Evaluation and Management of Elevated BP in Children in the ED.

PURPOSE OF REVIEW: Pediatric hypertension has been on the rise over the past four decades. While most cases are evaluated and managed in the primary healthcare setting, some children may be referred to the emergency department (ED) for an expedited workup of elevated blood pressure or for management of hypertensive crisis. RECENT FINDINGS: Acute severe hypertension without end-organ damage and hypertensive emergency are life-threatening conditions that healthcare providers must be prepared to accurately recognize and treat as pediatric hypertension increases in prevalence. In this article, we review the most recent definitions of elevated blood pressure and hypertension and discuss the updated literature on the evaluation and management of hypertension and hypertensive crisis of children in the ED.

Slow on the Draw-ED Management of Elevated BP in Older Adults.

PURPOSE OF REVIEW: The purpose of this study is to review data surrounding the emergency department management of elevated blood pressure in older adults, including the management of hypertensive crisis and outpatient management of markedly elevated blood pressure. RECENT FINDINGS: Acute lowering of blood pressure in older adults with markedly elevated blood pressure may lead to serious complications without improvements in hospital length of stay, return visits, or mortality. Older adults presenting with elevated blood pressures without evidence of end-organ damage should be referred for outpatient management of their blood pressure. Treatment of hypertensive emergency should follow standard guidelines with additional considerations for aging physiology. Acute lowering of elevated blood pressure in older adults without evidence of end-organ damage has the potential for harm. If the emergency physician opts to acutely treat, they should consider the increased risk of side effects in older adults and avoid Beers list medications including short-acting nifedipine and clonidine.

Reversible severe pulmonary hypertension related to scurvy in children.

BACKGROUND: Severe pulmonary hypertension (PH) in childhood is rare and can manifest as a life-threatening episode. We present 2 children with restrictive dietary habits with severe pulmonary hypertension secondary to scurvy and iron deficiency anemia with treatment and outcome. CASE PRESENTATION: The first case is a 2-year-old boy who presented with vomiting, diarrhea, and fever. After rehydration, he had recurrent episodes of hypotension with intermittent abdominal pain. Fluid resuscitation and inotropic medication were given. Then he suddenly collapsed. After 4-min cardiopulmonary resuscitation, his hemodynamic was stabilized. Most of the medical workup was unremarkable except for PH from the echocardiogram with estimated systolic pulmonary artery pressure (PAP) at 67 mmHg. Transient PH was diagnosed, and milrinone was prescribed. Since he had restrictive dietary habits and sclerotic rim at epiphysis in chest films, his vitamin C level was tested and reported low-level result. The second case is a 6-year-old boy with acute dyspnea, a month of low-grade fever, mild cyanosis, and a swollen left knee. Echocardiogram indicated moderate TR with estimated systolic PAP at 56 mmHg (systolic blood pressure 90 mmHg). Milrinone was given. Right cardiac catheterization showed PAP 66/38 (mean 50) mmHg and PVRi 5.7 WU.m2. Other medical conditions causing PH were excluded. With a history of improper dietary intake and clinical suspicion of scurvy, vitamin C was tested and reported undetectable level. Administration of vitamin C in both cases rapidly reversed pulmonary hypertension. CONCLUSION: Pediatric PH related to vitamin C deficiency can manifest with a wide range of symptoms, varying from mild and nonspecific to severe life-threatening episodes characterized by pulmonary hypertensive crises. PH associated with scurvy is entirely reversible with appropriate investigation, diagnosis, and treatment. Our report highlights the importance of considering nutritional deficiencies as potential confounding factors in pediatric PH, emphasizing the need for comprehensive evaluation and management of these patients.

Case report: a unique presentation of memantine overdose causing echolalia and hypertension.

BACKGROUND: Since 2003 when memantine was first approved for use in the management of moderate-severe Alzheimer's dementia, its use has become more widespread and is being explored in other diseases like neuropathic pain, epilepsy, and mood disorders. Our case uniquely highlights two important adverse effects in a patient who overdosed on memantine. One is hypertension, which is easy to overlook as a medication side effect. The other is echolalia which is the repetition of words and phrases spoken by another person. It is commonly seen in children with autism spectrum disorder and has been reported in older adults with head injuries, delirium, and neurocognitive disorders. The aim of this patient story is to highlight the importance of medication reconciliation with caregivers and knowledge of adverse drug reactions in patient management. This case report has been presented previously in the form of an abstract at the American Geriatrics Society Presidential poster session in May 2023. CASE PRESENTATION: Our patient is an 86-year-old man with mild dementia and hypertension, who was brought to the emergency department (ED) due to abrupt onset of altered mental status and auditory hallucinations. Investigations including blood work, CT head and an electroencephalogram (EEG) did not reveal an etiology for this change in his condition. Due to elevated blood pressure on presentation, a nicardipine drip was started, and he was given IV midazolam to assist with obtaining imaging. While reviewing medications with his daughter, it was noted that sixty memantine pills were missing from the bottle. Poison control was contacted and they confirmed association of these features with memantine. With supportive care, his symptoms resolved in less than 100 h, consistent with the half-life of memantine. Notably, our patient was started on Memantine one month prior to this presentation. CONCLUSIONS: Hypertensive urgency and echolalia were the most striking symptoms of our patient's presentation. Though hypertension is a known sign of memantine overdose, it can easily be contributed to medication non-compliance in patients with dementia, being treated for hypertension. According to our literature review, this the first case of memantine overdose presenting with echolalia, a sign that is not commonly associated with adverse reactions to medications. This highlights the importance of an early medication review, especially with caregivers of people with dementia.

Differences in intraoperative and surgical outcomes between normotensive pheochromocytomas and sympathetic paragangliomas (PPGLs) and hypertensive PPGLs: results from the PHEO-RISK STUDY.

PURPOSE: To compare the intraoperative and surgical outcomes of normotensive pheochromocytomas and sympathetic paragangliomas (PPGLs), hypertensive PPGLs and non-PPGL adrenal lesions. METHODS: This a retrospective multicenter cohort study of patients with PPGLs from 18 tertiary hospitals. A control group of histologically confirmed adrenocortical adenomas (non-PPGL group) was selected to compare intraoperative and surgical outcomes with of the normotensive PPGLs. RESULTS: Two hundred and ninety-six surgeries performed in 289 patients with PPGLs were included. Before surgery, 209 patients were classified as hypertensive PPGLs (70.6%) and 87 as normotensive PPGLs. A higher proportion of normotensive PPGLs than hypertensive PPGLs did not receive alpha presurgical blockade (P = 0.009). When we only considered those patients who received presurgical alpha blockers (200 hypertensive PPGLs and 76 normotensive PPGLs), hypertensive PPGLs had a threefold higher risk of intraoperative hypertensive crisis (OR 3.0 [95% 1.3-7.0]) and of hypotensive episodes (OR 2.9 [95% CI 1.2-6.7]) than normotensive PPGLs. When we compared normotensive PPGLs (n = 76) and non-PPGLs (n = 58), normotensive PPGLs had a fivefold higher risk of intraoperative complications (OR 5.3 [95% CI 1.9-14.9]) and a six times higher risk of postoperative complications (OR 6.1 [95% CI 1.7-21.6]) than non-PPGLs. CONCLUSION: Although the risk of intraoperative hypertensive and hypotensive episodes in normotensive PPGLs is significantly lower than in hypertensive PPGLs, normotensive PPGLs have a greater risk of intraoperative and postoperative complications than non-PPGL adrenal lesions. Therefore, it is recommended to follow the standard of care for presurgical and anesthetic management of PPGLs also in normotensive PPGLs.

Successful diagnosis and treatment of pheochromocytoma during severe coronavirus disease 2019 (COVID-19): a case report.

Pheochromocytoma is a rare but life-threatening condition due to catecholamine release induced by drug treatments such as ß-blockers or glucocorticoids. We present a case of hypertensive crisis due to pheochromocytoma, induced after the initiation of dexamethasone and landiolol during intensive care for severe coronavirus disease 2019 (COVID-19). Based on a detailed medical history review, the patient was previously diagnosed with primary aldosteronism by confirmatory tests, moreover, an abdominal computed tomography scan identified an adrenal tumor 2 years before current admission. We tentatively diagnosed the patient with pheochromocytoma and initiated α-blockers without conducting a catecholamine report, leading to stable hemodynamics. We present a successfully managed case of pheochromocytoma concomitant with COVID-19, which has become a global crisis.

Fragmented QRS as a predictor of hypertensive crisis in patients with newly diagnosed essential hypertension: 4-year follow-up data.

BACKGROUND: Hypertensive crisis (HC) is a life-threatening condition in patients with hypertension (HT). However, there is no electrocardiography (ECG) marker that can predict which hypertensive patient may develop HC. The fragmented QRS (fQRS) complex is an important prognostic marker in ECG that might be predict cardiovascular events and mortality. Our study aimed to investigate whether fQRS can predict the development of HC in patients with HT, within 4 years of follow-up. METHODS: Newly diagnosed patients with essential HT were recruited for the study from an outpatient clinic. The patients were divided into two groups according to the presence of HC: HC (+) and HC (-). During follow-up, the relationship between fQRS and HC was evaluated. RESULTS: The study group included 504 patients with newly diagnosed HT. During the follow-up period, HC occurred in 98 of the patients. In 57 (11.30%) patients, fQRS was observed on ECG; fQRS was detected in the ECG of 19 (19.38%) of the HC (+) patients (p = 0.008). The results of multivariate logistic regression analysis showed that fQRS (p < 0.001) was as independent predictor for HC development. Kaplan-Meier analysis further demonstrated that the presence of fQRS affects the development of hypertensive urgency in hypertensive patients (log-rank p < 0.001). CONCLUSION: In patients with newly diagnosed HT, the presence of fQRS was found to be an independent predictor of HC.

PHEOCHROMOCYTOMA, THE GREAT MASQUERADER, PRESENTING AS REVERSIBLE CARDIOMYOPATHY: PRIMUM NON NOCERE.

Background: Pheochromocytoma, the great masquerader, can have a varied spectrum of clinical manifestations. It can often cause a diagnostic challenge despite the availability of modern investigation modalities. Case: We present the case of a 38-year-old male who presented with uncontrolled hypertension for the past 10 years and heart failure for one year. The diagnosis of pheochromocytoma was missed in the initial setting, leading to a biopsy of the retroperitoneal mass. Fortunately, the patient survived the procedure. Subsequently, with the involvement of a multi-disciplinary team, he was optimized for surgery under strict cardiac monitoring. After the complete excision of the tumour, he showed significant improvement not only in his clinical symptoms but also in his cardiac status. Conclusions: This case emphasizes the age-old medical phrase of 'Primum non nocere or first, do no harm'. Any invasive procedure in a pheochromocytoma can lead to a massive release of catecholamines causing a hypertensive crisis, pulmonary oedema, and even cardiac arrest. Any young patient presenting with hypertension or heart failure should be investigated for secondary causes. Cardiomyopathy due to pheochromocytoma is because of catecholamine overload and usually reverses or improves after curative surgery.

Interpreting High-Sensitive Troponins in Patients with Hypertension.

PURPOSE OF REVIEW: As the high-sensitivity cardiac troponin (hs-cTn) becomes more broadly used, physicians must understand the strengths and limitations of using the hs-cTn in the hypertensive population. RECENT FINDINGS: The most common cause of hs-cTn elevation is cardiac myocyte injury and death; alternate mechanisms for hs-cTn elevation in the absence of cardiac myocyte death are not clearly understood. Hs-cTn elevation has been found in significant proportions of patients with asymptomatic hypertension, in patients with acute hypertensive crisis, and has even been used to predict patients who will go on to develop hypertension. While the mechanisms remain undefined, there is evidence that elevations in hs-cTn are associated with both short- and long-term morbidity and mortality. While ongoing research further defines the relationship between hypertension and hs-cTn, the emergency medicine physician must make clinical decisions today regarding the utility of this increasingly used biomarker. Given the current evidence, clinical context must be utilized including a complete clinical picture, EKGs findings, and importantly serial hs-cTn when needed to establish whether myocardial injury or myocardial infarction is occurring.

Efficacy of interatrial shunt devices: an opening window to acute pulmonary hypertensive crisis and chronic pulmonary arterial hypertension.

The current study aimed to elucidate the efficacy of interatrial shunt device (IASD) for the treatment of acute pulmonary hypertensive crisis (PHC) and chronic pulmonary arterial hypertension (PAH). After establishing chronic PAH models using dehydrogenized monocrotaline (DHMCT), PAH dogs were implanted with IASDs (group A) or received no intervention (group B). One month later, DHMCT was injected again to establish an acute PHC. The prognosis, hemodynamics, ultrasound cardiography, electrocardiogram, and lung pathology of the dogs were observed. The baseline mean pulmonary arterial pressure increased from 12.70 ± 1.03 to 19.95 ± 1.75 mmHg and established a chronic PAH model 2 months after DHMCT injection (1.50 mg/kg). After an additional injection of DHMCT (1.50 mg/kg) in the chronic PAH model, acute PHC occurred. Mean PAP, sPAP, and pulmonary vascular resistance increased to 22.67 ± 1.80 mmHg, 35.70 ± 1.66 mmHg, and 12.50 ± 3.50 WOOD U, respectively. Cardiac output (CO) decreased to 1.31 ± 0.26 L/min, and the right-to-left shunt caused hypoxemia. The survival rates of the dogs with and those without IASD were 70.0% and 22.2% (P = 0.037), respectively. Six months after PHC, the CO between the dogs with and those without IASD were 1.44 ± 0.11 L/min and 1.18 ± 0.04 L/min (P = 0.028). The long-term survival rates were 50.0% and 22.2%, respectively (P = 0.21). IASD might be efficacious and beneficial for treating acute PHC and chronic PAH, as well as improving prognosis.

Hypertensive Crisis-Related Hospitalizations and Subsequent Major Adverse Cardiac Events in Young Adults with Cannabis Use Disorder: A Nationwide Analysis.

Background and Objectives: With the growing recreational cannabis use and recent reports linking it to hypertension, we sought to determine the risk of hypertensive crisis (HC) hospitalizations and major adverse cardiac and cerebrovascular events (MACCE) in young adults with cannabis use disorder (CUD+). Material and Methods: Young adult hospitalizations (18−44 years) with HC and CUD+ were identified from National Inpatient Sample (October 2015−December 2017). Primary outcomes included prevalence and odds of HC with CUD. Co-primary (in-hospital MACCE) and secondary outcomes (resource utilization) were compared between propensity-matched CUD+ and CUD- cohorts in HC admissions. Results: Young CUD+ had higher prevalence of HC (0.7%, n = 4675) than CUD- (0.5%, n = 92,755), with higher odds when adjusted for patient/hospital-characteristics, comorbidities, alcohol and tobacco use disorder, cocaine and stimulant use (aOR 1.15, 95%CI:1.06−1.24, p = 0.001). CUD+ had significantly increased adjusted odds of HC (for sociodemographic, hospital-level characteristics, comorbidities, tobacco use disorder, and alcohol abuse) (aOR 1.17, 95%CI:1.01−1.36, p = 0.034) among young with benign hypertension, but failed to reach significance when additionally adjusted for cocaine/stimulant use (aOR 1.12, p = 0.154). Propensity-matched CUD+ cohort (n = 4440, median age 36 years, 64.2% male, 64.4% blacks) showed higher rates of substance abuse, depression, psychosis, previous myocardial infarction, valvular heart disease, chronic pulmonary disease, pulmonary circulation disease, and liver disease. CUD+ had higher odds of all-cause mortality (aOR 5.74, 95%CI:2.55−12.91, p < 0.001), arrhythmia (aOR 1.73, 95%CI:1.38−2.17, p < 0.001) and stroke (aOR 1.46, 95%CI:1.02−2.10, p = 0.040). CUD+ cohort had fewer routine discharges with comparable in-hospital stay and cost. Conclusions: Young CUD+ cohort had higher rate and odds of HC admissions than CUD-, with prevalent disparities and higher subsequent risk of all-cause mortality, arrhythmia and stroke.

Relevance of Troponin I Elevation among Individuals with Hypertensive Emergency.

How to cite this article: Maheshwarappa HM, Rai AV. Relevance of Troponin I Elevation among Individuals with Hypertensive Emergency. Indian J Crit Care Med 2022;26(7):767-769.

Perioperative management of patients with pulmonary hypertension undergoing non-cardiothoracic, non-obstetric surgery: a systematic review and expert consensus statement.

BACKGROUND: The risk of complications, including death, is substantially increased in patients with pulmonary hypertension (PH) undergoing anaesthesia for surgical procedures, especially in those with pulmonary arterial hypertension (PAH) and chronic thromboembolic PH (CTEPH). Sedation also poses a risk to patients with PH. Physiological changes including tachycardia, hypotension, fluid shifts, and an increase in pulmonary vascular resistance (PH crisis) can precipitate acute right ventricular decompensation and death. METHODS: A systematic literature review was performed of studies in patients with PH undergoing non-cardiac and non-obstetric surgery. The management of patients with PH requiring sedation for endoscopy was also reviewed. Using a framework of relevant clinical questions, we review the available evidence guiding operative risk, risk assessment, preoperative optimisation, and perioperative management, and identifying areas for future research. RESULTS: Reported 30 day mortality after non-cardiac and non-obstetric surgery ranges between 2% and 18% in patients with PH undergoing elective procedures, and increases to 15-50% for emergency surgery, with complications and death usually relating to acute right ventricular failure. Risk factors for mortality include procedure-specific and patient-related factors, especially markers of PH severity (e.g. pulmonary haemodynamics, poor exercise performance, and right ventricular dysfunction). Most studies highlight the importance of individualised preoperative risk assessment and optimisation and advanced perioperative planning. CONCLUSIONS: With an increasing number of patients requiring surgery in specialist and non-specialist PH centres, a systematic, evidence-based, multidisciplinary approach is required to minimise complications. Adequate risk stratification and a tailored-individualised perioperative plan is paramount.

Pulmonary hypertensive crisis: A potential reason for right ventricle and pacemaker lead failure.

Cardiac pacemakers have improved patient survival and quality of life, although malfunctions can be seen. We present the case of a girl with Seckel syndrome and congenital complete heart block. She had a single chamber permanent pacemaker in the right ventricle. When she referred us with a pulmonary hypertensive crisis (PHC), it was seen that the device was not pacing even in maximum threshold and pulse width values. After new epicardial lead implantation into the left ventricular apex, capture could be established again. For the cases presenting with capture failure, after eliminating lead-related problems and biochemical abnormalities, PHC should be kept in mind as a reason.

Emergency aortic valve replacement complicated by unmanaged pheochromocytoma.

A 53-year-old male undergoing emergency aortic valve replacement for infective endocarditis developed a hypertensive crisis early during the operation. Suspecting a pheochromocytoma, intravenous phentolamine was immediately administered, after which the procedure was completed as scheduled. Although quite rare, a pheochromocytoma can be encountered during emergency open heart surgery; thus, early recognition of abnormal blood pressure change and appropriate management are important. Here, we present details of blood pressure control mainly by use of phentolamine, in this case, to demonstrate effective management of a hypertensive crisis during emergency cardiac surgery because of a pheochromocytoma.

Complications of Hair Transplant Procedures-Causes and Management.

Hair transplant surgery per se has low risk, is relatively safe, and has minimum incidence of complications. However, it is a well-accepted fact that no medical science procedure exists without any potential risk of complications. The complication may be a single complaint in the form of pain, itching, dissatisfaction related to the procedure's outcome, or surgical complication in the form of infection, wound dehiscence or skin necrosis. Inadequate counselling increases unsatisfaction. Improper examination increases the complications, and incomplete medical history and history of allergy increases the risk during surgery. The author collected data of his 2896 patients, operated over a period of 10 years, and recorded the complains and complications. The most common complications were sterile folliculitis, noted in 203 patients, vasovagal shock in seven patients of, hypertensive crisis in one patient, hiccups in six patients, facial edema after hair transplant in 18 patients, graft dislodgement in 8 patients, infection in two diabetic patients, minor necrotic patches in recipient area in three patients, keloid development in one patient, numbness in 18 cases, and hypersensitivity in recipient and/or donor area. Donor area effluvium was seen in one case and three patients showed recipient area effluvium. Twenty-six patients were not happy with the results, and five cases showed partial loss of implanted hair. The overall significant life-threatening or major complications were zero, but the total minor complications' percentage was 0.10%. The key to minimize complaints and complications are detailed counselling, taking careful medical history and history of allergy, and proper examination of patients.

Peak blood pressure and prediction of posterior reversible encephalopathy syndrome in children.

BACKGROUND: Hypertension is a risk factor for posterior reversible encephalopathy syndrome (PRES), but the timing and severity of hypertension relative to PRES are unknown. The objective was to identify a clinically meaningful blood pressure (BP) threshold that predicts PRES development in high-risk children. METHODS: We recorded peak systolic BP, diastolic BP, BP z-scores, and mean arterial pressure over the 14 days preceding clinical concern for PRES in 35 subjects who developed PRES, compared to 14 controls who had normal brain magnetic resonance imaging and similar underlying disease, renal function, and medications. We used multivariable logistic regression models adjusted for fluid overload and obesity to estimate the association of peak BP with PRES. We used receiver operating characteristic curves to determine which peak BP thresholds best predicted PRES and calculated the corresponding sensitivity, specificity, and positive and negative predictive values. RESULTS: Peak systolic BP z-score was most strongly associated with PRES (OR 3.97, 95% CI 1.62-9.74), and peak systolic BP z-score ≥ 3.0 predicted PRES (area under the curve 0.95, 95% CI 0.88-1.0) with 91% sensitivity and 85% specificity, indicating 94% positive predictive value and 79% negative predictive value. CONCLUSIONS: We demonstrated that peak systolic BP z-score ≥ 3.0 in the preceding 14 days predicted PRES development in cases compared with controls in children at high risk. Our study suggests that stage 2 hypertension, corresponding to a z-score ≥ 3.0, could help define hypertensive emergency in high-risk children and indicate when more aggressive treatment is warranted to prevent neurologic injury.

A rare serious case of retroperitoneal paraganglioma misdiagnosed as duodenal gastrointestinal stromal tumor: a case report.

BACKGROUND: Pheochromocytoma (PCC) and Paraganglioma (PGL) are rare neuroendocrine neoplasms. These tumors harbour disastrous consequences during surgery due to catecholamine hypersecretion if they are undiagnosed or prepared inadequately preoperatively. CASE PRESENTATION: A 41- year- old lady presented with mild left flank discomfort. She had experienced recurrent anxiety attacks accompanied by palpitations and headache which were managed previously as panic attacks. Radiologic investigations showed a retroperitoneal mass that located anteromedial to the left kidney, separated from the left adrenal gland and adherent to the 4th duodenal segment. During admission, her vital signs showed slight elevation of blood pressure (140\90-160\110) mmHg, thus 24-h urine metanephrine and normetanephrine were requested and the results revealed normal values. Upper gastrointestinal endoscopy failed to pass beyond the 3th duodenal segment and showed no pathologic evidence. According to her findings, a diagnosis of duodenal gastrointestinal stromal tumor (GIST) was suspected. During laparotomy, crises of hypertension and tachycardia followed by severe hypotension made the resection of the misdiagnosed mass very tricky. Immunohistochemical staining studies confirmed the diagnosis of paraganglioma. CONCLUSION: Paraganglioma is a life threatening disease and should always be considered as a differential diagnosis of asymptomatic retroperitoneal mass. The aim of our study is to present a challenging case of an undiagnosed retroperitoneal paraganglioma and to alarm our colleagues from such troubles.

[New approaches to the old problems. Hypertension in the geriatric patients.]

A significant increase of the elderly population over the world leads to an increasing the relevance of the problems of maintaining health and adequate medical care for geriatric patients. Timely diagnosis and treatment of chronic noncommunicable diseases, the frequency of which increases with age, have been the particular importance. The researchers and practicing doctors have always paid special attention to hypertension in old and very old age due to its prevalence, changeable approaches to diagnosis and assessment of the impact on the prognosis, various ambiguous proposals for the management of the patients. Modern information about the international and domestic researches and recommendations on the issues of the pathophysiology of hypertension, features of its diagnosis and treatment in various clinical situations is presented in the review.

[Hypertensive crisis in a 3-year-old boy - neurovascular conflict?] / Przelom nadcisnieniowy u 3-letniego chlopca ­ konflikt naczyniowo-nerwowy?

Hypertensive crisis is a sudden rise in blood pressure with accompanying clinical symptoms. The disease is extremely rare in small children and is always a complication of secondary hypertension. CASE REPORT: 3-year-old boy (spontaneous delivery, 37 week of gestation, birth weight 2170g, 10 AS, unremarkable family history) was admitted to a hospital because of weight loss (1.5 kg, i.e. approx. 15% in 6 months), anorexia, abdominal and limb pain and lethargy. On admission, very high blood pressure values (190/150 mm Hg), lean subcutaneous tissue, frequent blinking, height 88 cm (<3c), body weight 9.5 kg (<3c). In additional tests: blood morphology, parameters of renal function, ions, gasometry, catecholamine urinary excretion, steroid profile and daily cortisol profile were within normal limits. Elevated plasma renin activity was found. In imaging studies kidneys, adrenal glands and renal arteries were normal. Normotension was not obtained on two antihypertensive drugs - metoprolol and amlodipine. In angio-CT tortuous right vertebral artery, extending to the left on the anterolateral surface of the medulla oblongata - possible compression of the vessel of the left side of medulla - was found. Diagnosis of neurovascular conflict was made. The patient was consulted by neurosurgeon who declare no possibility of surgical treatment of anomalies. In the treatment, according to the literature, a drug blocking the renin-angiotensin-aldosterone-enalapril system was used, which normalized blood pressure. At the same time, intensive nutritional treatment was used. Resolution of symptoms and weight gain was observed. In further follow-up patients' parents withdrew enalapril lawlessly, which did not lead to recurrent rise in blood pressure. The latter may suggest other, transient cause of hypertensive crisis e.g. intoxication. CONCLUSIONS: Severe hypertension in pediatric patients can give symptoms as weight loss and behavioral disorders. In the diagnostic of hypertensive crisis in children, neuroimaging studies and toxicological tests should be performed.