Spectrum of radiological changes in hypertensive children with reversible posterior leucoencephalopathy

Abstract

We prospectively studied 19 children with severe hypertension to evaluate the spectrum of radiological changes, severity and reversibility of this entity. All of them were subjected to clinical and biochemical evaluation, followed by magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA). Headache was seen in 17 children, 13 had confusion and drowsiness, 12 had nausea and vomiting, 10 patients had visual disturbances, seizure and dyspnoea. Only two had focal neurological deficit (one with right facial palsy and another with right lateral rectus palsy). Of these 19 children, 15 patients had hypertensive retinopathy and four had normal fundi. The positive MRI findings in 17/19 patients were: bilateral leukoencephalopathic changes in occipitoparietal region (9/17), diffuse white/grey matter lesion (3/17) patients, brain stem hyperintensity (2/17) and haemorrhagic lesions (3/17). On MRA, 12/19 patients had attenuation of cerebral arteries of different degree. On follow up, MRI findings resolved in all except three patients. All patients had normal MRA on follow up, except one with persistent minimal attenuation of middle cerebral artery and another had spasm in anterior, middle and posterior cerebral arteries. The intracranial abnormalities in these patients with severe hypertension were reversible in many of the cases after control of blood pressure was achieved. We therefore conclude that severe hypertension may lead to leuoencephalopathy, which had a wide radiological spectrum. A better understanding of this complex syndrome may obviate unnecessary investigations and allow management of associated problems in prompt and appropriate ways.

A case of acute post-streptococcal glomerulonephritis that developed posterior reversible encephalopathy syndrome

“…Permanent neurological damage may be observed as a result of prolonged hypertension and convulsions. Hence, the findings became permanent in three of 17 cases of PRES presented by Prasad et al (6). In addition, chronic epilepsy developed in two patients and abnormal EEG findings were observed in one patient in a series including 11 pediatric patients presented by Yamada et al (4).…”

“…The blood pressure values were found to be above the 99 th percentile in all 17 pediatric patients with PRES presented by Prasad et al (6). However, PRES may also be observed when the blood pressure is not increased (8).…”

“…Especially sudden increases in the systemic blood pressure lead to exceeding of the autoregulatory capacity in the brain vessels (8). Consequently, vasoconstriction, subsequently vasodilatation, increase in vascular permeability, disruption in the brain-blood barrier, fluid transduction and petechial hemorrhages occur (6,9). The reason that the findings are mostly observed in the posterior hemispheres is the fact that sympathetic innervation which provides autoregulation in cases of increased blood pressure is found less in the posterior cerebral vessels (6).…”

“…Consequently, vasoconstriction, subsequently vasodilatation, increase in vascular permeability, disruption in the brain-blood barrier, fluid transduction and petechial hemorrhages occur (6,9). The reason that the findings are mostly observed in the posterior hemispheres is the fact that sympathetic innervation which provides autoregulation in cases of increased blood pressure is found less in the posterior cerebral vessels (6). Posterior reversible encephalopathy syndrome occurs as a result of increased blood pressure or endothelial damage which is observed in relation with acute glomerulonephritis, HSP, lupus, nephrotic syndrome or immunosupressive drug usage which lead to disruption of the blood-brain barrier (4).…”

“…The diagnosis is made with typical MRI findings accompanying clinical findings. The most common radiological finding is edema which is especially observed in the parieto-occipital area (6). In addition, involvement of the brainstem, cerebellum, basal ganglia and even frontal lobes may be observed (6).…”