From the Guidelines
Yes, both hypertension (HTN) and arterial dissections can manifest as neurological deficits, with HTN causing conditions like posterior reversible encephalopathy syndrome (PRES) and hypertensive encephalopathy, and dissections leading to stroke-like symptoms, including unilateral weakness, sensory changes, and speech difficulties, as supported by the 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines 1.
The clinical presentation of these conditions can be variable, but they often involve sudden onset of symptoms. Hypertension can cause headaches, confusion, visual disturbances, and seizures, while arterial dissections may present with pain on one side of the head or neck, accompanied by Horner's syndrome, and can lead to cerebral or retinal ischemia in 50% to 95% of cases 1.
Key points to consider in the diagnosis and management of these conditions include:
- The importance of prompt medical attention to control blood pressure and prevent stroke
- The use of imaging studies such as CT angiography, MRI, or ultrasound to establish the diagnosis of dissections
- The consideration of anticoagulation or antiplatelet therapy to prevent stroke in patients with dissections
- The need for careful evaluation of patients with neurological symptoms to determine the underlying cause and appropriate treatment.
In terms of specific management, anticoagulation with heparin followed by warfarin is usually the treatment of choice for arterial dissections, with a favorable prognosis, as noted in the 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline 1. However, the management of hypertension and dissections should be individualized based on the specific clinical presentation and underlying cause of the condition.
From the Research
Hypertension and Dissections
- Hypertension (HTN) can lead to neurologic deficits, as it is a risk factor for cerebral vasculature atherosclerosis, medial hypertrophy, luminal narrowing, endothelial dysfunction, impaired arterial relaxation, and decreased ability to augment cerebral blood flow at low blood pressures 2.
- Acute severe hypertension can result in increased cerebral blood flow, leading to hypertensive encephalopathy, and can also cause neurologic deterioration, as seen in patients with acute severe hypertension who experienced lower minimal blood pressure values and were less likely to experience recurrent hypertension requiring intravenous treatment 3.
- Dissections, such as intracranial artery dissection (IAD) and cervical artery dissection (CAD), can also cause neurologic deficits, including stroke, transient ischemic attack (TIA), severe headache, neck pain, oculosympathetic defect, acute vestibular syndrome, and lower cranial nerve palsies 4, 5.
Neurologic Complications
- The most common neurologic diagnoses associated with acute severe hypertension are subarachnoid hemorrhage, intracerebral hemorrhage, and acute ischemic stroke 3.
- Cervical artery dissection accounts for nearly 20% of strokes in young and middle-aged adults, and can also cause other neurologic complications, such as severe headache and neck pain, oculosympathetic defect, and acute vestibular syndrome 5.
- Ruptured intracranial aneurysms can cause subarachnoid hemorrhage, resulting in high mortality and morbidity, with survivors often suffering permanent neurologic deficits and disability 5.
Treatment and Management
- Treatment of hypertensive emergencies, such as those associated with aortic dissection and aortic aneurysm surgery, requires parenteral antihypertensive agents to control blood pressure and prevent target organ damage 6.
- Antithrombotic therapy with either antiplatelet or classic anticoagulants is the mainstay of treatment for preventing further thromboembolic complications after a stroke caused by dissection or other conditions 4.
- Endovascular or surgical treatment options can be considered when medical therapies are not effective or when there is a high rate of recurrence or increased risk of bleeding 4.