Imaging findings in hypertensive encephalopathy

Hypertensive encephalopathy is a neurologic syndrome caused by a marked and rapid rise of blood pressure above baseline levels. Efficacy of current anti-hypertensive drugs greatly diminished the frequency of this situation in which diagnosis is essentially based on clinical parameters. This can justify the few papers found in radiologic literature. Nevertheless it is sometimes important to exclude ischemic or hemorrhagic complications or establish a differential diagnosis with other neuropathologic conditions. Then a striking imagiologic picture of focal or diffuse reversible edema of cerebral white matter can be found. We present three clinical cases of hypertensive encephalopathy. Imagiologic findings are reviewed and correlated with the pathophysiologic basis of the disease.     

The treatment of hypertension in pregnancy

Hypertensive disease in pregnancy remains a major cause of maternal and perinatal morbidity and mortality. Control of maternal hypertension with antihypertensive therapy improves maternal and foetal outcome. If the blood pressure is elevated in early pregnancy, complications are more likely to occur to both mother and foetus, and the outcome may not be favourable. In labour the threat of severe pre-eclampsia or eclampsia is a constant hazard.     

Hypertensive encephalopathy in childhood. Diagnostic problems

Oppenheimer and Fischberg's vasoconstriction-hypothesis on the pathogenesis of hypertensive encephalopathy was subsequently supported by animal experiments. Later on the role of decompensation of the autoregulatory mechanism of the cerebral blood flow was revealed. The transient symptomatology comprises headache, seizures, focal cerebral symptoms (hemiplegia etc.), visual disturbances, mental disorders, papiledema etc. The age-dependency of the influence of edema is probably expressed by the predominance of seizures in childhood and the long duration of the symptoms in our third and fourth patient. The differentiation between hypertensive encephalopathy and a local complication of hypertension (hemorrhage) can be difficult, not at least because the first disturbance may be followed by the second (patient 3). Hypertension is not always present as initial symptom (patient 1 and 2). Hence a series of blood pressure readings is required in acute cerebral incidents in childhood. Steroid-treatment may lead, especially in patients suffering from a hypocomplementemic form of membranoproliferative glomerulonephritis, to a sudden rise of the blood pressure and subsequently to hypertensive encephalopathy (patients 2 and 3). Hypertensive encephalopathy is a neuropediatric emergency. The urgent treatment with dioxaside, fursemide and sodium nitroprusside is shortly reviewed.     

Reversible intracerebral pathologic entities mediated by vascular autoregulatory dysfunction

Several cerebral pathologic processes thought to result from derangements in vascular autoregulatory mechanisms show reversible abnormalities on computed tomographic and magnetic resonance images. The hypertensive encephalopathies are characterized by intracranial abnormalities due to subacutely elevated blood pressure; these entities include hypertensive encephalopathy, preeclampsia and eclampsia, and cyclosporine toxicity. Imaging studies reveal symmetric confluent lesions with mild mass effect and patchy enhancement centered in the immediate subcortical white matter of the occipital lobes. The uremic encephalopathies are characterized by intracranial abnormalities due to an elevated level of blood urea nitrogen; these entities include uremia and glomerulonephritis, hemolytic-uremic syndrome, and thrombotic thrombocytopenic purpura. Imaging studies reveal multiple areas of symmetric edema in the basal ganglia; in severe cases, focal infarcts with or without hemorrhage can be seen. As radiologists become more familiar with these entities, cases can be recognized earlier in the disease process, allowing more timely initiation of appropriate therapy.     

Wernicke's encephalopathy and dialysis: report of two cases

Wernicke encephalopathy is considered a complication of dialytic therapy, but there are few reports of this complication. We report a 57 years old man and a 45 years old woman, with grade IV renal failure, who after acute peritoneodialysis and chronic hemodialysis respectively, had a confusional syndrome that responded to the administration of thiamine. CT scans in both patients discarded abnormal blood collections or new cerebrovascular episodes. The man bad two previous cerebrovascular episodes, a severe anemia that was corrected, angina and an episode of arrhythmia during the dialytic procedure previous to the confusional episode. The woman had an acute uremic syndrome and a concomitant urinary tract infection during the confusional episode. Wernicke encephalopathy must be suspected in patients in dialysis with confusional episodes.     

Intracranial hypotension presenting with severe encephalopathy. Case report

A patient with severe and protracted symptoms from intracranial hypotension is described. The patient's presentation was marked by diffuse encephalopathy and profound depression of consciousness. This case report expands the presently known clinical spectrum of this uncommon and generally benign illness. The clinical and laboratory findings typically observed in the syndrome of intracranial hypotension are outlined. The pathophysiological mechanisms of the phenomenon are briefly discussed. Intracranial hypotension is a potentially severe illness with specific treatments that are distinct from the treatment of most neurological diseases. Three cardinal features--postural headache, pachymeningitis, and descent of midline cerebral structures--should prompt the diagnosis.     

High blood pressure. A side effect of drugs, poisons, and food

A variety of therapeutic agents or chemical substances can induce either a transient or a sustained increase in blood pressure. These agents increase arterial pressure by either causing sodium retention and extracellular volume expansion or directly or indirectly activating the sympathetic nervous system. Some agents act directly on arteriolar smooth muscle. For certain agents, the mechanism of pressure elevation is mixed or unknown. Paradoxically, some agents that are used to lower arterial pressure may acutely increase arterial pressure. Also, a rebound increase in pressure may be encountered after discontinuation of certain antihypertensive agents. In general, these chemically induced increases in arterial pressure are small and transient; however, severe hypertension involving encephalopathy, stroke, and irreversible renal failure has been reported. Careful evaluation of a patient's drug regimen may identify chemically induced hypertension and prevent the need for evaluation and therapy. This study reviews the therapeutic agents or chemical substances that elevate blood pressure and their mechanisms of action.     

Acute carpal tunnel syndrome

Although the carpal tunnel is open at both ends, it has the physiologic properties of a closed compartment bounded by synovium proximally and distally. When the intracarpal canal interstitial pressure rises above a critical threshold pressure, capillary blood flow is reduced below the level required for median nerve viability. Acute carpal tunnel syndrome is recognized frequently as occurring secondary to wrist trauma and infrequently due to a variety of infectious, rheumatologic, and hematologic disorders. This condition warrants prompt recognition and the treatment is early carpal tunnel release.     

Posttraumatic acute renal insufficiency

Acute renal insufficiency is a severe, but most frequent reversible illness followed by sudden onset, oliguria or anuria of indefinite duration, by rapid increase in decomposition products of protein catabolism in serum, by acidosis and fluid balance and electrolytes disorder. The aetiologic factors of acute renal insufficiency are various. A very significant aetiological factor in the appearance of acute renal insufficiency is a trauma caused by any kind or type of weapons, arms or instruments [1-5, 6, 9-13, 15]. Of a total number of injured persons who were treated in our institution (4,086 injured persons), 251 (6.14 percent) were with acute renal insufficiency, and of that number with all signs and symptoms of acute renal insufficiency 37 (0.9 percent) were treated with haemodialysis. Of the number of dialysed patients 30 (80 percent) patients had oliguric form of acute renal insufficiency and 7 (19 percent) were with non oliguric form of acute renal insufficiency. The most frequent injuries were to abdomen and then to extremities, liver, chest and kidneys. The smallest percentage concerned isolated injuries in extremities. According to a pathogenic mortality mechanism, the highest mortality was in patients with haemorrhagic syndrome and in septic condition, and the minimal in patients with other syndromes, such as crush syndrome, etc. In 25 (68 percent) patients acute renal insufficiency was associated with haemorrhagic syndrome, in 7 (18.9 percent) with crush syndrome and in 5 (13.5 percent) with septic condition. In 36 (97 percent) patients haemodialysis was performed and in 1 (3 percent) subject peritoneal dialysis. The reason for such a small number of peritoneal dialysis are severe injuries to abdomen and chest, since this type of dialysis could not be performed for technical reasons. In 27 (73 percent) patients haemodialysis was performed as a type of intermittent heparinization. In 5 (14 percent) patients heparinization was a type of continual heparinization. Thanks to prompt haemodialysis together with medical therapy and surgical treatment, the mortality rate in our patients was lower in comparison to mortality rate in other centres (Table 3). The main causes of acute renal insufficiency in our patients were: Acute tubular nercosis, peripheral blood flow insufficiency (hypovolaemia, cardiovascular failure), and postrenal insufficiency (excretory obstruction, intrarenal obstruction, urinary organ ruptures, haemorrhagic shock) and the underlaying kidney disease. Acute renal insufficiency can be divided into acute renal insufficiency, primary parenchymal renal insufficiency and postrenal azotaemia [1-6, 9, 12, 13]. During the therapy of these patients it is important to evaluate the dehydration degree of patients by clinical and laboratory parameters. In case of hypovolaemia the complete compensation of fluid should consist of infusion together with administration of diuretics. The central venous pressure should be maintained at the values in a range from 6 to 8 cm H2O. In case of oliguric acute renal insufficiency the fluid intake should be equal to diuresis plus every other loss of fluids. Diet should be high-caloric with carbohydrates in the amount of 100 mg, and that amount should be given three to four times daily (both parenterally and orally) together with restriction of potassium intake due to a well known effect of potassium on myocardium function. Dosage of drugs which are eliminated via kidney should be managed promptly by parenteral administration of antibiotic agents [7, 8, 13-16]. Haemodialysis should be started at the very beginning of the patients admission to the hospital and should be associated with anticoagulant therapy for avoiding haemorrhages. Thanks to haemodialysis performed in time, the mortality rate in our patients was reduced in comparison to health centres where haemodialysis was delayed. Thanks to such treatment of patients with many severe injuries in whom the mortality rate is usuall     

Electroconvulsive therapy: a guide for family physicians

Electroconvulsive therapy, which works by creating a generalized seizure, is used most frequently to treat medication-resistant depression. Other indications for electroconvulsive therapy includes severe depression with suicidal ideation, acute mania and severe psychiatric illness with food and fluid refusal. Electroconvulsive therapy may be administered as an inpatient or outpatient procedure. Treatments are usually administered three times a week for six to 12 treatments. Before this therapy is used, a thorough medical and anesthetic history should be obtained, and a complete physical examination, an electrocardiogram and appropriate laboratory studies should be performed to rule out anemia, electrolyte imbalances, and cardiopulmonary and neurologic risk factors. Heart rate and rhythm, oxygenation, blood pressure and, often, the electroencephalogram are monitored continuously while the patient is anesthetized with a short-acting hypnotic agent and a muscle depolarizing agent. After electroconvulsive therapy, antidepressant or lithium therapy significantly reduces the symptom relapse rate.     

Hypertension and its treatment in pregnancy

Hypertensive disorders complicate approximately 10% of all pregnancies, about half due to transient and essential hypertension and the rest due to preeclampsia that continues to be a major contributor to maternal and perinatal mortality. However, when hypertensive pregnancies are carefully monitored, the neonatal mortality is low. Therefore, identification of women destined to have preeclampsia is essential, and it is the major purpose of the new classification proposed by M. A. Brown and M. L. Buddle to better stratify those hypertensive pregnant women who are at high risk and need intensive inpatient management. Prophylactic low-dose aspirin appeared to prevent preeclampsia in some studies and to be reasonably safe; however, the effectiveness in reducing the incidence of severe preeclampsia and improving pregnancy outcome remains uncertain. The basic therapy for hypertension during pregnancy is now hydralazine, labetalol and methyldopa; for preeclampsia the cornerstone for treatment is magnesium sulphate and hydralazine intravenously, and small doses of diazoxide, if necessary. Diuretics have a dubious place in treatment of hypertension during pregnancy, and ACE-inhibitors are contraindicated. In severe preeclampsia and eclampsia, the only solution is delivery; better knowledge of etiology and pathogenetics is needed for effective and safe treatment of gestational hypertension, as well as careful blood pressure monitoring and adequate laboratory control.     

Prevalence and correlates of blood pressure elevation in children with Guillain-Barré syndrome

While there have been case reports describing blood pressure elevation in adults and children with Guillain-Barré syndrome (GBS), no previous systematic study has explored the prevalence of hypertension in children with this condition. In a retrospective review, blood pressure elevation was seen in 20 of 30 (66.7%) patients with GBS admitted to a children's hospital during a 10-year period. There was a significant correlation between highest GBS stage and deviation of systolic blood pressure from age- and gender-specific norms (r = 0.93, p < 0.05). Since blood pressure may be markedly elevated in GBS, the clinician caring for a child with this condition should be aware of this complication.     

Secondary hypertension: a practical diagnostic approach

Secondary hypertension is a relatively uncommon, potentially reversible condition for which physicians should maintain a high index of suspicion. When a patient is found to have elevated blood pressure, a through history should be obtained and a complete physical examination should be performed. Depending on the findings, additional screening and diagnostic studies may be necessary. The most common causes of secondary hypertension are renal parenchymal disease, renovascular disease, coarctation of the aorta, pheochromocytoma, primary hyperaldosteronism, thyroid dysfunction and Cushing's syndrome.     

Reversible posterior leukoencephalopathy: significance in everyday clinical practice

Reversible posterior leukoencephalopathy (PLE) is a newly recognized syndrome with characteristic radiologic findings. The clinical picture resembles that of hypertensive encephalopathy. PLE is caused by uncontrolled hypertension as well as other neurotoxic conditions. We report on 3 patients with this syndrome. One patient also had transient hydrocephalus which may have been caused by PLE. Clinicians must be aware of this syndrome as its recognition obviates unnecessary diagnostic procedures. PLE is reversible by lowering elevated blood pressure and treating neurotoxic conditions such as uremia.     

Virus-associated hemophagocytic syndrome after hepatic resection: a case report

Virus-associated hemophagocytic syndrome (VAHS) is associated with a systemic viral infection and is mainly observed in immunosuppressed adult patients. This rare disease is characterized by symptoms which include a high fever, pancytopenia, and splenomegaly and sometimes results in a fatal outcome. However, thus far, little has been reported on VAHS in general surgical patients. We herein report this rare complication which occurred in a patient with hepatocellular carcinoma, as well as chronic hepatitis C, after a hepatic resection. A 66-year-old man with chronic hepatitis C and recurrent hepatocellular carcinoma underwent a repeat hepatic resection without any blood transfusions. In the early postoperative period, he recovered uneventfully. However, he suddenly began to suffer from a high fever (38.4 degrees C) and severe pancytopenia 8 days after surgery. Activated macrophages, which phagocytosed erythrocytes, were identified by a cytological study of the bone marrow. The patient was therefore treated with methylprednisolone pulse therapy 13 days after surgery. On the day following the initial administration of methylprednisolone, his clinical condition drastically improved. Fortunately, with methylprednisolone therapy, our patient recovered from acute, severe pancytopenia. In general surgery, it is often difficult for surgeons to use steroids due to their negative side effects. However, when symptoms such as fever, general fatigue and pancytopenia are observed, even in posthepatectomy patients with hepatocellular carcinoma and hepatitis, a bone marrow aspiration should be performed as soon as possible, and when VAHS is suspected, steroid pulse therapy should be the first treatment of choice. This rare but sometimes fatal complication should thus be taken into consideration in the postoperative management of hepatectomized patients with chronic hepatitis C.     

Encephalopathy due to capillary leak syndrome

Systemic capillary leak syndrome (SCLS) is characterized by intermittent attacks of leakage of intravascular fluids into the extravascular space. Hypovolemia, hemoconcentration, weakness, edema, and visceral congestion are resulting manifestations of SCLS. Most patients with SCLS have clear mentation during attacks, and encephalopathy is not a known manifestation of the syndrome. We report a patient with acute idiopathic capillary leak syndrome manifested in an acute encephalopathy. The possibility of SCLS should be considered in patients who have an encephalopathy and hemoconcentration.     

Severe head injury combined with orthopedic and vascular trauma of the limbs

From 1982 to 1992, 2766 brain injury patients were admitted to the University Hospital San Cecilio of Granada, Spain. In 873 cases head injury was concomitant with other injuries but the association of severe head injury and combined orthopedic and vascular trauma of the limbs was observed only in 23 cases (incidence 2%). Thirteen patients were scheduled for revascularization, and of these secondary amputation was mandatory in two cases to keep rising intracranial pressure under control. Except for epidural hematomas which constitute an absolute neurosurgical emergency, combined orthopedic and vascular trauma of the limbs can be treated before head injury. However, we prefer to work with two operating teams simultaneously. Physical examination and judicious arteriography provide means for prompt diagnosis and treatment of the injured limb. The compartment syndrome should be anticipated and fasciotomy should be used routinely. Vascular repairs normally using reverse autogenous vein are the first priority, but we must always bear in mind the deleterious effects of the revascularization syndrome which expose the brain to a second aggression, and amputation, when necessary, should be undertaken to reduce mortality.     

Minimizing alcohol exposure of the breastfeeding infant

A 50-year-old woman developed an acute febrile dermatosis on two occasions concurrently with recurrent Crohn's disease of the colon. Based on the presence of painful erythematous plaques on both hands and forearms, on the leukocytosis with excess bands in peripheral blood, on the histology showing dermal infiltration by mature granulocytes, and on the prompt response to steroids, the diagnosis was made of Sweet's syndrome associated with Crohn's disease. Sweet's syndrome is thought to be a hypersensitivity reaction that leads to parainflammatory (e.g., infections, autoimmune disorders, vaccinations) and paraneoplastic (myeloproliferative disorders, solid malignancy) associations, with a frequency of 10-30%. The association of Sweet's syndrome with Crohn's disease is very rare, but the gastroenterologist should readily differentiate it; it is important to be aware that such patients may have a nonspecific elevated activity index owing to the underlying dermatosis.     

Hemodialysis in the treatment of severe hypercalcemia

Severe hypercalcemia is a life-threatening problem that requires prompt therapy. With the exception of diuresis, most forms of therapy are either ineffective, slow in action, or have major serious disadvantages. In some instances diuresis is relatively ineffective. As shown in this case report, hemodialysis with a dialysate low in calcium is rapidly effective in such instances and should be considered for patients with severe hypercalcemia while they are being prepared for surgery or while diagnostic studies are being performed.     

Guidelines for the drug treatment of hypertensive crises

Hypertensive crises are a group of clinicopathological entities in which rapid reduction of hypertension is necessary to prevent serious end-organ damage. The diagnosis and treatment plan depends on the identification of specific end-organ dysfunction. The goal of treatment is to limit the progression of end-organ damage in patients with hypertensive crises. Several potent antihypertensive drugs, such as sodium nitroprusside, labetalol and urapidil, are available to produce an immediate fall in blood pressure. The choice of the drug should be made on the basis of its pharmacodynamic properties, clinical effects, advantages and contraindications. Additionally, rapid reduction of blood pressure carries a considerable risk, if it is performed in an uncontrolled manner, leading to further end-organ damage. The aim of the treatment is not just to reduce blood pressure, but to do so with minimal adverse effects while preserving organ function.