-stenosis, with a peak systolic velocity of 200?cm/s (normal