Frecuencia y características de la encefalopatia hipertensiva secundaria a glomerulonefritis posinfecciosa en pacientes internados en un hospital de referencia nacional

Introducción: La glomerulonefritis aguda pos infecciosa (GNPI) puede cursar con complicaciones como la encefalopatía hipertensiva en 7-11% de los casos. Objetivo : determinar la frecuencia y características de la encefalopatía hipertensiva (EH) secundaria a GNPI en pacientes internados en el Departamento de Pediatría del Hospital Nacional en el periodo enero/2000-diciembre/2018. Materiales y Métodos : Estudio observacional, descriptivo, retrospectivo de pacientes con síndrome nefrítico (SN) con C3 disminuido y normalización a los tres meses, con hipertensión arterial (HTA) severa acompañada de manifestaciones neurológicas (cefalea, náuseas, vómitos, alteración de conciencia, convulsiones), que cedieron al regularizarse la HTA. Se estudiaron las características sociodemográficas (edad, sexo, procedencia, escolaridad de los padres, número de hijos) y clínicas (edema periférico, edema agudo de pulmón, hematuria, y manifestaciones neurológicas). Los datos fueron analizados utilizando estadística descriptiva mediante EPIINFO (CDC, Atlanta), expresando las variables cuantitativas como mediana y rango intercuartílico (RIC) y las cualitativas como frecuencia absoluta y porcentual. Resultados: 27 /160 (16,8%) pacientes, desarrollaron EH. La edad varió entre 3 a 16 años (mediana: 10 años; RIC: 5); el antecedente infeccioso más frecuente fue piodermitis (40,7%), seguido de faringitis aguda (37%). Todos los pacientes presentaron edema periférico y cefalea intensa. La duración de la HTA tuvo una mediana de 5 días (RIC: 4) y los días de internación una mediana de 7 (RIC: 6). Ningún paciente requirió diálisis ni quedó con secuelas, no se registraron óbitos. Conclusión: en pacientes con EH debe considerarse el diagnóstico de GNPI, investigando antecedentes infecciosos y valorando adecuadamente la volemia.

Introduction: Acute post-infectious glomerulonephritis (APGN) can present with complications such as hypertensive encephalopathy in 7-11% of cases. Objective: to determine the frequency and characteristics of hypertensive encephalopathy (HE) secondary to APGN in patients admitted to the Department of Pediatrics of the National Hospital from January/2000 to December/2018. Materials and Methods: This was an observational, descriptive and retrospective study of patients with nephritic syndrome (NS) with decreased C3 and normalization at three months, with severe arterial hypertension (AHT) accompanied by neurological manifestations (headache, nausea, vomiting, altered consciousness, seizures), which subsided when the AHT was controlled. Sociodemographic (age, sex, place of residence, parental education level, number of children in home) and clinical (peripheral edema, acute pulmonary edema, hematuria, and neurological manifestations) characteristics were studied. The data were analyzed using descriptive statistics through EPI INFO (CDC, Atlanta), expressing the quantitative variables as median and interquartile range (IQR) and the qualitative ones as absolute frequency and percentage. Results: 27/160 (16.8%) patients developed HE. Age ranged from 3 to 16 years (median: 10 years; IQR: 5); the most frequent infectious history was pyodermitis (40.7%), followed by acute pharyngitis (37%). All patients presented peripheral edema and severe headache. The duration of AHT had a median of 5 days (IQR: 4) and the days of hospitalization a median of 7 (IQR: 6). No patient required dialysis or was left with sequelae, no deaths were recorded. Conclusion: in patients with HE, the diagnosis of APGN should be considered, a history of infections obtained and adequately assessing fluid status.

Diagnosis and management of posterior reversible encephalopathy syndrome in systemic lupus erythematosus. Case report / Diagnóstico y manejo de síndrome de encefalopatía posterior reversible asociado a lupus eritematoso sistémico. Reporte de caso clínico

ABSTRACT Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiological disorder that may include encephalopathy, seizures, headache, and visual disturbances. It is associated with conditions that induce endothelial damage, causing vasogenic cerebral edema that can be observed in magnetic resonance scans. It occurs in <1% of patients with systemic lupus erythematosus (SLE). It is usually resolved with timely treatment, but delays may lead to neurological sequelae or death. A case of PRES is presented in a patient with SLE with severe activity, a hypertensive emergency, and lupus glomerulonephritis debuting with epileptic status. The outcome was satisfactory with anticonvulsants, as well as treatment for her cerebral edema and hypertension, along with control of other causal factors.

RESUMEN El síndrome de encefalopatía posterior reversible (PRES) es un trastorno clínico-radiológico caracterizado por encefalopatía, convulsiones, cefalea y alteraciones visuales. Se asocia a entidades que ocasionan daño endotelial, causando edema cerebral vasogénico evidente en resonancia magnética. En pacientes con lupus eritematoso sistémico (LES) se presenta en < 1%. Con tratamiento oportuno usualmente resuelve; caso contrario puede producir secuelas neurológicas o muerte. Se reporta el caso de PRES en una paciente con LES con actividad severa, emergencia hipertensiva y glomerulonefritis lúpica que comienza con estatus epiléptico. Evolucionó satisfactoriamente con tratamiento anticonvulsivante, antiedema cerebral, antihipertensivo y control de los demás factores causales.

Study of brain perfusion with IVIM-DWI in early hypertension / 医疗卫生装备

Objective To explore the value of intra-voxel incoherent motion diffusion weighted imaging(IVIM-DWI)in brain perfusion of early hypertensive patients. Methods Totally 36 hypertensive patients and 14 volunteers were recruited and scanned using routine MRI sequences including axial T2WI, T1WI, T2FLAIR, TOF-MRA and IVIM-DWI sequence. Perfusion-related diffusion coefficient (D*) values and perfusion fraction (f) values in various regions were measured separately.The independent sample t test was used to analyze the data.Results Compared with the volunteers,both D*values and f values in lenticular nucleus,thalamus,superior frontal gyrus,occipital lobe,genu of corpus callosum(CC)and posterior horns of periventricular WM, were found to be lower (P<0.05) in hypertensive patients. For other regions, there were no significant difference(P>0.05).Conclusion IVIM-DWI has the ability to detect subtle brain perfusion abnormalities at early stages of hypertension.It has an important value to the prevention and treatment of hypertensive encephalopathy.

Cortical blindness secondary to posterior reversible encephalopathy syndrome, recovered by successful blood pressure management / Cegueira cortical secundária à síndrome de encefalopatia reversível posterior recuperada pelo controle bem sucedido da pressão arterial

ABSTRACT We report a case of cortical blindness secondary to posterior leukoencephalopathy syndrome, which was successfully treated by blood pressure management. A 66-year-old white man presented at the emergency room complaining of severe frontal headache, disorientation, and progressive blurred vision. The initial physical examination disclosed a blood pressure of 200/176 mmHg. One hour later the patient exhibited mental confusion and bilateral blindness. Computed tomography and magnetic resonance imaging were performed, and a systemic workup was conducted, resulting in a diagnosis of posterior leukoencephalopathy syndrome. This syndrome is a rare manifestation of systemic hypertension that requires proper diagnosis and management to avoid irreversible brain damage. Early recognition of this condition and prompt control of the patient's blood pressure are essential because they may bring about a reversal of the syndrome, which may otherwise result in permanent brain damage.

RESUMO Relatamos um caso de cegueira cortical secundário à síndrome de leucoencefalopatia posterior recuperado pelo controle bem sucedido da pressão arterial. Um homem branco de 66 anos de idade compareceu à emergência com queixa de dor de cabeça frontal severa, desorientação e embaçamento progressivo da visão. O exame físico inicial revelou uma pressão arterial de 200/176 mmHg. Uma hora depois, o paciente apresentou confusão mental e cegueira bilateral. Após a tomografia e a ressonância nuclear magnética, o tratamento sistêmico foram realizados e o diagnóstico de síndrome da leucoencefalopatia posterior foi realizado. A síndrome de leucoencefalopatia posterior é uma manifestação rara de hipertensão sistêmica que requer um diagnóstico e gerenciamento adequados para evitar danos cerebrais irreversíveis. O reconhecimento precoce desta condição e o controle imediato da pressão arterial são essenciais porque podem levar à reversão da síndrome, o que, de outra forma, pode resultar em dano cerebral permanente.

Hypertensive Brainstem Encephalopathy in a Patient with Acute Lacunar Infarction

No abstract available.

Implicancias neurológicas de la preclampsia, más que solo eclampsia

La preeclampsia es una enfermedad multisistémica que afecta a la gestante; se constituye en la segunda causa de muerte materna en el Perú y produce una alta morbilidad. La disfunción neurológica producida por la preeclampsia abarca múltiples síntomas, siendo el más conocido la eclampsia. El entendimiento de la encefalopatía posterior reversible como fenómeno que explica todas las manifestaciones neurológicas de la preeclampsia abre un sinnúmero de posibilidades terapéuticas y plantea la interrogante sobre el pronóstico a largo plazo de las pacientes afectadas. El sulfato de magnesio se muestra como la mejor alternativa terapéutica para bloquear los fenómenos fisiopatológicos que podrían devenir en eclampsia, entendiéndola como una forma de encefalopatía posterior reversible.

Preeclampsia is a multisystemic disease that affects pregnant women; it is the second cause of maternal death in Peru and morbidity is high. The neurologic dysfunction in preeclampsia includes various symptoms, and eclampsia is the most known. Understanding reversible posterior encephalopathy as the explanation of all neurological manifestations in preeclampsia would evolve to endless therapeutic possibilities and interrogations on long term prognosis. Magnesium sulfate appears as the best therapeutic alternative in blocking pathophysiologic phenomena resulting in eclampsia, if it is considered as a reversible posterior encephalopathy.

A Rare Case of Presacral Paraganglioma Presenting with Hypertensive Encephalopathy

Paragangliomas are exceptionally rare tumors in children of neural crest origin. Our case report represents an extremely rare location for paraganglioma including its imaging features, perioperative challenges and histopathological characteristics. In the present case, a 10-year-old boy had headache and blurring of vision for four years but was not diagnosed until he came with malignant hypertension and hypertensive encephalopathy. The symptoms raised urinary catecholamines and CT findings confirmed the diagnosis of a functioning paraganglioma in presacral region. Challenges during surgery are to control the fluctuating blood pressure which may suddenly rise during tumor handling and suddenly fall following its removal. The unusual location of the tumor in pararectal region also made surgical resection difficult. Paragangliomas are rare and should be kept in mind while evaluating a child with hypertension and complete excision is the treatment of choice.

Clinical and radiological features of hypertensive brainstem encephalopathy / 解放军医学杂志

Objective To discuss the diagnosis and treatment of hypertensive brainstem encephalopathy. Methods The clinical and imaging data of 3 cases of hypertensive brainstem encephalopathy were summarized and analyzed for the purpose of improving the acumen in diagnosis and treatment. Results All the 3 patients showed relatively mild clinical symptoms, and they were misdiagnosed in different degrees during the treatment, but their clinical symptoms were improved by rapid and effective antihypertensive therapy. Cerebral CT and MRI scans revealed extensive abnormal signals in brain stem, with or without supratentorial lesions and brain stem hemorrhage. The lesions as revealed by imaging were improved significantly after treatment. Conclusions Clinical-radiographic dissociation is the classic feature of hypertensive brainstem encephalopathy. The clinical symptoms and lesions as shown by imaging could be improved after active treatment.

Reversible Obstructive Hydrocephalus from Hypertensive Encephalopathy: A Condition that Neurosurgeons Must Know / Hidrocefalia obstrutiva reversível secundária a encefalopatia hipertensiva: uma condição que o neurocirurgião deve conhecer

The vasogenic edema in structures of posterior fossa secondary to elevated hydrostatic pressure can cause obstructive hydrocephalus, a condition called "reversible obstructive hydrocephalus from hypertensive encephalopathy." A case of a 27-year-old woman with arterial hypertension and sign of raised intracranial pressure is reported. Her radiologic studies have showed vasogenic cerebellar edema without structural lesion. This edema leads to obstruction of the cerebral aqueduct. We discuss the clinical and therapeutic aspects of this condition. In this clinical situation, the accurate control of blood pressure is themain goal on medical care, and the need of permanent ventricular shunt is quite infrequent.

O edema vasogênico secundário a elevação da pressão hidrostática capilar pode causar hidrocefalia obstrutiva, a chamada Hidrocefalia Obstrutiva Reversível secundária a Encefalopatia Hipertensiva. Nós apresentamos umcaso de umamulher de 27 anos com hipertensão arterial e sinais de hipertensão intracraniana. Sua investigação radiológica evidenciou sinais de edema vasogênico cerebelar bilateral sem lesão estrutural, determinando obstrução do aqueduto cerebral Nós discutimos os aspectos clínicos e terapêuticos deste caso. Nesta condição, o adequado controle da pressão arterial é a principal medida terapêutica, sendo a necessidade de derivação liquórica permanente infrequente.

A Case Report of ‘Pseudo Tumor Cerebri’

Pseudo tumor cerebri is a clinical entity of uncertain etiology characterized by intracranial hypertension. The syndrome classically manifests with headaches and visual changes in women with obesity. This case is being presented for the following points: raised ICT, bilateral CN VI palsy, bilateral papilledema (left > right), neck rigidity present without Kernig's and Brudginski signs. Keeping the history, Neurological findings, investigative results, point to the possibility of raised intracranial pressure with CN VI involvement. The final clinical diagnosis, to the above syndrome, points out to ‘Pseudo-tumor cerebri’.

Encefalopatia hipertensiva. Fisiopatologia e abordagem terapêutica / Hypertensive encephalopathy. Pathophysiology and therapeutic approach

A encefalopatia hipertensiva inclui-se dentre as emergências hipertensivas, ou seja, situação clínica caracterizada por elevação pressórica acentuada com lesão aguda progressiva em órgão-alvo, com maior risco de óbito, exigindo imediata redução da pressão arterial com agentes aplicados por via parenteral. Na emergência hipertensiva, ocorre elevação abrupta da pressão arterial ocasionando, em território cerebral, perda da autorregulação do fluxo sanguíneo e evidências de lesão vascular, com quadro clínico de encefalopatia hipertensiva, lesões hemorrágicas dos vasos da retina e papiledema. Na presença de elevação acentuada da pressão arterial é fundamental a identificação de lesões agudas de órgãos-alvo e o diagnóstico apropriado e precoce das emergências hipertensivas. Confirmado o diagnóstico de da encefalopatia hipertensiva e avaliadas outras condições clínicas associadas, o tratamento deve ser prontamente instituído, em unidade de terapia intensiva, preferencialmente com nitroprussiato de sódio endovenoso, mas tomando-se o cuidado para diminuição gradativa da pressão, e não necessariamente a sua normalização, com o objetivo de se evitar complicações isquêmicas.

Hypertensive encephalopathy is included among the hypertensive emergencies, that is, a clinical condition characterized by severe blood pressure elevation with acute progressive damage to the target organ, with higher risk of death, requiring immediate reduction of blood pressure with agents via parenteral application. In hypertensive emergency patients, an abrupt rise in blood pressure occurs, resulting in loss of autoregulation of blood flow and evidence of vascular injury, with clinical findings of hypertensive encephalopathy, hemorrhagic lesions of retinal vessels and papilledema in the cerebral area. In the presence of a marked elevation of blood pressure, it is essential to identify acute damages to target organs,and to diagnosis hypertensive emergencies appropriately andearly. Once the hypertensive encephalopathy diagnosis is confirmed and other associated clinical conditions are assesses, treatment should be promptly instituted in the intensive care unit, preferably with sodium nitroprusside, with special attention to keeping a gradual decrease in blood pressure, and not necessarily lowering it below the normal range, in order to prevent ischemic complications.

Emergências hipertensivas: epidemiologia, definição e classificação / Hypertensive emergencies: epidemiology, definition and classification

Embora vários termos tenham sido aplicados para hipertensão grave, tais como crise hipertensiva, emergências ou urgências, todos eles são caracterizados por elevações agudas da pressão arterial que podem estar associados com lesão de órgão-fim (crise hipertensiva). Práticas de tratamento variam consideravelmente por causa da falta de evidências que suportam o uso de um agente terapêutico em detrimento de outro. O objetivo desta revisão foi analisar a fisiopatologia das crises hipertensivas comumente encontradas, incluindo acidente vascular cerebral (AVC), encefalopatia hipertensiva, dissecção aórtica, edema pulmonar agudo e pré-eclâmpsia/eclâmpsia, e fornecer uma abordagem racional para o seu tratamento com base em princípios fisiopatológicos e farmacológicos relevantes.

Although various terms have been applied to severe hypertension, such as hypertensive crisis, emergencies, or urgencies, they are all characterized by acute elevations in blood pressure that may be associated with end-organ damage (hypertensive crisis). Treatment practices vary considerably to because of the lack of the evidence supporting the use of one therapeutic agent over another. The purpose of this review is to examine the pathophysiology of commonly encountered hypertensive crises, including stroke, hypertensive encephalopathy, aortic dissection, acute pulmonary edema and preeclampsia/eclampsia and to provide a rational approach to their treatment based upon relevant pathophysiologic and pharmacologic principles

Aspectos fisiopatológicos e clínicos das emergências hipertensivas / Pathophysiology and clinical aspects of hypertensive emergencies

Esta revisão objetivou descrever aspectos fisiopatológicos, epidemiológicos e clínicos das emergências hipertensivas (EHs). Para isso, caracterizou a emergência e a urgência hipertensiva dentro do contexto da crise hipertensiva (CH), discutiu aspectos fisiopatológicos da elevação aguda da pressão arterial (PA) e o comprometimento de órgãos-alvo envolvidos nas EHs; expôs os fatores de risco e as condições clínicas associadas a essa manifestação e apresentou uma abordagem clínica sucinta para o correto diagnóstico. Finalmente, analisou conceitos atuais sobre o tratamento das EHs, esquematizando a conduta terapêutica

This review aimed to describe the pathophysiology, epidemiology and clinical aspects of hypertensive emergencies. It addressed hypertensive emergencies and urgencies within the context of the hypertensive crisis, discussed the pathophysiology of acute elevations of blood pressure and the involvement of target organs affected by hypertensive emergencies; it described risk factors and associated clinical conditions of this event and presented a brief clinical approach to the correct diagnosis. Finally, this report analyzed current concepts on the treatment of hypertensive emergencies outlining therapy.

Probable Isolated Hypertensive Brainstem Encephalopathy Combined with Intracerebral Hemorrhage: a Case Report

Hypertensive encephalopathy and basal ganglia intracerebral hemorrhage (ICH) are a medical emergency caused by a sudden elevation of systemic blood pressure. Although the relationship between hypertensive encephalopathy and large ICH has not been clarified yet, Cushing reflex in acute elevations of ICP due to large ICH may induce or aggravate hypertensive encephalopathy. We report a rare case of isolated hypertensive brainstem encephalopathy combined with hypertensive ICH.

Clinical analysis of secondary hypertension in 120 children / 中华实用儿科临床杂志

Objective To analyze clinical features of secondary hypertension in children,and explore the etiology of secondary hypertension and improve the clinical diagnosis and treatment.Method Retrospective analysis of the clinical features in 120 children with secondary hypertension was performed.Results 1.Seventy-nine patients (65.8％,79/120 cases) were male,41 patients(34.2％,41/120 cases) were female.The mean age was (9.5-±4.1)years old.2.Main clinical manifestations:55 cases of edema (45.8％,55/120 cases),52 cases of seizure (43.3％,52/120 cases),49 cases of headache (40.8％,49/120 cases),44 cases of vomit (36.7％,44/120 cases),33 cases of dizziness (27.5％,33/120 cases),24 cases of oliguria (20.0％,24/120 cases).3.Seventy-seven patients (64.2％,77/120 cases) were renal hypertension,22 patients (18.3％,22/120 cases) were drug-induced hypertension,5 patients (4.2％,5/120 cases) were endocrine disease,4 patients (3.3％,4/120 cases) were rheumatic disease,3 patients (2.5 ％,3/120 cases) were cardiogenic disease,2 patients (1.7 ％,2/120 cases) were neuroblastoma.4.Seventy-one patients (59.2％,71/120 cases)were complicated with hypertensive encephalopathy,among them 47 patients (66.2％,47/77 cases)were acute glomerulonephritis.5.One hundred and eleven patients' blood pressure turned to normal after treatment of the primary diseases.The other 9 patients were discharged because they abandoned treatment.Conclusions Renal disease is the most common etiology of secondary hypertension in children.Children with secondary hypertension are easily complicated with hypertensive encephalopathy.The key of treatment is early diagnosis and early treatment of primary diseases.

Encefalopatía posterior reversible como primera manifestación del Síndrome de Guillain-Barré / Posterior reversible encephalopathy as the first manifestation of Guillain-Barré syndrome. Report of one case

Background: We report a 56year old male hypertensive, who presented with a posterior reversible encephalopathy syndrome (PRES) as an initial manifestation of Guillain-Barré syndrome (GBS). His first symptoms were right hemiparesis and hemihypoesthesia, followed by headache, dizziness, dysarthria and a general feeling of discomfort. On the third day, flaccid tetraparesis, impairment of consciousness, epileptic seizures and respiratory failure appeared, along with severe hypertension. Cerebral Magnetic Resonance Imaging showed the characteristic PRES lesions. Cerebrospinal fluid analyses revealed albumin-cytological dissociation and nerve conduction studies showed an axonal demyelinating polyradiculoneuropathy, which confirmed the diagnosis of GBS. Treatment with intravenous immunoglobulin was given together with antihypertensive therapy and mechanical ventilation, achieving an important clinical and imaging remission of PRES, but maintaining tetraparesis during the hospitalization. Twelve months after discharge and regular motor rehabilitation, the patient achieved complete autonomy on the activities of daily living. It has been postulated that the autonomic failure and the elevation of circulating pro-inflammatory cytokines in GBS may be the cause of a breach in the blood-brain barrier, thus causing PRES, that can completely remit with an adequate management.

Hypertensive Brainstem Encephalopathy with Atypical Supratentorial Involvement / 대한뇌졸중학회지

Hypertensive brainstem encephalopathy (HBE) is a variant of hypertensive encephalopathy characterized by brainstem and cerebellar involvement. Simultaneous supratentorial involvement in HBE is rarely reported as a vasogenic edema in subcortex and/or periventricular white matter. A 36-year-old woman visited hospital due to headache lasting 7 days before admission. Initial blood pressure was 270/170mmHg. T2-weighted and fluid-attenuated inversion recovery magnetic resonance imaging revealed multifocal high signal intensity lesions in upper medulla, pons, midbrain and cerebellar hemisphere. Especially, atypical periventricular lesions were shown as perpendicular fingers to the lateral ventricle like multiple sclerosis. Her clinical symptoms and radiological lesions were subsided with lowering blood pressure. We herein report a HBE with unusual supratentorial involvement mimicking multiple sclerosis.

A case of Creutzfeldt-Jakob disease in a patient on hemodialysis

We report an unusual case of probable Creutzfeldt-Jakob disease (CJD) in hemodialysis patient. A woman 59 years of age with a past history of hypertension and end-stage renal disease presented with a stuporous state preceded by rapidly progressive cognitive dysfunction, myoclonus, and akinetic mutism. At first, the cause of the altered mental status was assumed to be uremic or hypertensive encephalopathy combined with fever. Proper managements, however, did not improve the neurologic symptoms. Diffusion-weighted magnetic resonance imaging revealed bilaterally asymmetric high signal intensity in both basal ganglia and cerebral cortices. Electroencephalography showed diffuse generalized theta-to-delta range slow wave and intermittent medium-to-high voltage complexes with a characteristic triphasic pattern on both hemispheres. Cerebrospinal fluid assay for the 14-3-3 protein was positive and diagnostic of CJD.

The Effect of Systemic Hypertension on the Pediatric Brain

Hypertension is one of the most common chronic diseases in childhood and adolescence. Untreated hypertension adversely affects many organs including heart, brain, kidney and peripheral arteries. We reviewed the complication of central nervous system caused by pediatric hypertension. Cerebral blood flows are maintained constantly in response to changes in blood pressure by cerebral autoregulation. Severe hypertension which destructs cerebral autoregulation results in acute hypertensive encephalopathy syndrome, ischemic or hemorrhagic stroke. Chronic pediatric hypertension induces learning disability and cognitive defect which are subclinical symptom prior to brain damage caused by severe hypertension. We should consider the effect of hypertension on pediatric brain because appropriate antihypertensive drugs could prevent these complications.