[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.

UNLABELLED: 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.

Posterior reversible encephalopathy associated with nocturnal blood pressure non-dipping pattern.

We report the case of a 70-year-old man who presented with a recent history of headache, altered mental status and sleepiness. He was known to have type II diabetes mellitus, and a mild, treated and apparently well controlled hypertension. Brain magnetic resonance imaging demonstrated extensive abnormalities in the parieto-occipital white matter, suggestive of posterior reversible encephalopathy syndrome (PRES). An extensive diagnostic evaluation did not allow the detection of any known cause of the syndrome. Twenty-four-hour non-invasive ambulatory blood pressure monitoring showed a mild to moderate hypertension, with non-dipping pattern. This case suggests that, in the context of an overnight blunted blood pressure profile, even a mild or moderate hypertension can result in cerebral vasogenic oedema, underlining the diagnostic importance of 24-h blood pressure monitoring in patients with PRES without severe hypertension or other commonly recognized causes of posterior reversible encephalopathy.

[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.

Changes in middle cerebral artery velocity after carotid endarterectomy do not identify patients at high-risk of suffering intracranial haemorrhage or stroke due to hyperperfusion syndrome.

OBJECTIVES: To determine if significant increases in middle cerebral artery velocity (MCAV) or pulsatility index (PI) during and immediately after carotid endarterectomy (CEA) were predictive of patients suffering a stroke due to the hyperperfusion syndrome (HS) or intracerebral haemorrhage (ICH). METHODS: Transcranial Doppler (TCD) mean/peak MCAV and PI were recorded pre-operatively; pre-clamp; 1-min post-declamping; 10-min post-declamping and 30-min post-operatively. The study was divided into two time periods; Group 1 (1995-2007); where there was no formal guidance for managing post-CEA hypertension (PEH) and Group 2 (2008-2012); where written guidelines for treating PEH were available. RESULTS: 11/1024 patients in Group 1 (1.1%) suffered a stroke due to HS/ICH, compared to 0/426 patients (0.0%) in Group 2 (p = 0.02). In Group 1; intra-operative increases >100% in mean/peak MCAV and PI at 1 and 10-min post-clamp release had positive predictive values (PPV) of 1.2%, 6.3% and 20.0% and 2.9%, 8.0% and 16.6% respectively. Post-operatively; a >100% increase in mean and peak MCAV had a PPV of 6.3% and 2.7% respectively. CONCLUSION: We were unable to demonstrate that significant increases in MCAV and PI were able to predict patients at increased risk of suffering a post-operative stroke due to HS or ICH. The provision of written guidance for managing PEH in Group 2 patients was associated with virtual abolition of ICH/HS.

[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).

Posterior reversible encephalopathy syndrome.

Posterior reversible encephalopathy syndrome (PRES) is characterized by headache, altered mental status, visual disturbances, and seizures. Radiological features typically include edema of the posterior cerebral regions, especially of the parietooccipital lobes. Atypical imaging features, such as involvement of anterior cerebral regions, deep white matter, and the brain stem are also frequently seen. Vasoconstriction is common in vascular imaging. Different conditions have been associated with PRES, but toxemia of pregnancy, solid organ or bone marrow transplantation, immunosuppressive treatment, cancer chemotherapy, autoimmune diseases, and hypertension are most commonly described. The pathophysiology of PRES is unclear and different hypotheses are being discussed. Posterior reversible encephalopathy syndrome is best managed by monitoring and treatment in the setting of a neurointensive care unit. The prognosis is usually benign with complete reversal of clinical symptoms within several days, when adequate treatment is immediately initiated. Treatment of severe hypertension, seizures, and withdrawal of causative agents represent the hallmarks of specific therapy in PRES. Delay in diagnosis and treatment may lead to permanent neurological sequelae. Therefore, awareness of PRES is of crucial importance for the intensivist.

[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.

Reversible multifocal leukoencephalopathy associated with a nocturnal blood pressure non-dipper pattern.

The majority of cases of leukoencephalopathy related to hypertensive crisis show brain lesions predominantly in the posterior lobe. Such cases are usually classified as reversible posterior leukoencephalopathy syndrome (RPLS). A multifocal distribution pattern is also possible, but occurs seldom. Here we report two patients with extensive white matter lesions that affect the entire brain, related to hypertensive crisis associated with a non-dipper pattern of blood pressure during the night as well as renal dysfunction. This nocturnal blood pressure abnormality may be relevant for the distribution pattern of cerebral white matter lesions and underlines the concept that in these cases a 24-h ambulatory blood pressure monitoring is needed.

Hypertensive emergencies and urgencies in emergency departments: a systematic review and meta-analysis.

OBJECTIVES: The prevalence of hypertensive emergencies and urgencies and of acute hypertension-mediated organ damage (aHMOD) in emergency departments is unknown. Moreover, the predictive value of symptoms, blood pressure (BP) levels and cardiovascular risk factors to suspect the presence of aHMOD is still unclear. The aim of this study was to investigate the prevalence of hypertensive emergencies and hypertensive urgencies in emergency departments and of the relative frequency of subtypes of aHMOD, as well as to assess the clinical variables associated with aHMOD. METHODS: We conducted a systematic literature search on PubMed, OVID, and Web of Science from their inception to 22 August 2019. Two independent investigators extracted study-level data for a random-effects meta-analysis. RESULTS: Eight studies were analysed, including 1970 hypertensive emergencies and 4983 hypertensive urgencies. The prevalence of hypertensive emergencies and hypertensive urgencies was 0.3 and 0.9%, respectively [odds ratio for hypertensive urgencies vs. hypertensive emergencies 2.5 (1.4-4.3)]. Pulmonary oedema/heart failure was the most frequent subtype of aHMOD (32%), followed by ischemic stroke (29%), acute coronary syndrome (18%), haemorrhagic stroke (11%), acute aortic syndrome (2%) and hypertensive encephalopathy (2%). No clinically meaningful difference was found for BP levels at presentations. Hypertensive urgency patients were younger than hypertensive emergency patients by 5.4 years and more often complained of nonspecific symptoms and/or headache, whereas specific symptoms were more frequent among hypertensive emergency patients. CONCLUSION: Hypertensive emergencies and hypertensive urgencies are a frequent cause of access to emergency departments, with hypertensive urgencies being significantly more common. BP levels alone do not reliably predict the presence of aHMOD, which should be suspected according to the presenting signs and symptoms.

A case of hypertensive encephalopathy with prominent brainstem presentation.

A 39-year-old woman developed severe arterial hypertension associated with brainstem hyperintensity in T2-weighted images and hyperintense lesion in the left basal ganglia. Clinical findings were a sudden loss of consciousness, confusion, nausea, vomiting and headache. Rapid treatment of hypertension resulted in clinical and radiological improvement. Rapid identification and appropriate diagnostics are essential, as prompt treatment usually results in reversal of symptoms; permanent neurologic injury or death can occur with treatment delay.

Posterior reversible encephalopathy syndrome: a case of unusual diffusion-weighted MR images.

Posterior reversible encephalopathy (PRES) represents an uncommon entity related to multiple pathologies, the most common of which is hypertensive crisis. PRES is classically characterized as symmetrical parieto-occipital edema, but may affect other areas of the brain. Diffusion-weighted magnetic resonance imaging (DWI) is important for differentiating between vasogenic and cytotoxic edema. We present here the case of a 43-year-old woman, known to suffer from arterial hypertension and severe renal failure, who developed PRES with restricted apparent diffusion coefficients (ADC) in various cerebral areas, suggesting irreversible tissue damage. Nevertheless, follow-up cranial MRI revealed complete remission, indicating that restricted diffusion does not always lead to cell death in this pathology. The underlying pathophysiological mechanism is not well understood. Such reversibility of diffusion anomalies has already been reported with transient ischemia, vasospasm after subarachnoid hemorrhage and epilepsy but, to our knowledge, never before in PRES.

[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.

Reversible brainstem hypertensive encephalopathy (RBHE): Clinicoradiologic dissociation.

We report two cases of reversible brainstem hypertensive encephalopathy (RBHE) with unusual magnetic resonance (MR) findings. Patient 1, an 85-year-old man without a history of hypertension, developed acute severe hypertension and mild consciousness disturbance as the only symptoms. Patient 2, a 46-year-old man with an untreated hypertension, presented with extremely high blood pressure and general fatigue, vertigo, and mild dysarthria as the initial manifestations. In these patients, fluid-attenuated inversion recovery (FLAIR) and T2-weighted MR images revealed diffuse hyperintensities in the brainstem. Diffusion-weighted imaging (DWI) findings were normal, and apparent diffusion coefficient (ADC) values were increased in the brainstem. The supratentorial regions were largely spared, and mildly diffuse hyperintensities were noted in the white matter. There were no accompanying changes in the occipital lobe and cerebellum. The lesions completely resolved after stabilization of blood pressure. The normal DWI findings and high ADC values were consistent with vasogenic edema due to severe hypertension. The characteristics of RBHE are a very high blood pressure, mild clinical and neurologic symptoms, rapidly improved MR findings after initial treatment with the control of hypertension, and a marked clinicoradiologic dissociation.

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.

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.

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.

[Posterior reversible encephalopathy and renal failure. Value of the diffusion magnetic resonance]. / Encefalopatía posterior reversible e insuficiencia renal. Valor de la resonancia magnética por difusión.

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.

[An old woman with sudden pareses and blindness]. / En eldre kvinne med akutte pareser og synstap.

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.