Hypertensive Encephalopathy

M Stephen Ledbetter, MD
Richard B Schwartz, MD, PhD

July 17, 1997

Presentation

A G₇P₆ 40-year-old woman at 30 weeks gestation presented with preeclampsia, labile hypertension, and HELLP syndrome (hemolysis, elevated liver function tests, and thrombocytopenia). She complained of an occipital headache and had an episode of nausea and vomiting. Soon after labor was induced the patient became confused and then obtunded. There was evidence of fetal distress. An emergency Cesarean section resulted in successful delivery of a male infant. A CT scan of the mother's head was performed after the delivery.

Imaging Findings

CT images of the head

Computed tomograms (CT) of the head demonstrate large bilateral intraparenchymal hemorrhages involving the parietooccipital white matter (arrows) with extension into the ventricles. Mass effect from the hemorrhages has resulted in effacement of the basilar cisterns (arrows). Vasogenic edema is evident in the subcortical white matter of the posterior occipital lobes (arrows). There is no midline shift or hydrocephalus.

Differential Diagnosis

Hypertensive encephalopathy of pregnancy (complicated by hemorrhage)
Hemorrhagic transformation of bilateral watershed infarcts
Arteriovenous malformation with hemorrhage
Hemorrhagic metastases from choriocarcinoma
Multiple hemorrhagic venous infarcts from sagittal sinus thrombosis

Diagnosis

Large bilateral parenchymal hemorrhages resulting from hypertensive encephalopathy of pregnancy in the setting of thrombocytopenia

Discussion

Hypertensive encephalopathy is a neurologic syndrome that occurs in patients with acutely elevated blood pressure, as may be seen in association with preeclampsia, cyclosporine therapy, and renal disease. Symptoms most commonly include headache, seizures, and cortical visual disturbances. Characteristic radiographic findings are bilateral areas of low attenuation on CT and increased T2 signal on MR, usually localized to brain regions supplied by the posterior circulation but potentially involving any region. The occipital lobes are almost always involved; the posterior parietal lobes, posterior fossa, frontal lobes, and basal ganglia may also be affected. Usually the abnormalities are reversible with reduction of blood pressure, but in the setting of thrombocytopenia, intracranial hemorrhage may occur.

References

1. Schwartz RB, Jones KM, Kalina P, Bajakian RL, Mantello MT, Garada B, Holman BL. Hypertensive encephalopathy: Findings on CT, MR imaging, and SPECT imaging in 14 cases. AJR 1992;159:379-383.

2. Schwartz RB, Bravo SM, Klufas RA, Hsu L, Barnes PD, Robson CD, Antin JH. Cyclosporine neurotoxicity and its relationship to hypertensive encephalopathy: CT and MR findings in 16 cases. AJR 1995;165:627-631.

Return to the Teaching Case Database search page
Return to Professional Education
About BrighamRAD

Dear Visitors: Nothing on this World Wide Web site should be considered medical advice. Only your own doctor can help you make decisions about your medical care. It is not the policy of the Brigham and Women's Hospital Department of Radiology to provide consultation on the World Wide Web or via e-mail. If you have a specific medical question or are seeking medical care, please call the Brigham and Women's Hospital toll-free physician referral line at 1-800-294-9999.

Is this a mirrored page?
The official homepage of the BrighamRAD Teaching Case Database is http://brighamrad.harvard.edu/education/online/tcd/tcd.html

Contact the BrighamRAD Design Team for additional information about this website.