Can chronic hypertension cause peri-ventricular and juxtacortical lesions?

Chronic Hypertension Can Cause Periventricular and Juxtacortical Lesions

Yes, chronic hypertension can cause both periventricular and juxtacortical lesions, which are visible as white matter hyperintensities on MRI and represent a form of cerebral small vessel disease. 1, 2

Hypertension and Periventricular Lesions

• Chronic hypertension is strongly associated with periventricular white matter lesions, with the duration of hypertension being a significant risk factor 2
• MRI studies in persons with chronic hypertension have revealed greater numbers of subcortical white matter lesions compared to age-matched controls 3
• Periventricular lesions associated with hypertension typically appear as multiple white matter lesions involving paraventricular regions, suggestive of ischemic small-vessel disease 3
• These hypertension-related periventricular lesions often present as symmetric linear hyperintensities abutting the lateral ventricles or periventricular "capping" at the frontal and occipital horns 3

Hypertension and Juxtacortical Lesions

• Juxtacortical lesions (white matter lesions abutting the cortex) can occur in ischemic small-vessel disease caused by chronic hypertension 4
• In hypertensive small vessel disease, juxtacortical lesions are typically in the deep white matter with a rim of white matter separating them from the cortex, unlike the U-fiber involvement seen in multiple sclerosis 3
• Juxtacortical hyperintensities have been identified as independent predictors of seizures in patients with cerebral small vessel disease, highlighting their clinical significance 4

Pathophysiology of Hypertension-Induced White Matter Lesions

• Chronic hypertension leads to narrowing and sclerosis of small penetrating arteries in the subcortical regions of the brain 3
• These vascular changes contribute to hypoperfusion, loss of autoregulation, compromise of the blood-brain barrier, and ultimately to subcortical white matter demyelination and microinfarction 3
• Hypertension-related pathological changes include small vascular lesions, inflammatory reactions, oxidative stress, and damage to autoregulatory processes 5
• The resulting white matter lesions represent areas of demyelination, axonal loss, and gliosis due to chronic ischemia 6

Distinguishing Features from Other Causes of White Matter Lesions

• Hypertensive white matter lesions differ from multiple sclerosis lesions in several ways:
  • They typically do not have an ovoid shape or orientation perpendicular to the ventricles ("Dawson's fingers") 3
  • They often present with symmetric distribution rather than the asymmetric pattern seen in MS 3
  • They may be accompanied by lacunar infarcts or microbleeds 3
• U-fibers (subcortical arcuate fibers) are generally spared by hypertension and cerebrovascular diseases since these fibers are well vascularized by both cortical branches and medullary arteries 3

Clinical Implications

• White matter lesions in hypertensive patients should be considered a silent early marker of brain damage 1
• These lesions are associated with cognitive impairment, dementia risk, and increased stroke risk 3, 6
• Effective antihypertensive therapy may reduce the risk of developing significant white matter changes on MRI 3
• However, existing white matter changes, once established, do not appear to be reversible 3
• Long-standing hypertension significantly increases the risk of white matter lesions, with relative risks as high as 24.3 for subcortical and 15.8 for periventricular lesions in patients with >20 years of hypertension 2

Importance of Blood Pressure Control

• Successfully treated hypertension is associated with only moderately increased rates of white matter lesions compared to poorly controlled hypertension 2
• Adequate treatment of hypertension may therefore prevent white matter lesions and associated cognitive decline 2, 6
• The optimal systolic/diastolic blood pressure to prevent cognitive decline in older individuals is thought to be in the range of 135-150 mmHg systolic and 70-79 mmHg diastolic 3