[The influence of citoflavin on molecular mechanisms of hypertensive encephalopathy development in patients with systolic arterial hypertension]

The molecular pharmacological effects of cytoflavin in patients with hypertensive encephalopathy (HE) and isolated systolic arterial hypertension (ISAH) have been investigated using the following methods: assessment of complaints, 24-hour arterial pressure monitoring, ultrasound diagnostics including echocardiography, measurement of lipid profiles and coagulograms, and molecular phenotyping by MALDI-TOF/TOF-MS. A combination of cytoflavin administration with standard therapy of HE and ISAH led to the most expressed return development of clinical symptoms, restoration of the hemodynamic, structural, and geometrical parameters of cardiovascular system, and normalization of the indices of lipid profiles and coagulograms in comparison to patients with HE and ISAH, which accepted only standard therapy. Molecular mechanisms of cytoflavin action have been revealed, which include control of the activity of cellular signaling pathways by means of intermolecular interactions. The optimized therapy of HE and ISAH is recommended for clinical application, which assumes a combined use of standard therapy and cytoflavin and provides a geroprotective action upon the cardiovascular system.

[Cytoflavin® effect on endothelium function and cerebral hemodynamics in patients with hypertensive enceplalopathy]

One hundred forty patients (the average age of 46.7 ± 7.7 years) with hypertensive encephalopathy (HE) were observed. 74 patients of the main group received Cytoflavin in a dose of 2 tablets twise a day in the standard basic therapy. 66 patients of the reference group received the basic therapy alone. The arterial endothelium function was estimated and ultrasonic examination of the hemodynamics at five structurally functional levels of the cerebral vascular course was used. All the patients with HE had endothelial dysfunction, bloodstream depression in the arterial course of the brain vascular system, decreased reactivity of the intracranial veins, difficulty in venous outflow. In the course of the therapy with Cytoflavin restotation of the arterial endothelial function in the patients with HE I stage, the linear and volume speed of bloodstream in the main and intracranial cerebral arteries in the patients with HE I-II stages, restoration of the intracranial veins reactivity, the linear speed of bloodstream in intracranial veins in the patients with all three stages of HE, the linear speed of bloodstream in the main veins up to the control values in the patients with I-III stages of HE were observed. Interrelation between the values of the cerebral hemodynamics and the state of the endothelium function was shown.

[Efficacy of the energy-modifier cytoflavin in the treatment of patients with hypertensive encephalopathy]

AIM

To evaluate the efficacy of cytoflavin in the treatment of patients with hypertensive encephalopathy (HE).

SUBJECTS AND METHODS

One hundred and forty patients aged 39 to 73 years, diagnosed with HE, were examined and randomized to 2 groups. A study group (n = 74) received cytoflavin in a dose of 2 tablets b.i.d. on days 1 to 25 days inclusive during standard basic therapy. A comparison group (n = 66 persons) had standard basic therapy only. A control group consisted of 30 apparently healthy individuals. The investigators studied the frequency of headache, dizziness, and other complaints and the intensity of cephalalgic syndrome, by using a visual analog scale, the quality of life by the Medical Outcomes Study 36-Item Short-Form Health Survey (MOS SF-36) questionnaire, that of sleep by the subjective sleep characteristics questionnaire elaborated at the Moscow City Somnological Center, the level of asthenia by a subjective asthenia rating scale (Multidimensional Fatigue Inventory (MFI-20), and autonomic status, by applying objective and subjective scales on days 1 and 25 of therapy.

RESULTS

The study has shown that cytoflavin used in the above dose for 25 days reduces the frequency and magnitude of complaints of headache, dizziness, "venous" complaints, the degree of autonomic and asthenic disorders, and impairments in the quality of sleep and life in the patients with HE at all disease stages. A stepwise discriminant analysis has indicated that the degree of cephalgic syndrome, and autonomic disorders, and worse sleep quality are the most effective points for using the energy-modifier cytoflavin.

CONCLUSION

HE treatment based on the current pathogenetic principles may have a preventive impact on the development of HE or slow down the rate of its progression.

[Cognitive functions and extracranial circulation in patients with hypertonic crisis]

We studied effects of enalaprilate and infedipine therapy on the cognitive functions and extracranial circulation in 60 patients with chronic AH complicated by acute encephalopathy. 10% of them had predemential disorders on day 1 of hospitalization and 90% mild cognitive problems. Half of the patients suffered reduced circulation in the common carotid artery. The contribution of impaired extracranial circulation to cognitive dysfunction in the acute period of hypertonic crisis was higher than that of high SAD and DAD. Antihypertensive therapy improved bloodflow in extracranial vessels, decreased their systolic and diastolic indices but failed to eliminate mild cognitive disorders in 65% of the patients. Visual-spatial orientation was restored more frequently than verbal auditory memory. Enalaprilate and infedipine had similar angio- and cerebroprotective effects but the latter had more pronounced favourable effect on verbal auditory memory than the former. The degree of recovery of cognitive function 2 weeks after hypertonic crisis depended not only on the form of cognitive disorder and therapeutic modality but also on the patient's age. Hemodynamic parameters and age 2 weeks after antihypertensive therapy are predictors of residual cognitive dysfunction soon (2 weeks) after recovery.

[Neyromidin in the treatment of stage I hypertensive dyscirculatory encephalopathy]

AIM

To evaluate the efficacy and safety of neyromidin in the treatment of Stage I hypertensive dyscirculatory encephalopathy (HDE) and to analyze long-term treatment results.

SUBJECTS AND METHODS

Fifty-seven with Stage I dyscirculatory encephalopathy in the presence of grades 1-2 arterial hypertension were examined. Clinical, psychological, and electrophysiological studies were performed and the efficacy of neyromidin was evaluated using the SANDOS geriatric scale. Neyromidin as monotherapy was used as one tablet (20 mg) b.i.d. during a meal. The duration of course treatment was 3 months.

RESULTS

Positive changes in the early manifestations of HDE were observed just on day 45 of therapy. The therapeutic effect of the drug manifested as a reduction in the degree of clinical symptoms. There were positive changes in attention, memory, kinetics, verbal associations, counting. The most noticeable improvement was seen in the values of memory and intellectual processes, suggesting higher working capacity, reduced fatigability, and eliminated sluggishness of intellectual processes. EEG displayed a higher amplitude level, a better response to rhythmic photostimulation, and a total power rise in a- and 8-ranges, which was indicative of the activated effect of neyromidin on the functional state of brain structures.

CONCLUSION

Neyromidin (20 mg b.i.d. for 3 months) was shown to be effective and well tolerated. The drug reduced the magnitude of clinical manifestations and improved psychological functions and electrophysiological parameters.

[Cardiorenal syndrome and prerenal azotemia in patients with acute hypertensive encephalopathy]

AIM

To estimate changes in renal function in patients with acute hypertensive encephalopathy (AHE) during standard inpatient antihypertensive therapy.

SUBJECTS AND METHODS

Patients were selected for the trial in the cardiology and admission units of a Perm hospital. The group included 60 patients with AHE. The patients received inpatient antihypertensive therapy for 10-14 days. Within the first 2 hours, enalaprilate 1.25 mg was intravenously injected, by monitoring blood pressure. After 6 hours, the patients were given enalaprilate tablets 20 mg b.i.d. plus hydrochlorothiazide 12.5 mg (Subgroup 1) or nifedipine 60 mg plus hydrochlorothiazide 12.5 mg (Subgroup 2). The laboratory parameters of kidney function were measured twice: on admission to and before discharge from hospital. Plasma creatinine and urea concentrations were estimated. Glomerular filtration rate (GFR) and urea/creatinine ratio were calculated. The patients were found to have proteinurea, low GFR, high plasma creatinine concentrations, and increased urea/creatinine ratio.

RESULTS

Transient proteinuria was observed in 25% of the patients with AHE within the first 24 hours of the disease. The proportion of patients with lower GFR was unchanged during a 2-week treatment period (20 and 16%, respectively; p = 0.22). There was a rise in the proportion of patients with higher urea/creatinine ratio (83 and 95%, respectively; p = 0.006).

CONCLUSION

The course of AHE is complicated by cardiorenal syndrome (CRS) with transient proteinuria and low GFR, as well as by prerenal azotemia (PRA). The number of patients with PRA increased after 2-week conventional inpatient antihypertensive therapy (enalaprilate + hydrochlorothiazide 12.5 mg or nifedipine + hydrochlorothiazide 12.5 mg).

Acute cortical blindness in preeclampsia--a case of reversible posterior encephalopathy syndrome

BACKGROUND

Cortical blindness is one the most disturbing symptoms of reversible posterior encephalopathy syndrome in preeclamptic and eclamptic patients. The disease has been previously associated with a hypertensive breakthrough in the autoregulation of posterior cerebral arterioles followed by extravasation of the fluid into the brain tissue.

CASE

22-year-old primigravida in the 39th week of gestation diagnosed with gestational diabetes mellitus presented with mild preeclampsia and was admitted to our hospital. Antihypertensive treatment was initiated. Her blood pressure remained between 120/80 to 140/90 mm Hg. Glucose levels were within acceptable range. Before the labor induction she developed acute cortical blindness. Magnetic resonance imaging showed vasogenic edema localized in occipital lobes. Cesarean section was performed and anti-edematous treatment initiated. Blindness resolved by the fifth day postpartum.

CONCLUSIONS

Reversible posterior encephalopathy developed in our patient in spite of normalized blood pressure that remained within autoregulation limits. Alternative pathogenesis and precipitating factors are discussed.

Hypertensive encephalopathy: a rare presentation of Williams-Beuren Syndrome

A male child of four years is reported with Williams-Beuren Syndrome (WBS). It was not recognized initially when he presented with odd facies and developmental delay since early infancy. The diagnosis was established later when he developed hypertensive encephalopathy secondary to bilateral renal artery stenosis, a congenital anomaly that must be looked for in such patients. No echographic evidence of congenital heart disease was found. Blood pressure estimation on routine physical examination of every child is emphasized. The diagnosis is mainly clinical as the definitive chromosomal studies are presently not available in Pakistan.

[Hypertensive emergency and urgency: clinical update]

Hypertensive crises (i.e., blood pressure > 180/120 mmHg) are common issues in the emergency department. This term is used to indicate both emergencies and urgencies, characterized by presence and absence of target organ damage, respectively. A wide range of therapeutic options are available. The aim of this article is to review current knowledge and treatment trends in the literature to provide clinicians with diagnostic and therapeutic tools.

Reversible cortical blindness: posterior reversible encephalopathy syndrome

Cortical blindness is defined as visual failure with preserved pupillary reflexes in structurally intact eyes due to bilateral lesions affecting occipital cortex. Bilateral oedema and infarction of the posterior and middle cerebral arterial territory, trauma, glioma and meningioma of the occipital cortex are the main causes of cortical blindness. Posterior reversible encephalopathy syndrome (PRES) refers to the reversible subtype of cortical blindness and is usually associated with hypertension, diabetes, immunosuppression, puerperium with or without eclampsia. Here, 3 cases of PRES with complete or partial visual recovery following treatment in 6-month follow-up are reported.

[When should a patient with severe hypertension be referred to the emergency ward?]

When a severe elevation of blood pressure occurs in conjunction with failure of a target organ, immediate referral of the patient to hospital is an easy decision for the primary care physician. However, when severe elevation of blood pressure is observed in the absence of any significant symptom, it is a much more difficult decision to take. Indeed, if some clinical situations require an immediate and aggressive anti-hypertensive therapy, such a treatment can be clearly deleterious for a number of other cases. This paper attempts to clarify in which situations the primary care physician should refer hypertensive crisis to the emergency department.

Posterior reversible encephalopathy syndrome: a case series in patients with eclampsia

Posterior Reversible Encephalopathy Syndrome (PRES) refers to a clinicoradiologic entity with characteristic features on neuro-imaging and non-specific symptoms comprising headache, confusion, visual disturbances and seizures. The lesions in PRES are thought to be due to vasogenic oedema, predominantly in the posterior cerebral hemispheres, and are reversible with appropriate management. We report 3 cases of acute PRES who had eclampsia and presented with recurrent episodes of seizures and hypertension. Their MRI scan showed diffuse abnormal signal intensities involving predominantly deep white matter of the occipital lobes. Based on the findings the most probable diagnosis of PRES was suggested. They were started on antihypertensive drugs. On follow-up examination after 5-7 weeks, the patients showed marked improvement clinically and on neuro-imaging following which they were discharged in stable condition.

[Impact of antihypertensive therapy on clinical status and quality of life in patients with initial manifestations of hypertensive encephalopathy]

AIM

To study the clinical and instrumental characteristics of hypertensive encephalopathy (HE) in early stages, as well as the time course of their changes during long-term antihypertensive therapy (AHT).

SUBJECTS AND METHODS

Prior to and after 9-month AHT, 57 patients aged 50-70 years who had uncomplicated grades 1-2 arterial hypertension (AH) with grades I-II HE underwent comprehensive examination comprising the studies of cognitive functions, quality of life (QL), hemorheology, and hemostasis, duplex scanning of great and intracerebral vessels, echocardiography, 24-hour blood pressure monitoring, magnetic resonance imaging.

RESULTS

Early-stage HE was characterized by more cerebral complaints, higher rates of hypertensive crises, a greater degree of psychoautonomic syndrome, and worse QL. Focal brain lesions were detected in 74%; left ventricular hypertrophy (LVH) was diagnosed in 61% of cases. All the patients were observed to have cognitive dysfunctions. AHT (amlodipine, lisinopril) produced a good antihypertensive effect and substantial improvements of the patients' cognitive functions, health status, and QL. LVH regression was achieved.

CONCLUSION

HE is a clinical manifestation of damage to the brain as the principal target organ in AH and should be therefore kept in mind in estimating the cardiovascular risk. The diagnosis of HE requires the use of tests to evaluate cognitive functions.

MR imaging findings of medulla oblongata involvement in posterior reversible encephalopathy syndrome secondary to hypertension

Although the combination of MR imaging findings and clinical evidence of hypertension may suggest the diagnosis of posterior reversible encephalopathy syndrome (PRES), MR imaging findings with only involvement of the medulla oblongata pose a diagnostic dilemma. In the cases presented here, we demonstrated MR imaging findings of a presumed brain stem (medulla oblongata) variant of PRES and emphasized the diagnostic value of diffusion-weighted imaging (DWI).

[How urgent is it to decrease high blood pressure?]

Severe hypertension represents a frequent problem for the general practitioner. One has to decide if the blood pressure needs to be decreased immediately (hypertensive emergency), or if the blood pressure maybe progressively decreased in a few hours and normalized in a few days (hypertensive crisis). Thus it is crucial to identify on the basis of the clinical history and a careful physical examination, the patients for whom the arterial blood pressure elevation represents an acute danger for organ damage or a vital threat in the absence of immediate blood pressure control. In the case of hypertensive crisis, oral medication is usually sufficient (slow release or GITS nifedipine, nitroglycerin, labetalol, captopril). The hypertensive emergency sometimes requires an oral medication before the admission to the emergency room, then followed by intravenous drug administration (sodium nitroprussiate, nitroglycerin, labetalol).

Clinical experience of childhood hypertensive encephalopathy over an eight year period

BACKGROUND

Hypertensive encephalopathy is an uncommon neurological syndrome in children, usually with reversible clinical and neuroimaging findings. Little is known about the precipitating factors, clinical presentations, neuroimaging findings and outcomes of childhood hypertensive encephalopathy in Taiwan.

METHODS

To characterize this syndrome, we retrospectively analyzed 12 children with hypertensive encephalopathy in a tertiary institution from 1998 through 2005. We investigated the precipitating factors, clinical findings, courses, neuroimaging characteristics and outcomes.

RESULTS

Twelve patients (10 boys and 2 girls) with hypertensive encephalopathy were identified. Post-streptococcal glomerulonephritis was the most common precipitating underlying disease. Common clinical presentations included mental change (100%), seizure (91.6%), headache (66.6%), nausea or vomiting (75%), and blurred vision (41.6%). Brain imaging studies showed vasogenic edema over the bilateral parietal, occipital and parasagittal regions, or the cerebellum. All patients had a reversible clinical course.

CONCLUSION

Hypertensive encephalopathy is predominant in males, and mental change is the most common clinical presentation. Renal origin is a common precipitating factor. A characteristic lesion of hypertensive encephalopathy is occipitoparietal region edema. The overall clinical outcome is good after prompt treatment.

Status epilepticus secondary to hypertensive encephalopathy as the presenting manifestation of Guillain-Barré syndrome

Malignant hypertension due to autonomic dysfunction is a known complication of Guillain-Barré syndrome. We describe a child who presented with status epilepticus secondary to hypertensive encephalopathy who, in recovery, was found to be areflexic. Nerve conduction studies confirmed the clinical diagnosis of Guillain-Barré syndrome. She was treated with antihypertensive and antiseizure medications and intravenous immune globulin with complete resolution of her autonomic symptoms and improvement in her weakness. Guillain-Barré syndrome may result in hypertensive encephalopathy that can manifest as status epilepticus before the onset of motor symptoms.

Management of hypertensive crises

Hypertensive emergencies are life-threatening conditions because their course is complicated with acute target organ damage. They can present with neurological, renal, cardiovascular, microangiopathic hemolytic anemia, and obstetric complications. After diagnosis, they require the immediate reduction of blood pressure (in <1 hour) with intravenous drugs such as sodium nitroprusside, administered in an intensive care unit. These patients present with a mean arterial pressure >140 mm Hg and grade III to IV retinopathy. Only occasionally do they have hypertensive encephalopathy, reflecting cerebral hyperperfusion, loss of autoregulation, and disruption of the blood-brain barrier. In hypertensive emergencies, blood pressure should be reduced about 10% during the first hour and another 15% gradually over the next 2 to 3 hours to prevent cerebral hypoperfusion. The exception to this management strategy is aortic dissection, for which the target is systolic blood pressure <120 mm Hg after 20 minutes. Oral antihypertensive therapy can usually be instituted after 6 to 12 hours of parenteral therapy. Hypertensive urgencies are severe elevations of blood pressure without evidence of acute and progressive dysfunction of target organs. They demand adequate control of blood pressure within 24 hours to several days with use of orally administered agents. The purpose of this review is to provide a rational approach to hypertensive crisis management.

Delayed diagnosis of posterior reversible encephalopathy syndrome (PRES) in a parturient with preeclampsia after inadvertent dural puncture

Posterior reversible encephalopathy syndrome is a rare complication generally associated with headache and acute changes in blood pressure. We present a case of posterior reversible encephalopathy syndrome where diagnosis was delayed because the patient also had preeclampsia and an inadvertent dural puncture, both associated with headache. The clinical challenge and the need for prompt diagnosis and treatment are emphasized.

[An old woman with sudden pareses and blindness]

We present a patient with Posterior Reversible Encephalopathy Syndrome (PRES). A 74-year-old woman was admitted with sepsis, which originated from erysipelas on her neck the following day. She developed respiratory obstruction due to oedema, septic shock, disseminated intravascular coagulation (DIC), acute renal failure and atrial fibrillation. She responded well to treatment and improved rapidly, despite of her serious condition. When she had almost fully recovered after 15 days, her general condition worsened, and she developed confusion, blindness and pareses. MRI showed vasogenic oedema in the parietooccipital regions of the brain and in the cerebellum, consistent with PRES. PRES is a clinical and radiological diagnosis consisting of headache, confusion, cortical blindness, convulsions and sometimes pareses. MRI of the cerebrum with diffusion-weighted imaging (DWI) and Apparent Diffusion Coefficient (ADC) map are decisive to the diagnosis, and usually shows a characteristic bilateral vasogenic oedema in the parietooccipital region. This can distinguish PRES from brain infarction, which shows a cytotoxic oedema on MRI. We discuss our patient in the light of different conditions leading to PRES, possible pathophysiological factors and treatment options.

[Efficacy of cognitive-behavioral psychotherapy in combined treatment of patients with initial hypertensive encephalopathy]

To assess efficacy of cognitive-behavioral psychotherapy in patients with initial hypertensive encephalopathy, we made a study including 65 neurological patients. Of them, 35 patients received basic therapy plus cognitive-behavioral therapy, 25 patients were given basic therapy only. The results of the study demonstrate high therapeutic efficacy of cognitive-behavioral psychotherapy in combined treatment of patients with initial hypertensive encephalopathy. The highest effect was shown in anxious symptoms and high critical attitude of the patients to their negative emotions.

Brainstem involvement in hypertensive encephalopathy: a report of two cases and literature review

The cerebral hemispheres show prominent involvement in hypertensive encephalopathy far more frequently than the brainstem. Two patients with severe paroxysmally accelerated hypertension associated with brainstem hyperintensity in T2-weighted magnetic resonance images are presented. Both present hyperintense lesions improved dramatically in appearance after stabilization of blood pressure. Extreme acceleration of hypertension may be essential for breakdown of autoregulation in the brainstem circulation. The marked clinicoradiologic dissociation ruled out major brainstem infarction and made tumor unlikely.

Hyperperfusion syndromes: insight into the pathophysiology and treatment of hypertensive encephalopathy

Hypertensive encephalopathy is one of the manifestations of a hypertensive crisis. It is not the absolute value of the blood pressure that causes the encephalopathy, rather the presence of an abrupt rise in pressure. In terms of clinical and radiographic findings, there are many similarities among a group of entities, including hypertensive encephalopathy, eclampsia, and immunosuppressant neurotoxicity. Hyperperfusion syndromes may represent these clinical disease states that may share the same pathophysiology. Magnetic resonance imaging fluid attenuated inversion recovery sequences have recognized the prominent cortical involvement of the disease that had been previously missed on computed tomography. Studies have found cortical involvement in 94% of their patients, particularly in mild cases. Animal models demonstrate endothelial damage and enhanced pinocytosis in the cortex as reasons why edema may begin in that region of the brain. Patients diagnosed with hypertensive encephalopathy should be diagnosed and treated promptly in order to avoid further neurological complications. The mean arterial pressure should be lowered by 20% to 25% within the first hour of patient presentation, followed by further gradual reduction in blood pressure over the following 24 hours. Hypertensive emergency in acute ischemic stroke should be managed with more caution. According to the 2003 American Stroke Association treatment guidelines, for patients with ischemic stroke not eligible for thrombolytic therapy, target blood pressures are a diastolic blood pressure <120 mmHg and systolic blood pressure <220 mmHg. The systolic pressure must be <185 mmHg and diastolic pressure <110 mmHg at all times if eligible for thrombolytic therapy.

Posterior reversible encephalopathy syndrome in intensive care medicine

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) is a well-recognized clinico-neuroradiological transient condition. Early recognition is of paramount importance for prompt control of blood pressure or removal of precipitating factors and treatment of epileptic seizures or status epilepticus. Delay in the diagnosis and treatment may in fact results in death or in irreversible neurological sequelae.

DISCUSSION

PRES is characterized by headache, altered mental status, seizures, and visual disturbances and is associated with a number of different causes, most commonly acute hypertension, preeclampsia/eclampsia, and immunosuppressive agents. Clinical symptoms and neuroradiological findings are typically indistinguishable among the cases of PRES, regardless of underlying cause. Magnetic resonance studies typically show edema involving the white matter of cerebral posterior regions, especially parieto-occipital lobes but frontal and temporal lobes, and other encephalic structures may be involved.

CONCLUSIONS

Intensivists and other physicians involved in the evaluation of patients with presumed PRES must be aware of the clinical spectrum of the associated conditions, the diagnostic modalities, and the correct treatment.

Spontaneous posterior fossa hemorrhage associated with low-molecular weight heparin in an adolescent recently diagnosed with posterior reversible encephalopathy syndrome: case report and review of the literature

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) constitutes a well-described clinical entity, classically entailing characteristic edematous lesions on imaging studies in a patient with altered mental status, visual disturbances, headache, and seizures. PRES is reversible in the vast majority of cases, although progression to ischemia and hemorrhage has been documented.

METHODS

We report a case of a 16-year-old male with chronic renal failure who developed PRES during a hypertensive crisis. The hypertension was successfully managed and PRES-associated symptomatology showed complete regression. However, approximately 2 months later, the patient returned with a spontaneous posterior fossa hemorrhage. Two weeks before this second admission, treatment with low-molecular weight heparin had been initiated. The patient finally succumbed, despite surgical evacuation. The pertinent literature is reviewed.

CONCLUSION

We suggest that the administration of low-molecular weight heparin in the setting of recent PRES might increase the risk for the development of intracranial hemorrhage.

Posterior reversible encephalopathy syndrome caused by hypertensive encephalopathy and acute uremia

INTRODUCTION

The posterior reversible encephalopathy syndrome (PRES) is a recently proposed cliniconeuroradiological entity. The most common causes of PRES are hypertensive encephalopathy, eclampsia, cyclosporin A neurotoxicity, and the uremic encephalopathy. On magnetic resonance imaging (MRI) studies, edema has been reported in a relatively symmetrical pattern, typically in the subcortical white matter and occasionally in the cortex of the posterior circulation area of the cerebrum.

METHODS AND RESULTS

A 19-year-old woman undergoing chronic hemodialysis was admitted with encephalopathy. High signal intensity was seen bilaterally in the subcortical and deep white matter areas of the temporal, frontal, parietal, and occipital lobes on cranial MRI.

CONCLUSION

Particular attention needs to be given to PRES because initiation of appropriate intervention can reverse the encephalopathic condition in most cases. Cerebral lesions may be more prominent in the anterior circulation area in some patients.

[Complexities of "reversible posterior leukoencephalopathy syndrome"]

We report a case of reversible posterior leukoencephalopathy syndrome in a 50-year-old patient with severe untreated hypertension. Recent advances in magnetic resonance imaging (especially diffusion-weighted imaging) allow new pathopysiological insight: it was found that the resulting vasogenic edema was restricted neither to the posterior vascular territories nor to white matter. The apparent diffusion coefficient helps to differentiate between reversible vasogenic edema and cytotoxic edema, the latter indicating irreversible neuronal death.

Reversible Posterior Leukoencephalopathy in Patients with Systemic Lupus Erythematosus

BACKGROUND

The development of central nervous system (CNS) symptoms in patients with preexisting systemic lupus erythematosus (SLE) evokes a wide differential diagnosis. Reversible posterior leukoencephalopathy (RPLE) is a rapidly evolving neurologic syndrome with characteristic clinical and radiographic features. Conditions commonly associated with RPLE include hypertensive encephalopathy, eclampsia, immunosuppressive drugs, and inflammatory disorders.

OBJECTIVES

To describe our experience with RPLE in patients with concomitant SLE and review the literature.

METHODS

The details of 5 novel cases and a MEDLINE review of the literature concerning the development of RPLE in association with SLE are presented.

RESULTS

All cases included patients with SLE who developed the acute onset of headache, altered mental status, visual changes, and seizures. Neuroimaging demonstrated posterior white matter edema involving the parietal, temporal, and occipital lobes. Complete clinical and radiographic recovery occurred with prompt antihypertensive treatment and supportive care. Literature review identified 16 additional cases of RPLE occurring in patients with active SLE; the majority of these reports was similar in presentation and outcome to our experience.

CONCLUSIONS

It is likely that the clinical manifestations and neuroimages in these lupus patients were the result of the RPLE syndrome. Fortunately, this cause of "secondary" CNS symptoms in patients with SLE is readily reversible when diagnosed early and treated with blood pressure control and supportive care.

Zerebrale Veränderungen bei krisenhafter arterieller Hypertonie: MRT-Befunde der hypertensiven Enzephalopathie sind wegweisend für Diagnose und Therapie

PURPOSE

In the nine years since the posterior reversible (leuc) encephalopathy syndrome (PRES) was first described, a number of causes have been under discussion. These not only include arterial hypertension, i. e. hypertensive crises, but also various toxic substances, i. e. immunosuppressive or chemotherapeutic agents, that are responsible for the formation of the symptoms and characteristic MR tomographic brain findings.

MATERIALS AND METHODS

Initial and follow-up MRI examinations of 8 patients were analyzed. All patients had acute neurological symptoms (headaches, seizures, visual disorders and vigilance disturbances) together with a detectable hypertensive crisis.

RESULTS

MRI disclosed increased signal intensity in subcortical and some cortical lesions in all patient FLAIR sequences. These changes were particularly extensive in the posterior circulation (occipital, cerebellum and brain stem) although they were also detected in brain areas supplied by the carotid artery. However, a cytotoxic genesis of the changes was ruled out in each patient by means of a normal DWI. Furthermore, when the blood pressure was normalized, reversibility of the lesions as proof of the diagnosis was detectable.

CONCLUSION

The imaging findings can be typically analyzed as a predominantly posterior distribution of encephalopathic lesions with a high probability of reversibility after lowering blood pressure was patients suffering from a critical increase in blood pressure with corresponding neurological symptoms. The exact pathophysiology remains unclear, but the cause currently most favored is a vasculopathy of the posterior circulation due to diminished adrenergic autoregulation in combination with a dysfunction of the endothelial cells. In conclusion, we suggest designating this subpopulation from the non-uniform pool of patients with posterior (leuc) encephalopathy as "hypertensive encephalopathy". "Hypertensive encephalopathy" has to be distinguished from "toxic encephalopathy", particularly due to different therapeutic and prognostic consequences.

Reversible posterior leukoencephalopathy syndrome in systemic lupus erythematosus with thrombocytopenia treated with cyclosporine

Thrombocytopenia is one of the common manifestations of systemic lupus erythematosus (SLE). Its treatment consists of corticosteroids and/or other immunosuppressive drug such as azathioprine, vincristine, cyclosporine, and mycophenolate mofetil. Common adverse reactions of immunosuppressive treatment are infections, hematologic and liver function abnormalities, but neurologic complications may also be seen. Reversible posterior leukoencephalopathy syndrome (RPLS) is a syndrome manifested by headache, nausea, vomiting, seizures, cortical blindness, and visual disturbances. Neuroimaging shows bilateral subcortical and cortical edema with prominent posterior distribution. Moreover, treatment with immunosuppressive drugs such as cyclosporine, cisplatin, tacrolimus, and interferon-alpha can induce a condition resembling RPLS. We report a case of a young woman with SLE and thrombocytopenia, who developed severe perspiration, headache, and seizure after receiving cyclosporine. A brain magnetic resonance image showed multiple high signal intensities on T2-weighted images predominantly located at the parietooccipital lobe. The patient recovered completely clinically and radiologically after discontinuing cyclosporine.

Postpartum focal neurologic deficits: posterior leukoencephalopathy syndrome

The postpartum patient who presents with focal neurologic deficits presents a wide range of diagnostic possibilities. We report the case of a previously healthy woman who presented 7 days postpartum with a focal deficit and who was ultimately diagnosed with eclampsia and posterior leukoencephalopathy syndrome (PLES). The hallmark of this entity is reversible parieto-occipital white matter edema as seen on magnetic resonance imaging (MRI). Advanced MRI techniques, such as echo-planar diffusion-weighted images and apparent diffusion coefficient maps, suggest cerebral artery dilatation as the underlying mechanism. Laboratory findings and computed tomography (CT) scans are typically unremarkable. PLES has a favorable prognosis if treated promptly and appropriately.

Hypertensive encephalopathy involving the brainstem and deep structures: a case report

Hypertensive encephalopathy rarely presented with widespread edema in the cerebral white matters, deep structures and whole brainstem. A 80-year-old woman manifested as high arterial blood pressure, visual disturbance, severe headache, nausea, and vomiting. T2-weighted and fluid-attenuated inversion recovery magnetic resonance imaging showed high signal-intensity lesions in the cerebral white matter, cerebellum, basal ganglia, thalamus, and brainstem. Diffusion-weighted brain MRI did not show hyperintense signals in these lesions. These findings suggested the pathological basis of vasogenic edema. After control of hypertension, clinical symptoms and these edematous lesions on MRI gradually reduced.

[Hypertensive encephalopathy: differential diagnosis of brain edema with midline shift]

Hypertensive encephalopathy is a severe complication of hypertensive crisis or malignant hypertonia. We report a case with grave clinical and radiological features. The patient was comatose, with pupillary dysfunction, and initial CT suggested a local intracranial mass with edema. Cranial MRI showed almost completely hyperintensive supratentorial white matter, with edema and midline shift, and hypertensities in cerebellum and brainstem. The patient recovered, and the radiological findings improved after antihypertensive therapy. Hypertensive encephalopathy may be differentiated by MRI, manifests acutely, and is potentially reversible when adequate therapy is rapidly performed.