Hypertensive brainstem encephalopathy with isolated headache and blurred vision: A case report

A 34-year-old man, previously in good health with no past history of hypertension, presented with a 2-day history of bitemporal headaches and a sudden onset of left-sided weakness 4 days after ingesting traditional Chinese medications for nonspecific abdominal pain. He was afebrile, drowsy, disoriented, and dysarthric, with a blood pressure of 270/170 mm Hg. Clinical examination revealed mild left facial weakness and strength of Medical Research Council grade 4/5 in the left upper and lower limbs. Deep tendon reflexes were brisk, and he demonstrated bilateral extensor plantar responses. Fundoscopy revealed grade 4 hypertensive retinopathy changes (Figure 1). ECG was consistent with left ventricular hypertrophy. Treatment with intravenous glyceryl trinitrate was commenced to achieve normotension. …

Hypertensive encephalopathy (HE) is one of the acknowledged hypertensive emergencies. Isolated hypertensive brainstem encephalopathy (HBE) without concomitant typical parietooccipital lesion is unusual. Patients with HBE may or may not present with symptoms attributable to brainstem and the diagnosis is challenging in an emergency setting. The most important differential diagnosis in HBE is brainstem infarction, because the goals of blood pressure treatment are different. Evidence of vasogenic edema on magnetic resonance image, i.e. absence of high signal lesions on diffusion weighted images and increased value of apparent diffusion coefficient are diagnostic indicators of HBE, but not brainstem infarction. Prompt recognition of HBE and adequately lowering blood pressure offer the best outcomes.

Hypertensive encephalopathy is a neurological emergency characterised by breakdown of cerebral autoregulation resulting in symptoms ranging from headache to seizures, reduced consciousness and death. Posterior reversible encephalopathy syndrome (PRES) is...

he recognition of the risks of high blood pressure (BP) in the last century was highlighted by observing the acute association between very high BP and medical catastrophes in emergency settings, including stroke, acute left ventricular failure, and myocardial infarction.Edward Freis was among the first authors to propose the concept of "hypertensive crisis," which he characterized as a life-threatening disorder caused by acute or severe elevation of BP and clinical manifestations secondary to hypertension. 1 According to Freis, the clinical manifestations included encephalopathy, neuroretinitis, evidence of rapidly advancing renal impairment, and acute heart failure.Hypertension guidelines incorporated the diagnosis of hypertensive crisis, and the 1984 Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure report proposed the classification of hypertensive emergencies and urgencies. 2Hypertensive emergencies were characterized by hypertensive encephalopathy, intracranial hemorrhage, acute left ventricular failure, dissecting aortic aneurysm, severe hypertension, toxemia, head trauma, extensive burns, unstable angina pectoris, and acute myocardial infarction, in which BP should be lowered within 1 hour.Urgencies were defined as situations in which BP should be controlled within 24 hours, including accelerated or malignant hypertension, perioperative hypertension, and patients requiring emergency surgeries.With slight variations in the criteria for the definition of urgencies and emergencies, these recommendations have been repeatedly copied and pasted into the Joint National Committee guidelines and the guidelines from Europe and other countries.The 2017 American Heart Association/American College of Cardiology hypertension guidelines 3 defined hypertensive emergencies as severe BP elevations (>180/120 mm Hg) associated with evidence of hypertensive encephalopathy, intracerebral hemorrhage, acute ischemic stroke, acute myocardial infarction, acute left ventricular failure, unstable angina pectoris, dissecting aortic aneurysm, acute renal failure, and eclampsia.The guideline defined hypertensive urgencies as situations associated with severe BP elevation in patients without an acute or impending change in target organ damage or dysfunction.The 2018 European Society of Cardiology/European Society of Hypertension guidelines of hypertension 4 included the diagnosis of malignant hypertension (characterized by funduscopic changes or disseminated intravascular coagulation), excluded any presentation of stroke from the criteria to characterize hypertensive emergencies, and proposed a similar definition for hypertensive urgencies.Patients with high BP in emergency departments have worse long-term cardiovascular outcomes than those with lower BP. 5 This consequence is expected because these patients already have high BP levels and a longer duration of hypertension.The diagnoses of urgency and emergency would be justified if short-term outcomes were influenced by prompt therapy in emergency departments.Nevertheless, there is no clinical trial in patients diagnosed as having

Hypertensive brainstem encephalopathy: a diagnosis often overlooked

Work presented aims at the optimization and the realization of a gyrometer micro-machined with vibrating beam on substrate silicon. This work falls under the continuity of theses previously carried out to FEMTO-ST institute and devoted to the development of a structure of star gyrometer. This configuration is appropriate to the realization of velocity angular measurements in the plan of the substrate. The context of the thesis is consisted a research project submitted an evolution of the gyrometer silicon with passage of a capacitive detection to an optical detection. This is why the report naturally proposes an in-depth redimensioning of the sensor. Thus, a significant number of studies by finite elements were carried out to optimize the vibrating structure. This optimization enabled us to respect the schedule of conditions with respect to the frequencies of excitation and detections, while rejecting the parasitic modes. Complementary electromechanical studies made it possible to include/understand in detail specificities resulting from the choice of the capacitive excitation. This work led to the development of an optimized structure, associated a redefinition of the manufactoring processes in clean room. Several series of micro-machined sensors thus could be carried out, giving place to exploitable structures, validating the new design with its associated process. The recourse to a probe heterodyne receiver then made it possible to measure out-plan displacements according to the signal of excitation, thus validating the primary dynamic behavior of the structures.

1. Andrea Herman, MD* 1. 2. *Doernbecher Children’s Hospital, Oregon Health Sciences University, Portland, OR. An 11-year-old boy is admitted to the pediatric intensive care unit because of high blood pressure. Eight hours earlier, he suddenly developed intermittent nosebleeding. His parents brought him to the emergency department because they could not stop the bleeding over the previous hour. On arrival, the patient’s blood pressure was 250/170 mm Hg. He denied headache, dizziness, or blurred vision. The nosebleed was stabilized with pressure and packing. Because his blood pressure improved minimally after three separate administrations of intravenous labetolol, he was transferred to the intensive care unit for further evaluation and therapy. The patient’s medical history revealed a 6-month history of episodic headaches, vomiting, and fatigue. Three months ago, these episodes occurred weekly, prompting the patient to seek medical care. Findings on physical examination were normal, including a systolic blood pressure of 95 mm Hg. Results of laboratory evaluation, consisting of complete blood cell count, urinalysis, serum glucose, thyroid stimulating hormone, and computed tomography (CT) of the head (Fig. 1⇓ ), were normal. Migraine headaches were diagnosed, and the patient was treated with propranolol. After 2 weeks without symptomatic improvement, the boy’s parents discontinued propranolol therapy. Figure 1. Normal CT scan of the head. Two weeks later, the patient developed blurred vision, returned to the hospital, and was admitted for evaluation. His systolic blood pressures ranged from 115 to 164 mm Hg and diastolic blood pressures from 75 to 103 mm Hg. An ophthalmologist noted decreased vision in the right eye as well as papilledema and stellate macular changes on retinal examination. Magnetic resonance imaging (MRI) of the head demonstrated patchy high-signal changes in the white matter (Fig. 2⇓ ). Cerebrospinal fluid evaluation revealed an opening pressure of 27 mm H2O, a white blood cell count of 2 cells/mcL, a red blood cell count of 7 …

Bilateral disc edema in hypertensive emergency

We report on a 42-year-old female patient who presented with high arterial blood pressure of 245/150 mmHg and hypertensive brainstem encephalopathy that involved the brainstem and extensive supratentorial deep gray and white matter. The lesions were nearly completely resolved several days after stabilization of the arterial blood pressure. Normal diffusion-weighted imaging findings and high apparent diffusion coefficient values suggested that the main pathomechanism was vasogenic edema owing to severe hypertension. On the basis of a literature review, the absolute value of blood pressure or whether the patient can control his/her blood pressure seems not to be associated with the degree of the lesions evident on magnetic resonance imaging. It remains to be determined if the acceleration rate and the duration of elevated arterial blood pressure might play a key role in the development of the hypertensive encephalopathy pattern.

Malignant hypertension and hypertensive encephalopathy are life-threating manifestations of hypertension. These syndromes primarily occur in patients with a history of poorly controlled hypertension. The purpose of this study was to investigate national trends in hospital admissions for malignant hypertension, hypertensive encephalopathy, and essential hypertension. This was a retrospective cohort study that used the Nationwide Inpatient Sample. We identified all hospitalizations between 2000 and 2011, during which a primary diagnosis of malignant hypertension (ICD 9 code: 401.0), hypertensive encephalopathy (ICD 9 code: 437.2), or essential hypertension (ICD 9 code: 401.9) was recorded. Time series models were estimated for malignant hypertension, hypertensive encephalopathy, essential hypertension and also for the combined series. A piecewise linear regression analyses was performed to investigate whether there were changes in the trends of these series. In addition, we also compared the characteristics of patients with these diagnoses. The estimated number of admissions for both malignant hypertension and hypertensive encephalopathy increased dramatically after 2007, whereas discharges for essential hypertension fell, and there was no change in trend for the combined series. Costs rose substantially for patients with these diagnoses after 2007, but mortality significantly fell for malignant hypertension and mortality for hypertensive encephalopathy did not change. The dramatic increase in the number of hospital admissions for hypertensive encephalopathy and malignant hypertension should have resulted in dramatic increases in morbidity, but it did not. The change is most likely related to changes in coding related to diagnostic-related groups that occurred in 2007.

Hypertensive encephalopathy is a life-threatening medical condition manifested by headache, confusion, seizures, and visual disturbance, and, if treatment is delayed, it may progress to coma and death [1, 2] (Chester et al., Neurology 28:928-939, 1978; Vaughan and Delanty, Lancet 356:411-417, 2000). Involvement of the brainstem with or without supratentorial lesions has been reported and is termed hypertensive brainstem encephalopathy (HBE). Cases of HBE involving supratentorial deep gray and white matter are rare and extensive hyperintensity was predominantly seen in brainstem regions on fluid-attenuated inversion recovery and T2-weighted magnetic resonance images. We present radiologic findings of a patient with HBE involving deep supratentorial gray and white matter, causing tonsillar herniation and noncommunicating hydrocephalus by mass effect.

A Pressing Headache

A rapid, marked and persistent rise in blood pressure (BP) levels above 180/120 mmHg is a clinical condition currently defined as hypertensive emergency or urgency in the presence or absence of acute signs of hypertension-mediated organ damage, respectively [1]. Beyond the magnitude of BP rise and absolute BP levels, early recognition of these conditions is crucial from both a prognostic and a therapeutic point of view. Indeed, current European guidelines recommend clinical observation with repeated BP measurements and gradual BP reductions throughout the administration of oral antihypertensive drug therapies in individuals with hypertensive urgencies [2]. On the other hand, patients with hypertensive emergencies should immediately receive pharmacological and non-pharmacological interventions for lowering BP levels, mostly through the administration of intravenous drugs, and undergo specific treatment protocols for the clinical management of associated clinical conditions, such as acute coronary syndromes, stroke, pulmonary oedema, eclampsia, and aortic dissection [2]. Similar recommendations have been issued by the United States guidelines on hypertension [3].

Classification of hypertensive crises, including malignant hypertension, has evolved over time. As first described by Volhard and Fahr [1], malignant hypertension was characterized by severe hypertension, renal insufficiency, fibrinoid necrosis of renal arterioles, retinopathy with papilledema, and a rapidly progressive and fatal clinical course. Subsequently, the definition was expanded to include severe hypertension accompanied by papilledema (grade IV Keith-Wagener retinopathy). In contrast, accelerated hypertension was considered to be severe elevation of blood pressure (BP) in the presence of retinal hemorrhages and exudates, but without papilledema (grade III Keith-Wagener retinopathy) [2]. Subsequent studies demonstrated that severe hypertension complicated by retinal hemorrhages and exudates with or without papilledema had similar clinical features and prognosis, so that the terms malignant and accelerated hypertension came to be used interchangeably [3]. Presently, the terms hypertensive emergency, which includes malignant hypertension, and urgency are preferred [2]. Hypertensive urgency is arbitrarily defined by the absolute level of BP (SBP >180 or DBP >120 mmHg) and hypertensive emergency is defined by the presence of acute end-organ damage and typically in the setting of severely elevated BP [4]. In spite of the definition used, clinicians frequently face the challenge of diagnosing and treating hypertensive crisis in their offices or in the emergency department. Although the cause of hypertensive crisis is often unknown, the identification of prognostic predictors that correctly identify higher risk patients might allow for application of more effective treatment strategies. In this issue of the Journal of Hypertension, Shantsila et al.[5] analyzed the impact of pulse pressure (PP) on outcomes in a cohort of 365 patients with malignant hypertension identified from The West Birmingham Malignant Phase Hypertension Study. The definition of malignant hypertension was DBP more than 130 mmHg in association with bilateral retinopathy including hemorrhages and/or cotton wool spots or exudates, with or without papilloedema. After a median follow-up of 7 years, 203 (55%) and 39 (11%) patients were dead or had started dialysis, respectively, confirming the devastating effects of malignant hypertension. Age, smoking status, severity of renal failure (assessed by proteinuria and creatinine levels) at presentation were identified as independent predictors of the risk of death or dialysis. DBP and SBP, mean arterial pressure and PP at baseline did not predict these same outcomes. The degree of BP elevation does not correlate closely with the severity of end-organ deterioration [6,7]. Lack of predictive value of PP in the present study may be explained by various reasons as discussed by authors. Furthermore, the underlying pathophysiologic mechanisms related to BP elevation and PP in patients with malignant hypertension differ from those in patients with chronic hypertension. In the present study, the increases in PP were mostly determined by elevations in SBP rather than reductions in DBP, which likely does not represent changes in age-related arterial stiffness. Among older individuals, in whom vascular stiffness is common, both reductions in DBP and increases in SBP determine PP elevation [8]. The acute organ deterioration encountered in patients with hypertensive emergencies is more likely attributable to impairment of autoregulatory function secondary to maladaptive changes in a number of neurohumoral and inflammatory factors [2]. It is of importance, as demonstrated by Shantsila et al., that an absence of symptoms (shortness of breath, chest pain, and focal neurologic deficits) does not rule out malignant hypertension. In the current analysis, presence of proteinuria and elevated creatinine levels were independent predictors for both death and dialysis, whereas the presence of hematuria predicted future dialysis [5]. These findings highlight that currently there is a lack of evidence-based recommendations to guide physicians on how to best exclude acute end-organ damage, and that over reliance on the absence of symptoms may delay or prevent critically needed treatment [4]. The current findings support further investigation to identify the clinical utility of potentially predictive markers of acute organ deterioration in asymptomatic patients with severely elevated BP, including electrocardiograms, cardiac enzymes, brain-natriuretic peptide, urinalysis, creatinine, full blood count, chest radiography and computed tomography of the brain [4]. Due to a lack of evidence, clinical management of patients with malignant hypertension remains controversial. If diagnostic assessments indicate acute organ deterioration, patients should be considered to be having an hypertensive emergency, warranting admission into an ICU, with prompt BP reduction and, if appropriate, treatment of specific end-organ complications. However, in the absence of acute end-organ deterioration, the benefit of prompt BP reduction is unclear, with some advocating outpatient referral for reassessment and management prior to beginning of antihypertensive treatment in the emergency department [9], and others suggesting immediate initiation of pharmacologic treatment in select patients [10,11]. If immediate treatment is not initiated, patients should, at a minimum, be referred to a primary care physician for prompt follow-up, or, alternatively, admitted to hospital for BP control. In conclusion, this article demonstrates that in a patient presenting with a severely elevated BP, accurate and prompt identification of acute end-organ damage, and appropriate clinical management are more important than absolute BP levels. Clinicians should remember that when managing hypertensive crises, a comprehensive evaluation, including a proper patient interview and physical examination and appropriate laboratory testing are more important than the BP level alone. ACKNOWLEDGEMENTS Conflicts of interest There are no conflicts of interest.

Physicians treat chronic hypertension almost exclusively in ambulatory care settings according to evidence-based guidelines1 based on blood pressure (BP) measurements obtained under prescribed conditions.2 Other recommendations cover how to deal with hypertension in dialysis units2 and emergency departments,3 but none address a very commonly encountered problem: what to do about acutely elevated BP (which I refer to below in the common parlance of “acute hypertension”) in patients hospitalized for reasons other than hypertension. Indeed, excluding articles on patients with hypertensive emergencies and urgencies, there is little published about treatment of acutely elevated BP in hospitalized patients, although the practice seems to be common and based on firmly held, but poorly justified, beliefs.4 In this commentary, I argue for developing a rational approach to treating acute hypertension that de-emphasizes “treating the numbers” and focuses on patient safety. ### How Common Is Acute Hypertension in Hospitalized Patients? Most patients hospitalized for reasons other than hypertensive emergency or urgency who subsequently sporadically manifest acute hypertension deemed worthy of clinical concern probably also have chronic hypertension. In recent national data of hospitalizations, hypertension was listed as a primary diagnosis (International Classification of Diseases [ICD]–9 CM code 401) for 301 000 admissions but as a secondary diagnosis for 9 003 000 hospitalizations.5 These figures are probably an underestimate of the actual prevalence of hypertension in inpatients because 29% of the US adult population is now affected.6 One estimate of the rate of hypertension in patients in our center (the University of Michigan Health System[UMHS]) can be derived from patients attending our anesthesiology preoperative evaluation clinic, who have an incidence of 26.7% of stage 1 and 10.9% of stage 2 hypertension (unpublished data, 2010). Using these prevalence figures, during a 1-year period (October 1, 2007, to September 30, 2008) in which there were 29 545 adult admissions to …