New Developments in Hypertensive Encephalopathy

  • Joseph B. Miller
  • Kushak Suchdev
  • Namita Jayaprakash
  • Daniel Hrabec
  • Aditya Sood
  • Snigdha Sharma
  • Phillip D. Levy
Hypertension and Emergency Medicine (T Rainer and P Levy, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Hypertension and Emergency Medicine


Purpose of Review

This review summarizes the latest science on hypertensive encephalopathy and posterior reversible encephalopathy syndrome (PRES). We review the epidemiology and pathophysiology of these overlapping syndromes and discuss best practices for diagnosis and management.

Recent Findings

Diagnosis of hypertensive encephalopathy largely relies on exclusion of other neurological emergencies. We review the extensive causes of PRES and its imaging characteristics. Management strategies have not changed substantially in the past decade, though newer calcium channel blockers simplify the approach to blood pressure reduction. While this alone may be sufficient for treatment of hypertensive encephalopathy in most cases, management of PRES also depends on modification of other precipitating factors.


Hypertensive encephalopathy and PRES are overlapping disorders for which intensive blood pressure lowering is critical. Further research is indicated to both in diagnosis and additional management strategies for these critical conditions.


Hypertensive encephalopathy Posterior reversible encephalopathy PRES Hypertensive emergency 


Compliance with Ethical Standards

Conflict of Interest

Dr. Levy reports grants and funds in part by the National Heart, Lung and Blood Institute, grants from Novartis, Trevena, Cardiorentis, and BMS, and personal fees from Novartis, Trevena, and Cardiorentis, outside the submitted work. The other authors declare no conflicts of interest relevant to this manuscript.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance, •• Of major importance.

  1. 1.
    •• Whelton PK, Carey RM, Aronow WS, Casey DE, Jr., Collins KJ, Dennison Himmelfarb C et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2017. doi: Newest guidelines from multiple specialties that redifines hypertension and provides extensive recommendations for evaluation and management.
  2. 2.
    Johnson W, Nguyen ML, Patel R. Hypertension crisis in the emergency department. Cardiol Clin. 2012;30(4):533–43. Scholar
  3. 3.
    Adebayo O, Rogers RL. Hypertensive emergencies in the emergency department. Emerg Med Clin North Am. 2015;33(3):539–51. Scholar
  4. 4.
    Manning L, Robinson TG, Anderson CS. Control of blood pressure in hypertensive neurological emergencies. Curr Hypertens Rep. 2014;16(6):436. CrossRefPubMedGoogle Scholar
  5. 5.
    Suneja M, Sanders ML. Hypertensive emergency. Med Clin North Am. 2017;101(3):465–78. Scholar
  6. 6.
    Polgreen LA, Suneja M, Tang F, Carter BL, Polgreen PM. Increasing trend in admissions for malignant hypertension and hypertensive encephalopathy in the United States. Hypertension. 2015;65(5):1002–7. Scholar
  7. 7.
    • Fischer M, Schmutzhard E. Posterior Reversible encephalopathy syndrome. J Neurol. 2017;264(8):1608–16. Excellent review focusing on posterior reversible encephalopathy. CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Brust JCM. Cerebral circulation: stroke. In: Kandel ER, Schwartz JH, Jessell TM, editors. Principles of neural science. Nowalk, Connecticut: Appleton & Lange; 1991. p. 1041–9.Google Scholar
  9. 9.
    Orjuela K, Ruland SD. Hypertensive encephalopathy, posterior reversible encephalopathy syndrome, and eclampsia. In: Aiyagari V, Gorelick P, editors Hypertension and stroke clinical hypertension and vascular diseases Humana Press, Cham; 2016.Google Scholar
  10. 10.
    Oppenheimer BS, Fishbery AM. Hypertensive encephalopathy. Arch Intern Med. 1928;41(2):264–78. Scholar
  11. 11.
    Hinchey J, Chaves C, Appignani B, Breen J, Pao L, Wang A, et al. A reversible posterior leukoencephalopathy syndrome. N Engl J Med. 1996;334(8):494–500. Scholar
  12. 12.
    •• Fugate JE, Rabinstein AA. Posterior reversible encephalopathy syndrome: clinical and radiological manifestations, pathophysiology, and outstanding questions. Lancet Neurol. 2015;14(9):914–25. Overview of radiological findings in PRES. CrossRefPubMedGoogle Scholar
  13. 13.
    Gao B, Lyu C, Lerner A, McKinney AM. Controversy of posterior reversible encephalopathy syndrome: what have we learnt in the last 20 years? J Neurol Neurosurg Psychiatry. 2017;
  14. 14.
    Hamati AI. Neurological complications of systemic disease: children. In: Daroff RB, Jankovic J, Mazziotta JC, Pomeroy S, editors. Bradley’s neurology in clinical practice. China: Elsevier; 2016. p. 835–849.Google Scholar
  15. 15.
    Lee SY, Dinesh SK, Thomas J. Hypertension-induced reversible posterior leukoencephalopathy syndrome causing obstructive hydrocephalus. J Clin Neurosci. 2008;15(4):457–9. Scholar
  16. 16.
    Bruce BB, Thulasi P, Fraser CL, Keadey MT, Ward A, Heilpern KL, et al. Diagnostic accuracy and use of nonmydriatic ocular fundus photography by emergency physicians: phase II of the FOTO-ED study. Ann Emerg Med. 2013;62(1):28–33 e1. Scholar
  17. 17.
    Lamy C, Oppenheim C, Meder JF, Mas JL. Neuroimaging in posterior reversible encephalopathy syndrome. J Neuroimaging. 2004;14(2):89–96. Scholar
  18. 18.
    Kozak OS, Wijdicks EF, Manno EM, Miley JT, Rabinstein AA. Status epilepticus as initial manifestation of posterior reversible encephalopathy syndrome. Neurology. 2007;69(9):894–7. Scholar
  19. 19.
    Bartynski WS. Posterior reversible encephalopathy syndrome, part 1: fundamental imaging and clinical features. AJNR Am J Neuroradiol. 2008;29(6):1036–42. Scholar
  20. 20.
    McKinney AM, Jagadeesan BD, Truwit CL. Central-variant posterior reversible encephalopathy syndrome: brainstem or basal ganglia involvement lacking cortical or subcortical cerebral edema. AJR Am J Roentgenol. 2013;201(3):631–8. Scholar
  21. 21.
    McKinney AM, Short J, Truwit CL, McKinney ZJ, Kozak OS, SantaCruz KS, et al. Posterior reversible encephalopathy syndrome: incidence of atypical regions of involvement and imaging findings. AJR Am J Roentgenol. 2007;189(4):904–12. Scholar
  22. 22.
    de Havenon A, Joos Z, Longenecker L, Shah L, Ansari S, Digre K. Posterior reversible encephalopathy syndrome with spinal cord involvement. Neurology. 2014;83(22):2002–6. Scholar
  23. 23.
    Ahn KJ, You WJ, Jeong SL, Lee JW, Kim BS, Lee JH, et al. Atypical manifestations of reversible posterior leukoencephalopathy syndrome: findings on diffusion imaging and ADC mapping. Neuroradiology. 2004;46(12):978–83. Scholar
  24. 24.
    Covarrubias DJ, Luetmer PH, Campeau NG. Posterior reversible encephalopathy syndrome: prognostic utility of quantitative diffusion-weighted MR images. AJNR Am J Neuroradiol. 2002;23(6):1038–48.PubMedGoogle Scholar
  25. 25.
    Toledano M, Fugate JE. Posterior reversible encephalopathy in the intensive care unit. Handb Clin Neurol. 2017;141:467–83. Scholar
  26. 26.
    •• Jacquot C, Glastonbury CM, Tihan T. Is posterior reversible encephalopathy syndrome really reversible? Autopsy findings 4.5 years after radiographic resolution. Clin Neuropathol 2015;34(1):26–33. doi: Interesting evaluation of potential non-reversible damage from PRES.
  27. 27.
    Zhang R, Jin L, Cheng H, Yang J, Duan YL, Huang S, et al. Reversible posterior leukoencephalopathy syndrome sometimes could be irreversible: a case following tumor lysis syndrome in childhood Burkitt's lymphoma. Chin Med J. 2016;129(4):480–3. Scholar
  28. 28.
    Muiesan ML, Salvetti M, Amadoro V, di Somma S, Perlini S, Semplicini A, et al. An update on hypertensive emergencies and urgencies. J Cardiovasc Med (Hagerstown). 2015;16(5):372–82. Scholar
  29. 29.
    Strandgaard S. Autoregulation of cerebral circulation in hypertension. Acta Neurol Scand Suppl. 1978;66:1–82.PubMedGoogle Scholar
  30. 30.
    Udeh CI, Ting M, Arango M, Mick S. Delayed presentation of nitroprusside-induced cyanide toxicity. Ann Thorac Surg. 2015;99(4):1432–4. Scholar
  31. 31.
    • Miller JB, Kinni H, Amer A, Levy PD. Therapies to reduce blood pressure acutely. Curr Hypertens Rep. 2016;18(6):43. Updated literature on medications for rapid blood pressure reduction. CrossRefPubMedGoogle Scholar
  32. 32.
    Ipek E, Oktay AA, Krim SR. Hypertensive crisis: an update on clinical approach and management. Curr Opin Cardiol. 2017;32(4):397–406. Scholar
  33. 33.
    Perez MI, Musini VM. Pharmacological interventions for hypertensive emergencies. Cochrane Database Syst Rev. 2008;1:CD003653. Scholar
  34. 34.
    Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289(19):2560–72. CrossRefPubMedGoogle Scholar
  35. 35.
    James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507–20. Scholar
  36. 36.
    Deeks ED, Keating GM, Keam SJ. Clevidipine: a review of its use in the management of acute hypertension. Am J Cardiovasc Drugs. 2009;9(2):117–34. Scholar
  37. 37.
    Gijtenbeek JM, van den Bent MJ, Vecht CJ. Cyclosporine neurotoxicity: a review. J Neurol. 1999;246(5):339–46. Scholar
  38. 38.
    Hayes D Jr, Adler B, Turner TL, Mansour HM. Alternative tacrolimus and sirolimus regimen associated with rapid resolution of posterior reversible encephalopathy syndrome after lung transplantation. Pediatr Neurol. 2014;50(3):272–5. Scholar
  39. 39.
    Fugate JE, Rabinstein AA. Posterior reversible encephalopathy syndrome: clinical and radiological manifestations, pathophysiology, and outstanding questions. Lancet Neurol. 2015;14(9):914–25. Scholar
  40. 40.
    Parikh NS, Schweitzer AD, Young RJ, Giambrone AE, Lyo J, Karimi S, et al. Corticosteroid therapy and severity of vasogenic edema in posterior reversible encephalopathy syndrome. J Neurol Sci. 2017;380:11–5. Scholar
  41. 41.
    Eaton JM. A reversible posterior leukoencephalopathy syndrome. N Engl J Med. 1996;334(26):1744–5. author reply 6PubMedGoogle Scholar
  42. 42.
    • Janke AT, McNaughton CD, Brody AM, Welch RD, Levy PD. Trends in the incidence of hypertensive emergencies in US emergency departments from 2006 to 2013. J Am Heart Assoc. 2016;5(12) Key epidemiological data on hypertensive emergencies.
  43. 43.
    Tsalach A, Ratner E, Lokshin S, Silman Z, Breskin I, Budin N, et al. Cerebral autoregulation real-time monitoring. PLoS One. 2016;11(8):e0161907. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Joseph B. Miller
    • 1
  • Kushak Suchdev
    • 2
  • Namita Jayaprakash
    • 3
  • Daniel Hrabec
    • 1
  • Aditya Sood
    • 4
  • Snigdha Sharma
    • 5
  • Phillip D. Levy
    • 6
  1. 1.Department of Emergency Medicine, Department of Internal MedicineHenry Ford Hospital and Wayne State UniversityDetroitUSA
  2. 2.Department of Neurology, Division of Neurocritical CareWayne State UniversityDetroitUSA
  3. 3.Department of Emergency Medicine, Division of Pulmonary Critical Care MedicineHenry Ford Hospital and Wayne State UniversityDetroitUSA
  4. 4.Department of Internal Medicine, Division of CardiologyWayne State UniversityDetroitUSA
  5. 5.Department of Internal Medicine, Division of Pulmonary Critical CareWayne State UniversityDetroitUSA
  6. 6.Department of Emergency MedicineWayne State UniversityDetroitUSA

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