HTN Emergencies

Question 1

Discuss hypertensive intracerebral haemorrhage

Answer 1

Most common cause of intracerebral haemorrhages. Can be divided according to their typical locations which inlude in order of frequency
-basal ganglia haemorrahge - usually present with ipsilateral deviation of the eyes due to descending capsular pathways from the frontal eye field

• thalamic haemorrahge- often presents with downard deviation of the eyes and lack of pupillary response to light
• pontine haemorrahge - usually causes coma due to disruption of the reticular activiating system and quadriparesis due to disruption of the corticospinal tract
• cerebella haemorrahge

Question 2

Discuss pathogensis of HTN intracerbebral haemorrahges + DDX of cause

Answer 2

Long standing poorly contolled hypertension leads to a variety of pathological changes in the vessels
#microaneurysms of perofrating arteries
-small diameter
-occur on small diameter arteries
-distribution which amtches the incidence of htn haemorrahges
—80% lenticulostriate
—10% pons
—10% ceebrellum
#accelateraed atherosclerosis affects larger vessels

DDX
# Unruptured asymptomatic vascular malformation 
-asymptomatic cavernous malformations 
-AV malformation
-Developmental venous anomaly
#haemorrahgeic metastases

Question 3

Discuss management and prognosis of HTN intracerebral haemorrhages

Answer 3

Basal ganglia

• mainstay of treatment is mediacl with control of HTN and attempts to prevent secondary cerebrla injury
• if intraventricular component is present then hydrocephalus is a common sequale and CSF drainage with an extra ventricular drain is often needed
• Evacuation of clot is controversial and only potentially useful in large haemorrahge

Thalamic
?TXA nil different from other stroke

Pontine

• Very poor prognosis with large bleeds being almost universally fatal
• Open surgical evacuation of the clot is not usually perfmored
• in smaller bleed medical management and treatment of hydrocephalus with EV drains may be life saving but will likley still have significant residual deficit

Question 4

Define hypertensive urgency and emergency

Answer 4

Urgency BP >180/110 wihtout evidence of TOD
Emergency BP >180/110 with evidence of TOD

Although frequently accompanied by an elevated BP symtpoms such as headache, epistaxis and dizziness are not in and of themsevles evidecne of acute TOD

Question 5

Describe HTN encephalopathy

Answer 5

Results from diffuse vasogenic cerebral oedema, it is caused by a failure of autoregulation in the brain, with vasospasm, ischaemia increased vascular pereability punctate haeorrhage and interstitial odema.

When present focal neurological deficits do not follow a singular anatomic pattern and may occur on opposite sides of the body indicated diffuse cerebral dysfunction, rather than an anatomically localised stroke syndrome or space occupying lesion.

CT head can be normal

HTN encephalopathy is fully reversible with early and prompt BP reduction

Question 6

Describe PRES

Answer 6

Posterior reversible encephaloapthy syndrome has a neurological presentation similar to that of hypertensive encephalopathy albiet with less global and more region specifc features.

Also caused by increased vascular permeability secondary to endothelial damage with vasogenic oedema

Constellation of symptoms related to posterior cerebral impairment including visual changes headache altered mental state and seizures.

MRI for diagnosis

Aetiology is HTN most commonly - kidney disease, malignancies, cytotoxic therapy and autoimmune disaee can all cause press