OBJECTIVE : To explore the clinical and imaging characteristics and summarize the causes of missed diagnosis of reversible posterior leukoencephalopathy syndrome (RPLS) in eclampsia. METHODS : We collected the data of a total of 45 patients with RPLS who were misdiagnosed initially (27 cases were confirmed and 18 cases were suspicious) out of 804 patients with severe eclampsia who had presented themselves to the Affiliated Hospital of Xuzhou Medical University from January 2014 to December 2016. We summarized the clinical and imaging characteristics of the patients and analyzed the possible causes of the misdiagnosis. RESULTS : Among the 804 patients with eclampsia, 45 were misdiagnosed the first time. Their clinical manifestations included headache (20 cases), epilepsy (13 cases), blurred vision (11 cases), disturbance of consciousness (2 cases), and drowsiness (3 cases). The parietal lobe was involved in 22 cases, the occipital lobe in 15 cases, the frontal lobe in 20 cases, basal ganglia in 9 cases, and the temporal lobe in 8 cases. Low-density lesions were observed on computed tomography (CT) scans. Head magnetic resonance (MR) scans showed hypo-intense lesions on T1-weighted image (T1WI), hyper-intense lesions on the T2-weighted image (T2WI) and fluid-attenuated inversion recovery (FLAIR), iso-intense or slightly hyper-intense lesion on diffusion-weighted imaging (DWI), and slightly hyper-intense or hypo-intense lesion on apparent diffusion coefficient (ADC). CONCLUSIONS : The incidence of reversible posterior leukoencephalopathy syndrome is extremely high. The clinical features include headache, mental disturbance, seizures, blurred vision, and other neurological symptoms. The lesion area is mainly limited to the parietal and occipital lobes; however, the frontal lobe, basal ganglia, temporal lobe, corpus callosum, and cerebellum can also be involved. The prognosis is good with timely and appropriate treatments.