[THE EFFECTIVENESS OF DIAGNOSIS AND TREATMENT OF CEREBROVASCULAR DISORDERS IN HYPERTENSIVE ENCEPHALOPATHY IN ELDERLY PATIENTS BY STUDYING THE CHARACTERISTICS OF CEREBRAL HEMODYNAMICS AND CEREBRAL PERFUSION STATUS]

Intrigue progression of hypertensive encephalopathy (HE) in older patients is that the development of cognitive impairment and high blood pressure underestimated, aslo exist without clinical manifestations. In recent decades convincing proved that the basis for the development of various diseases is cerebral dysfunction systems regulating brain blood flow, including--autoregulation system, which largely affects the blood supply to the brain. This explains the fact that patients with chronic brain ischemia cerebral hemodynamic status largely depends on the condition and stability of the regulatory mechanisms of systemic and cerebral hemodynamics, particularly of systemic blood pressure, regional cerebral blood supply, normalization which, in the early stages of development disorders, prevents of serious complications. In this paper the theoretical generalization and new solution of scientific and practical problems of hypertension influence on the formation of chronic cerebral ischemia in elderly patients on a background of hypertension--specified risk factors and especially the formation of a comprehensive study on the basis of clinical and neurological data, tool sand methods for neuroimaging research developed and improved methods of diagnosis. Found that in elderly patients with HE and HBP observed significant (P < 0.05) increase in the thickness of the intima-media complex was significantly higher (dextra--1.12 ± 0.03 and sinistra--1.11 ± 0.03), than middle-aged patients with hypertension at HE, which constitutes a violation of the elastic properties of the vascular wall. Established correlation data radionuclide study ultrasonic duplex scanning of vessels of the head and neck. A negative correlation of intima-media and severity of lesions according to hypoperfusion of computer tomography single photon emission (r = -0.49; P < 0.05); confirming the progression of HE in elderly patients needs improvement and treatment.

Hypertensive encephalopathy as a late complication of autonomic dysreflexia in a 12-year-old boy with a previous spinal cord injury

The scope of paediatric autonomic disorders is not well recognised, and paediatricians seem to be generally unaware of the complexity and diversity of their clinical manifestations. We report a 12-year-old boy presenting with hypertensive encephalopathy caused by autonomic dysreflexia.

CONCLUSION

This observation emphasises the importance of the recognition of this rare autonomic disorder, which can have potentially life-threatening neurological complications.

[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.

[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.

[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).

[Psychophysiological analysis of efficiency of cerebral hemodynamics with dopplerographic and reoencephalographic imaging]

The authors designed the integrated diagnostic test as a model for psychophysiological assessment and prediction of the effectiveness of cerebral hemodynamics in subjects. The test includes the recording of blood flow velocity in the CCA and the level of psychopathisation.

[Analysis of single-photon emission computed tomography in patients with hypertensive encephalopathy complicated with previous hypertensive crisis]

In cerebrovascular diseases pefuzionnaya single photon emission computed tomography with lipophilic amines used for the diagnosis of functional disorders of cerebral blood flow. Quantitative calculations helps clarify the nature of vascular disease and clarify the adequacy and effectiveness of the treatment. In this modern program for SPECT ensure conduct not only as to the calculation of blood flow, but also make it possible to compute also the absolute values of cerebral blood flow.

Protease-activated receptor 2 and bradykinin-mediated vasodilation in the cerebral arteries of stroke-prone rats

Protease-activated receptor 2 (PAR(2)) expression is up-regulated during vascular injury associated with edema. PAR(2) and bradykinin subtype 2 receptor (B(2)) expression and function were assessed in relation to hypertensive encephalopathy (HE) and cerebral hemorrhage (CH) in middle cerebral arteries (MCA) of Kyoto Wistar stroke-prone spontaneously hypertensive rats (SHRsp). Before stroke, bradykinin and PAR(2) activation by 2-furoyl-leucine-isoleucine-glycine-arginine-leucine-ornithine-amide (2Fly) produced endothelium-dependent vasodilation that was inhibited by K(+) depolarization, carbenoxolone, and the blockade of intermediate (IK(Ca)) plus small (SK(Ca)) and (in the case of bradykinin) smooth muscle (SM) large conductance (BK(Ca)) calcium-activated K(+) channels. Responses were not altered by N omega-nitro-L-arginine methyl ester, indomethacin, 17-octadecynoic acid or Ba(2+)+ouabain. We concluded that vasodilation to 2Fly or bradykinin was not mediated by NO, cyclooxygenases, arachidonic acid-metabolizing cytochrome P450s or SM K(ir) channels+Na(+)/K(+) ATPase activation. Vasodilation likely involved the spread of endothelial hyperpolarization (generated by IK(Ca)+SK(Ca)) through myoendothelial junctions and in some cases SM BK(Ca) activation. SHRsp with HE or CH had MCA that could not constrict to pressure and did not vasodilate to bradykinin. Their responses to 2Fly remained unaltered. The patterns and densities of PAR(2) and B(2) immunoreactivity in frozen MCA sections were not altered with stroke. MCA function remained normal in SHRsp subjected to dietary manipulations that prevented stroke without altering hypertension. Despite the presence of vascular injury, edema, inflammation and the loss of endothelium-dependent bradykinin vasodilation we found no evidence that PAR(2) expression or vascular function was altered in MCA after stroke.

[Clinical and neurophysiological parameters in patients with discirculatory encephalopathy]

We studied clinical parameters and characteristics of the nonspecific brain activity, reflecting interhemispheric interactions, in patients with discirculatory encephalopathy (DEP) who had arterial hypertension. Forty-six patients with DEP (25 - with DEP, II stage, 21 - with DEP, III stage) without epileptic changes on EEG were examined. The control group included 44 healthy people. EEG was assessed using the visual analysis according to E.A. Zhimunskaya, spectral analysis programs with mapping, degree of interhemispheric asymmetry of brain biopotential power. The more severe was the disease, the lower was the power of brain bioelectric activity. Variants of functioning of nonspecific brain activity in different stages of DEP were found in the study of the degree of interhemispheric asymmetry of brain biopotential power. The activity of synchronization areas of the brain dominated in the initial DEP stages, and that of desynchronization areas - in the later stages.

[Cerebral circulation in chronic hypertensive encephalopathy]

Cerebral blood supply was studied in 123 patients with stage III hypertensive encephalopathy (HE) in the absence of occlusion of main head arteries. Duplex scanning was used to measure blood flow rate in common carotid (CCA), vertebral (VA) and medial cerebral (MCA) arteries. Cortical cerebral blood flow (CBF) was measured by single-photon emission CT using 99mTc- ceretec. Normal and stable blood flow in CCA and VA was documented at all HE stages whereas it decreased in MCA of patients with HE II-III. Cortical CBF in frontal and parietal segments in HE II-II was higher than in HE I (p < 0.05). These findings suggest impaired subcortical perfusion and correlation of the discrepancy between cortical and subcortical blood supply with the severity of HE. Leukoaraosis is an indicator of hypoperfusion.

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.

[Posterior reversible encephalopathy and renal failure. Value of the diffusion magnetic resonance]

INTRODUCTION

Posterior reversible encephalopathy (PRE) is a radiological clinical syndrome described for the first time in 1996. The most frequent symptoms are headache, visual disorders, altered mental states and seizures. The basic characteristics is the presence of reversible cerebral injuries generally. They mainly affect the later regions of the brain of bilateral form and they are more prominent in the white matter. It is mainly associated with severe arterial hypertension of fast development and states of immunosuppression.

CASE REPORT

An 11-year-old male child with renal failure that it developed a PRE with extensive affectation corticosubcortical of the cerebral white matter of posterior predominance. Also injuries in frontal lobes, hard body and bulb existed. Its precocious diagnosis by means of conventional magnetic resonance (MR) and diffusion MR allowed a fast treatment, that caused a complete recovery, clinical as much radiological.

CONCLUSION

The MR and the diffusion MR allow to make a diagnosis of certainty of the PRE and to differentiate it from other injuries. The diffusion MR is a fast sequence and of easy essential handling in the precocious diagnosis of this syndrome.

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.

Spectrum of radiological changes in hypertensive children with reversible posterior leucoencephalopathy

We prospectively studied 19 children with severe hypertension to evaluate the spectrum of radiological changes, severity and reversibility of this entity. All of them were subjected to clinical and biochemical evaluation, followed by magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA). Headache was seen in 17 children, 13 had confusion and drowsiness, 12 had nausea and vomiting, 10 patients had visual disturbances, seizure and dyspnoea. Only two had focal neurological deficit (one with right facial palsy and another with right lateral rectus palsy). Of these 19 children, 15 patients had hypertensive retinopathy and four had normal fundi. The positive MRI findings in 17/19 patients were: bilateral leukoencephalopathic changes in occipitoparietal region (9/17), diffuse white/grey matter lesion (3/17) patients, brain stem hyperintensity (2/17) and haemorrhagic lesions (3/17). On MRA, 12/19 patients had attenuation of cerebral arteries of different degree. On follow up, MRI findings resolved in all except three patients. All patients had normal MRA on follow up, except one with persistent minimal attenuation of middle cerebral artery and another had spasm in anterior, middle and posterior cerebral arteries. The intracranial abnormalities in these patients with severe hypertension were reversible in many of the cases after control of blood pressure was achieved. We therefore conclude that severe hypertension may lead to leuoencephalopathy, which had a wide radiological spectrum. A better understanding of this complex syndrome may obviate unnecessary investigations and allow management of associated problems in prompt and appropriate ways.

[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.

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: a case study

A young woman 4 days postpartum was admitted after experiencing two seizures. Her mentation waxed and waned until, after several hours, staff were unable to arouse her with voice or touch. A computed tomography scan demonstrated considerable white-matter edema. The patient's condition declined to a coma. She remained comatose despite therapeutic interventions to control increased intracranial pressure. To her family, her condition was a source of anguish. To the physicians and nurses, she was a puzzle. The final diagnosis was posterior reversible encephalopathy syndrome, which was related to a preeclamptic condition and its associated hypertension. The collaboration of obstetricians and neurologists with vigilant care by neuroscience nurses resulted in a positive outcome for this challenging patient.

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.

[Topical electrophysiological correlates of emotional states (on the evidence of incipient hypertension encephalopathology)]

Comprehensive investigations of 97 patients with incipient hypertension encephalopathologies were performed with the use of standard psychodiagnostic questionnaires and EEG. Topographic analysis of spectral power showed stable constellation of altered alpha- and beta-zones in the EEG parietal, temporal and occipital leads. Given the clinical implications of this finding, we can view it as a potential neurophysiological background for depression, and a "functional" phase in disease development.

Coma, hypertension, and brainstem imaging abnormalities in a paraplegic man with necrotizing fasciitis

In this 2-part article, the reader has the opportunity to identify the differential diagnosis for the patient described in the title, on the basis of the history, examination results, laboratory evaluations, and neurophysiologic and imaging findings. The differential diagnosis and a discussion of the case are presented on pages 136-138.

Acute hypertensive encephalopathy with widespread small-vessel disease at MRI in a diabetic patient: pathogenetic hypotheses

We report unusual magnetic resonance imaging (MRI) findings in a diabetic patient with neglected hypertension and hyperglycemia, presenting with seizures and coma. Outcome was fatal despite intensive care. The MRI findings included bilateral insular and temporo-occipital grey and white matter involvement, and numerous, scattered, lacunar-like lesions involving the peripheral and deep white matter, basal ganglia grey matter, and brainstem. Lesions had a low apparent diffusion coefficient, and some enhanced following contrast injection. Hypertensive encephalopathy with widespread and severe acute small-vessel disease was considered. Pathophysiology is discussed.

Treatment of Hypertensive Complications in Pregnancy

Hypertension is the most common medical disorder during pregnancy. Approximately 70 percent of women diagnosed with hypertension during pregnancy will have gestational hypertension-preeclampsia. The term gestational hypertension-preeclampsia is used to describe a wide spectrum of patients who may have only mild elevation in blood pressure to those with severe hypertension with various organ dysfunctions (acute gestational hypertension, preeclampsia, eclampsia, and the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome). The exact incidence of gestational hypertension-preeclampsia in the United States is unknown. Estimates range from 6% to 8% of all pregnancies. The treatment of hypertensive disorders in pregnancy requires careful assessment of the maternal and fetal conditions. Therapeutic decisions must take into account fetal age, maternal symptoms, tests of fetal well-being, as well as maternal status, in order to ensure the best overall outcome. Treatment of mild gestational hypertension with antihypertensive medications has not been shown to improve outcome, however, in cases of severe disease treatment has been shown to be beneficial. The purpose of this review is to discuss the different treatment modalities used in the hypertensive disorders of pregnancy. Management strategies will not be discussed.

Reversible posterior leukoencephalopathy syndrome: a misnomer reviewed

Reversible posterior leukoencephalopathy is a syndrome of headache, seizures and visual loss, often associated with an abrupt increase in blood pressure. Prompt diagnosis and therapy with antihypertensives, anticonvulsants, removal of any offending medication and treatment of associated disorders is essential since early treatment might prevent progression to irreversible brain damage. We present six illustrative cases presenting to Christchurch Hospital and review the condition. All were hypertensive, two were receiving immunosuppressant therapy after transplantation and one chemotherapy. Only three made a full recovery. The term reversible posterior leukoencephalopathy is a misnomer as the condition is not always reversible, is not necessarily confined to the posterior regions of the brain and can affect both white and grey matter. Magnetic resonance imaging findings of increased T2 and fluid attenuated inversion recovery signal predominantly involving the posterior regions of the cerebral hemispheres should alert the clinician to the possibility of this diagnosis.

Cortical blindness: Clinical and radiologic findings in reversible posterior leukoencephalopathy syndrome

PURPOSE

To alert ophthalmologists to the recognition of cortical visual loss as the presenting feature in patients with reversible posterior leukoencephalopathy syndrome (RPLES). Unique radiologic findings are paramount to the diagnosis.

DESIGN

Interventional case report.

METHODS

A patient was seen with perioperative bilateral cerebral visual loss that was misinterpreted initially as an irreversible ischemic event. Further detailed analysis of the radiologic findings and clinical history led to the correct diagnosis.

MAIN OUTCOME MEASURES

Visual acuity and magnetic resonance imaging (MRI) of the brain.

RESULTS

Recognition of the correct diagnosis of RPLES led to the institution of antihypertensive therapy and recovery of normal vision.

CONCLUSIONS

The diagnosis of RPLES should be considered in all patients with acute cerebral visual loss, especially in the setting of recent surgery, blood transfusion, chemotherapy, immunosuppressant use, hypertension, eclampsia, or seizures. Prompt diagnosis requires close collaboration with a radiologist and an emergent MRI study, which ideally should include diffusion-weighted imaging with calculation of an apparent diffusion coefficient map. Differentiation from acute cerebral ischemia is important in order to avoid permanent visual loss by prompt and vigorous treatment of exacerbating factors such as intermittent hypertension. Prompt diagnosis will also help to avoid potentially dangerous invasive procedures such as thrombolytic therapy.

[Antihypertensive management in acute cerebral stroke]

Hypertensive emergencies encompass a variety of clinical conditions and several drugs are now available for use in these situations. The clinician should take into account the specific etiology of the severe hypertension, co-existing conditions of patient, and the pharmacology of agents when selecting a drug for treatment. In the case of hypertensive encephalopathy, the lowering of blood pressure is therapeutic as well as diagnostic. If the mental status does not improve within a few hours of lowering the blood pressure, other causes of hypertension should be considered. Historically, nitroprusside has been the most commonly used agent in this clinical situation. Alternative drugs that are easy to administer include labetalol and fenoldopam. Nitroglycerin and nicardipine may also be effective but clinical experience in hypertensive encephalopathy is limited. Drugs that cause sedation such as clonidine should not be used in order to avoid confusion with the neurological assessment.

Headache and hypertension

Headache is generally regarded as a symptom of high blood pressure in spite of conflicting opinions on the association of headache and arterial hypertension. Most studies have shown that mild chronic hypertension and headache are not associated and this demonstration needs to be implemented in clinical practice. Whether moderate hypertension predisposes to headache remains controversial, but there is little evidence that it does. Headaches caused by significant disturbances in arterial pressure are included in the section "Headache attributed to a disorders of homeostasis" (code 10.3) of the 2nd edition of the International Classification of Headache disorders.

Brainstem involvement in hypertensive encephalopathy: Clinical and radiological findings

Predominant brainstem or cerebellar edema is rare in hypertensive encephalopathy and usually affects patients with secondary hypertension. Despite the severity of the radiologic findings, clinical features of brainstem involvement are uncommon. The authors report the clinical and radiologic features of two patients.

[Evaluation of autonomic regulation in patients with chronic hypertensive encephalopathy]

Hemodynamics and vegetovascular regulation features in patients with chronic vascular encephalopathy was analyzed by the authors by means of diurnal monitoring of arterial pressure and heart rhythm.

Recurrent posterior reversible encephalopathy syndrome (PRES)

Posterior reversible encephalopathy syndrome is a proposed cliniconeuroradiological entity characterized by headache, altered mental status, cortical blindness, seizures, and other focal neurological signs, and a diagnostic magnetic resonance imaging picture. A variety of different etiologies have been reported like hypertension, pre-eclampsia/eclampsia, cyclosporin A or tacrolimus neurotoxicity, uraemia and porphyria. With early diagnosis and prompt treatment, the syndrome is usually fully reversible. We report a case of recurrent PRES of unknown aetiology following intensive care unit treatment and only moderately elevated blood pressure. Clinicians as well as radiologists must be familiar with this clinically frightening, underdiagnosed condition to assure timely diagnosis and treatment to prevent persistent deficits.

[Posterior reversible encephalopathy syndrome: some case reports]

INTRODUCTION

In 1996, Hinchey et al described a clinico-radiological picture they called posterior reversible leukoencephalopathy syndrome (PRLS), which is characterized by visual disorders, seizures, altered mental states and changes in the subcortical white matter of the temporoparietooccipital lobes that are shown up in the neuroimages. These clinical manifestations are associated with arterial hypertension. Later, other triggering elements, such as cytostatic drugs, were described without being linked to hypertension. Other authors have suggested the name of posterior reversible encephalopathy, since magnetic resonance imaging (MRI) reveals a high percentage of cortical compromise.

CASE REPORTS

We present three cases of posterior reversible encephalopathy with different origins. Two of the cases involved females, one of whom was a 19-year-old hypertensive with lupus nephropathy and the other was a 33-year-old with eclampsia. The third case was an 11-year-old male child with post streptococcal glomerulonephritis and hypertension. The most relevant signs and symptoms included seizures, visual disorders, arterial hypertension and sensory deterioration. MR played a decisive role in diagnosis and it revealed an alteration of the signal in the supra and infratentorial white matter of the cortex and the subcortex, which was predominant in the posterior areas of the encephalon. The three cases presented a significant radiological and clinical improvement in a short time.

CONCLUSION

Failure of the self regulation of cerebral vascular circulation, with development of oedema, is the most widely accepted hypothesis to explain the pathophysiological mechanism at work in this entity.

Alterations in autoregulatory and myogenic function in the cerebrovasculature of Dahl salt-sensitive rats

BACKGROUND AND PURPOSE

Dahl salt-sensitive rats fed an 8.7% NaCl diet exhibited hypertensive encephalopathy and developed seizures associated with areas of blood-brain barrier (BBB) disruption without brain ischemia. The incidence of hemorrhagic stroke was low (7/47). We tested the hypothesis that a defect in cerebral blood flow (CBF) autoregulation under hypertensive conditions preceded hypertensive encephalopathy.

METHODS

Brain ischemia and BBB disruption were assessed with the use of tetrazolium red staining and Evans blue dye extravasation, respectively. Myogenic constriction to pressure was measured in isolated middle cerebral arteries (MCAs) with a pressure myograph. CBF autoregulation was assessed with the use of laser-Doppler techniques.

RESULTS

Asymptomatic rats fed 8.7% NaCl had MCAs that developed an age-related attenuation in their ability to constrict to pressure, which was amplified in rats exhibiting hypertensive encephalopathy. The MCAs of rats with hemorrhagic stroke lost this function and developed large degrees of basal tone. The majority (4/6) of asymptomatic rats fed high salt for longer than 3 weeks exhibited a linear relationship between CBF and blood pressure. The characteristics of CBF regulation were consistent with the possible absence of autoregulation coupled with cerebrovascular vasoconstriction.

CONCLUSIONS

Both MCA pressure-dependent constriction and CBF autoregulation in the MCA perfusion domain were lost before the development of hypertensive encephalopathy or hemorrhagic stroke. These defects could contribute to the development of BBB disruption during hypertension. Cerebrovascular vasoconstriction in the absence of CBF autoregulation may protect the brain from excessive overperfusion during hypertension and could account for the low incidence of cerebral hemorrhage in this model.

Hypertensive encephalopathy: antecedent to hippocampal sclerosis and temporal lobe epilepsy?

The authors describe three patients with refractory temporal lobe epilepsy (TLE) following an episode of hypertensive encephalopathy as their only identified antecedent event. All patients had typical MR features of hippocampal sclerosis (HS), and the two operated cases had typical HS histology and became seizure-free postoperatively. These cases suggest that hypertensive encephalopathy may be a rare form of initial precipitating injury, leading to TLE and HS.

[Hypertensive angioencephalopathies]

The results of clinical and physiological study of 2000 patients, aged 20-60 years, suffering from hypertensive encephalopathy with differential evaluation of varying cerebrovascular pathology types (according to RAMS Neurology Institute classification) and stages of their development were summarized. The complex of methods used comprised psychological personality questionnaires, neuropsychological methods, computed tomography, rheoencephalography, ultrasonic diagnosis, etc. The data was computer processed. The main diagnostic and prognostic criteria for chronic hypertensive angioencephalopathies on early stages of arterial hypertension and the principles of their prevention are outlined.