Neuroimaging Findings in Symptomatic Hypertensive Encephalopathy

To assess the relevance clinicians and radiologists assign to making hypertension (HTN) explicit in acutely symptomatic subjects admitted for either stroke, confusion or cognitive deficit, a revision was carried out of cases discussed in our institution in the last eleven years, at either the Neuroradiology-Stroke or the Neuropsychiatry multidisciplinary meetings (MDTs). Consistency of the provided clinical information and radiological findings concerning HTN were checked in 11810 subjects (Group 1), since both influence neuroimaging interpretation, diagnosis and management.

Similar information was collected in a subgroup of 25 subjects (Group 2), with signs of stroke included in Group 1 in whom there was pre-existent history of severe HTN, who were evaluated with multimodality neuroimaging in 48 hours from admission and who had improved clinically in 72 hours.

The word “hypertension” included in the initial neuroimaging request, blood pressure (BP) levels on admission, radiology reports describing intra axial bleed, mentioning “hypertensive encephalopathy”, “chronic hypertensive encephalopathy”, “hypertensive microbleeds”, “amyloid microbleeds”, features and quantification of cerebral small vessel disease (CSVD), a non-specific pattern of cortical atrophy, dolicoarteriopathy, presence and degree of carotid or vertebrobasilar stenosis were tabled.

Electronic records of blood pressure (BP) were available in 10003/11810 cases and in written notes in 1807/11810; 1582/11810 were not hypertensive and 8421/11810 hypertensive. Imaging requests did explicitly include the word “hypertension” in 1184/11810.

Radiology reported acute intracranial bleed on admission in 1516/11810, hypertensive encephalopathy in 248/11810, chronic hypertensive encephalopathy in 148/11810, hypertensive-type microbleeds in 295/11810, amyloid-type microbleeds in 390/11810, SVD features without quantification in 1554/11810, SVD 1/3 in 577/11810, SVD 2/3 in 1402/11810, SVD 3/3 in 776/11810, non-specific cerebral atrophy in 800/11810, vessel tortuosity in 128/11810 and significant carotid or vertebrobasilar stenosis in 1292/11810 of cases. On neuroimaging revision, one or more HTN features were found in 10311/11810 cases.

In group 2 mean systolic BP on admission was 193mmHg, diastolic 104mmHg, age 55 years, 15/25 had PRES, 7/25 acute on chronic hypertensive encephalopathy, 2/25 CAA and 1/25 normotensive PRES. HTN findings were reported in 22/25 cases.

Results suggest an initial underestimation of HTN by both referrers and radiologists in acutely symptomatic subjects, later identified and characterised when reviewed and discussed at MDTs.