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.

New Developments in Hypertensive Encephalopathy.

PURPOSE OF REVIEW: This review summarizes the latest science on hypertensive encephalopathy and posterior reversible encephalopathy syndrome (PRES). We review the epidemiology and pathophysiology of these overlapping syndromes and discuss best practices for diagnosis and management. RECENT FINDINGS: Diagnosis of hypertensive encephalopathy largely relies on exclusion of other neurological emergencies. We review the extensive causes of PRES and its imaging characteristics. Management strategies have not changed substantially in the past decade, though newer calcium channel blockers simplify the approach to blood pressure reduction. While this alone may be sufficient for treatment of hypertensive encephalopathy in most cases, management of PRES also depends on modification of other precipitating factors. Hypertensive encephalopathy and PRES are overlapping disorders for which intensive blood pressure lowering is critical. Further research is indicated to both in diagnosis and additional management strategies for these critical conditions.

Rhazes and an Early Case With Possible Hypertensive or Reversible Encephalopathy.

In one of Rhazes' medical treatises, Tales and Stories of Patients, descriptions, medical manifestations, and treatment approaches of 34 patients were mentioned. Among those, an epileptic patient with a florid face and congested veins was cured by performing venesection on his saphenous and basilic veins. Signs and symptoms of the case might correspond to hypertensive or reversible encephalopathy.

Hypertensive brain stem encephalopathy.

A 48-year-old man presented with headache and extreme hypertension. Computed tomography showed diffuse brain stem hypodensity. Magnetic resonance imaging revealed diffuse brain stem vasogenic edema. Hypertensive brain stem encephalopathy is an uncommon manifestation of hypertensive encephalopathy, which classically occurs at parietooccipital white matter. Because of its atypical location, the diagnosis can be challenging. Moreover, the coexistence of hypertension and brain stem edema could also direct clinicians toward a diagnosis of ischemic infarction, leading to a completely contradictory treatment goal.

Post-streptococcal glomerulonephritis leading to posterior reversible encephalopathy syndrome: a case report.

BACKGROUND: Posterior reversible encephalopathy syndrome is a clinical radiographic syndrome of heterogeneous etiologies. Developing hypertensive encephalopathy following post-streptococcal glomerulonephritis is a known but uncommon manifestation and developing posterior reversible encephalopathy syndrome in such a situation is very rare. We report a case with contrast-enhanced computed tomography and magnetic resonance imaging findings of posterior reversible encephalopathy syndrome in the background of acute post-streptococcal glomerulonephritis. CASE PRESENTATION: A thirteen-year-old Sri Lankan boy presented with a focal fit by way of secondary generalization with duration of 10 minutes, and developed 2 similar fits subsequently following admission. He later developed severe hypertension with evidence of glomerulonephritis, which was diagnosed as acute post-streptococcal glomerulonephritis. A contrast-enhanced computed tomography imaging of brain done on day-3 revealed non-enhancing low-attenuating areas in fronto-parietal regions. A T2 weighted film of magnetic resonance imaging was done on day-10 of the admission and found to have linier sub-cortical hyper intensities in both parietal regions which were compatible with the radiological diagnosis of posterior reversible encephalopathy syndrome. CONCLUSION: Post-streptococcal glomerulonephritis is an important cause of acute nephritic syndrome especially in children. This case report illustrates a rare association of posterior reversible encephalopathy syndrome in a patient with post-streptococcal glomerulonephritis.

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.

Recurrent posterior reversible encephalopathy syndrome in a pediatric patient with end-stage renal disease.

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) is a condition manifested by altered mental status, seizures, headaches, and visual loss. Specific abnormalities are seen by computed tomography or magnetic resonance imaging. Awareness of this syndrome is important for Emergency Physicians because visual loss can be reversible with prompt treatment of the underlying cause. OBJECTIVE: We present a case of recurrent PRES in a 14-year-old female who presented to the Emergency Department (ED) for headache and photosensitivity. CASE REPORT: A patient with a history of end-stage renal disease of unknown etiology was brought in by her mother for headache and photosensitivity. The patient developed blurry vision, seized in the ED, and required intubation. She was discharged 2 weeks later with complete return of vision. The same patient presented to the ED many times during the next several months for hypertensive emergencies, with three subsequent episodes that involved either seizures, vision loss, or both. Each of the episodes resolved with aggressive control of blood pressure in the pediatric intensive care unit. CONCLUSIONS: PRES should be considered in all patients presenting to the ED with visual loss, seizures, or headache, and can be recurrent in some individuals. Prompt treatment can help prevent permanent vision loss.

Reversible obstructive hydrocephalus from hypertensive encephalopathy.

BACKGROUND: Diffuse edema involving the posterior fossa may be seen with hypertensive encephalopathy and has rarely been reported to cause hydrocephalus. We present three such cases and review the literature to better delineate this uniquely reversible syndrome. METHODS: Case reports and review of literature. RESULTS: Three patients with hypertensive encephalopathy presented to our institutions with clinical and radiographic features of obstructive hydrocephalus associated with brainstem and cerebellar edema. This required transient external drainage of cerebrospinal fluid (CSF) in two of the three patients. However, with recognition of this unusual syndrome and aggressive management of elevated blood pressure, both edema and hydrocephalus resolved. All patients made complete recoveries and did not require permanent CSF shunting. A review of the literature yielded 15 additional case reports describing reversible obstructive hydrocephalus related to hypertensive encephalopathy. All had mean arterial pressures above 130 mmHg and presented primarily with altered mental status. While half required ventriculostomy, only one required shunting. Excluding a patient who died from sepsis, all recovered neurologically once blood pressure was controlled. CONCLUSION: It is imperative to recognize such cases where hypertension causes edema within the posterior fossa resulting in secondary hydrocephalus. Focusing management on lowering blood pressure avoids unnecessary or prolonged CSF diversion.

Posterior reversible encephalopathy syndrome and eclampsia: pressing the case for more aggressive blood pressure control.

OBJECTIVE: To assess the prevalence, clinical presentations, and neuroimaging abnormalities in a series of patients treated for eclampsia at Mayo Clinic in Rochester, MN. PATIENTS AND METHODS: We reviewed the records of all pregnant patients diagnosed as having eclampsia at Mayo Clinic in Rochester, MN, between January 1, 2001, and December 31, 2008. All patients who underwent neuroimaging were identified, and all studies were reviewed by an independent neuroradiologist. Comparisons were made between groups who did and did not undergo imaging to identify differentiating clinical or laboratory variables. RESULTS: Thirteen cases of eclampsia were found, with neuroimaging studies available for 7: magnetic resonance imaging (n=6) and computed tomography (n=1). All 7 patients developed eclamptic seizures, and 2 of 7 patients had severe hypertension, with recorded systolic blood pressures exceeding 180 mm Hg. Neuroimaging showed characteristic changes of posterior reversible encephalopathy syndrome (PRES) in all patients. Follow-up imaging showed resolution in 2 of 3 patients; 1 patient had residual neuroimaging abnormalities. CONCLUSION: Our results suggest that the clinical syndrome of eclampsia is associated with an anatomical substrate that is recognizable by neuroimaging as PRES. The levels of blood pressure elevation are lower than those reported in cases of PRES because of hypertensive encephalopathy. Further studies are needed to determine whether more aggressive blood pressure control and early neuroimaging may have a role in the management of these patients.

[Hypertension due to aortic coarctation--a missed clinical diagnosis]. / Hypertonie bei Aortenisthmusstenose--eine übersehene klinische Diagnose.

HISTORY AND FINDINGS: A 30-year-old woman presented to our emergency department with severe headaches, dizziness and uncontrolled hypertension. She had arterial hypertension and a known heart murmur since adolescence. Previous medical work up did not reveal any cause for secondary hypertension. Recently her blood pressure had been difficult to control. A systolic murmur as well as absent inguinal and feet pulses were notable at the physical examination. INVESTIGATIONS: When performing doppler ultrasound the closing pressures of the dorsalis pedis arteries were only 70 mm Hg compared to a blood pressure reading of 160 mm Hg on the upper arms. Thoracic magnetic resonance imaging showed subtotal aortic coarctation causing the differences in blood pressures. Echocardiography and cardiac catheterization additionally revealed a moderately stenosed bicuspid aortic valve, the pressure gradient across the coarctation was 30 mm Hg. THERAPY AND COURSE: Despite the severity of the coarctation an interventional approach was favoured instead of a classical operative therapy. Balloon dilatation with stent implantation was performed without complications. Since the intervention blood pressure have remained normotensive, the coarctation gradient being markedly reduced. CONCLUSIONS: In young patients with arterial hypertension, as well as in cases of severe and refractory hypertension, causes of secondary hypertension must be looked for and excluded. Especially when hypertension occurs in adolescence, aortic coarctation should be taken into account, in addition to renal or endocrine causes. A thorough physical examination with cardiac auscultation and checking of all peripheral pulses is the crucial step to the diagnosis.

Reversible brainstem edema due to hypertensive encephalopathy in an 8-year-old girl.

The authors report an 8-year-old girl with refractory status epilepticus due to hypertensive encephalopathy, secondary to end-stage renal disease. Brain magnetic resonance imaging (MRI) in the acute phase showed striking hyperintensities in the brain stem and medial thalamus along with subtle cortical lesions. After successful control of hypertensive crisis and status epilepticus, the patient recovered to her baseline. Near total resolution of the lesions was noted on follow-up imaging performed 9 days later. Predominant brainstem involvement as a feature of posterior reversible encephalopathy syndrome due to hypertensive crisis is extremely rare in children and has not been well documented.

Reversible posterior leukoencephalopathy syndrome in a patient with severe uremic encephalopathy.

A 59-year-old male presented at our hospital with disturbance of consciousness. He had severe neurological disturbances associated with uremia caused by severe renal insufficiency. Cranial computed tomography (CT) was normal on admission. FLAIR-weighted MRI showed increased signal intensities bilaterally in the cortical and subcortical areas of the occipital lobe. Repeated hemodialysis resulted in improvement of the clinical symptoms and blood chemistry, and normalization of the MRI findings. Although the patient was discharged without neurological deficit, he had to be maintained on regular intermittent hemodialysis due to persistent renal failure. These reversible neuroradiological abnormalities may have been caused by reversible brain edema, but other pathoetiological factors should be also considered, such as abnormalities of cerebral metabolism and effects of uremic toxins.

Recurrent posterior reversible encephalopathy syndrome in a hypertensive patient with end-stage renal disease.

Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiologic entity characterized by headache, variable mental status, epilepsy, visual disturbances, and typical transient changes in the posterior cerebral perfusion. Recurrence of PRES is not common, but increasingly in recent years, studies demonstrate recurrence of this syndrome in populations with different diseases. In this report, we describe recurrent PRES in a hypertensive patient with end-stage renal disease, and discuss recurrence as the least-characterized feature of PRES. This condition can cause neurological sequelae such as persistent brain damage and epilepsy, arising from delays in diagnosis and therapy. To the best of our knowledge, this is the first report demonstrating recurrent PRES in a patient on hemodialysis for end-stage renal disease.

The posterior reversible encephalopathy syndrome.

The posterior/potentially reversible encephalopathy syndrome is a unique syndrome encountered commonly in hypertensive encephalopathy. A 13-year-old boy presented with of intermittent high grade fever, throbbing headache and non-projective vomiting for 5 days. The patient had a blood pressure of 120/80 mmHg but fundoscopy documented grade 3 hypertensive retinopathy. The patient improved symptomatically following conservative management. However, on the 5(th) post-admission day headache reappeared, and blood pressure measured at that time was 240/120 mmHg. Neuroimaging suggested white matter abnormalities. Search for the etiology of secondary hypertension led to the diagnosis of pheochromocytoma. Repeated MRI after successful surgical excision of the tumor patient showed reversal of white matter abnormalities. Reversible leucoencephalopathy due to pheochromocytoma have not been documented in literature previously.

Posterior reversible encephalopathy syndrome: an emerging clinical entity in adult, pediatric, and obstetric critical care.

PURPOSE: To describe the signs, symptoms, causative factors, and treatment for posterior reversible encephalopathy syndrome (PRES), an emerging clinical neuroradiologic entity which may be encountered by nurse practitioners in almost any clinical setting. DATA SOURCES: Extensive review of worldwide literature, including peer-reviewed medical specialty journals, supplemented by an actual case study. Currently, a paucity of information exists in the nursing literature. CONCLUSIONS: PRES occurs as a result of disordered cerebral circulatory autoregulation and/or endothelial dysfunction, usually as a result of acute, intermittent hypertension. Clinical manifestations include mental status change, headache, visual disturbance, and seizures. Characteristic abnormalities in the posterior cerebral white matter, seen best on diffusion-weighted magnetic resonance imaging, confirm the presence of the syndrome. PRES has been documented worldwide among a diverse patient population, yet many clinicians are still unfamiliar with this diagnosis. IMPLICATIONS FOR PRACTICE: PRES is a clinical-radiographic diagnosis that requires close collaboration between the clinician and interpreting radiologist. 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.