Definition

Encephalopathy is a condition that occurs when the structure or function is abnormal of the brain due to a specific medical condition. This abnormality can be temporary but also permanent. Therefore, early detection and management of this condition are necessary to improve the chances of recovery.

Hypertensive encephalopathy is an acute neurological syndrome characterized by one or more clinical manifestations such as severe headache, vomiting, visual disturbances, decreased consciousness, and seizures associated with high blood pressure. Hypertension is part of hypertensive urgency, where blood pressure exceeds 140/90 without damage or minimal complications to related organs. In adults, hypertensive encephalopathy can be a complication of uncontrolled chronic hypertension, while in children, it's associated with acute hypertensive attacks.

Causes

Hypertensive encephalopathy is caused by high blood pressure exceeding 140/90 which causes disorders in the structure or function of the brain. Hypertension itself is not the only condition that triggers encephalopathy. Several other things can also increase a person's risk of developing encephalopathy, namely lack of oxygen supply to the brain due to infection or anemia, electrolyte disorders, namely when electrolyte levels in the body are unbalanced, hypotension, namely blood pressure that is too low, poisoning or side effects of drugs, liver disease, including jaundice, head injury, kidney failure, namely a condition that occurs when the kidneys cannot work properly, Hashimoto's disease, namely a disease that occurs due to the immune system attacking the thyroid gland in the body, glycine protein that is too high in the brain due to genetic disorders, Wernicke-Korsakoff syndrome, namely a condition that occurs due to vitamin B1 deficiency triggered by alcohol addiction, Lyme disease, namely a bacterial infection transmitted due to frequent nail biting in dirty conditions, mad cow disease, namely a brain disorder due to consuming beef infected with the disease. These conditions can trigger symptoms of encephalopathy that require immediate medical attention.

In children, hypertensive encephalopathy can be caused by several diseases such as GNAPS (Acute Post-Streptococcal Glomerulonephritis), hemolytic uremic syndrome, Schonlein-Henoch nephritis, lupus nephritis, proliferative glomerulonephritis, pyelonephritis, obstructive uropathy, polycystic kidneys and post-kidney transplantation.

Risk factor

 Several factors can exacerbate the occurrence of hypertensive encephalopathy, including:

• Age: Elderly individuals have a higher risk of developing hypertensive encephalopathy.
• Gender: Males are more likely to experience hypertensive encephalopathy than females.
• Medical history: People with a history of heart disease, stroke, kidney failure, or a history of seizures are at a higher risk of developing hypertensive encephalopathy.
• Children with a history of kidney disease are more susceptible to hypertensive encephalopathy.

Symptoms

Hypertension-induced encephalopathy can lead to the emergence of several symptoms such as:

• Severe headache
• Blurred vision
• Confusion
• Seizures
• Fainting
• Loss of concentration
• Impaired motor coordination
• Loss of problem-solving abilities or decision-making.

In addition, encephalopathy can also cause symptoms such as muscle twitching, difficulty swallowing or speaking, muscle weakness in one limb, and a decrease in consciousness, ranging from appearing drowsy to coma.

Diagnosis

The diagnosis of hypertensive encephalopathy can be established through a thorough interview (anamnesis) to assess whether there are severe headaches, nausea, vomiting, blurred vision, decreased consciousness, seizures, a history of previous hypertension, kidney disease, medication use, and other relevant factors. 

Physical examinations can include a fundoscopy to check for retinal haemorrhage and papilledema as signs of increased intracranial pressure. The doctor will also conduct examinations of the heart and lungs to determine the presence of enlargement of the jugular veins or additional sounds in the lungs, urinalysis, and blood tests to assess kidney function.

 CT scans or MRI of the head can also be performed to support the diagnosis and reveal brain swelling and the presence of bleeding.

Management

Treatment and therapy for patients with hypertensive encephalopathy aim to reduce arterial blood pressure by 25% over 1-2 hours and diastolic blood pressure to 100-110 mmHg. Injection of antihypertensive drugs may be administered to quickly lower blood pressure.

Monitoring in the intensive care unit (ICU) involves monitoring arterial blood pressure, drug dosages, and organ function. Potential complications of medical therapy such as extreme blood pressure reduction and side effects or drug toxicity should be monitored.

Medications commonly chosen for hypertensive encephalopathy therapy include labetalol, nicardipine, fenoldopam, and sodium nitroprusside. Other management options may include implementing a predetermined diet, providing additional oxygen, correcting fluid and electrolyte imbalances through intravenous fluid administration, providing additional nutrition, administering antibiotics, lactulose medication, dialysis, or kidney transplantation in encephalopathy due to kidney disorders (uremia). In severe cases, kidney transplantation procedures may be required to address kidney failure that causes encephalopathy.

Complication

Delayed treatment of hypertensive encephalopathy can lead to complications such as kidney failure, retinal damage, heart failure, and stroke. High blood pressure in patients with encephalopathy can also trigger brain swelling, which can worsen into status epilepticus, coma, and death. However, aggressive hypertension therapy (sudden or extreme blood pressure reduction) is not recommended as it can cause ischemic conditions (blood deficiency) in target organs, especially in patients with chronic hypertension.

Prevention

Some types of encephalopathy can still be prevented by taking simple steps. Encephalopathy caused by hypertension can be prevented by modifying lifestyle habits, including:

• Following a specific diet for hypertension patients
• Limiting salt intake
• Losing weight if overweight or obese
• Avoiding alcohol consumption
• Not smoking
• Regular exercise
• Taking medication regularly as prescribed by a doctor
• Undergoing regular check-ups to ensure blood pressure remains normal.

Regular monitoring is crucial to prevent complications. Consistent consumption of antihypertensive medications as prescribed by a doctor can also prevent further complications that may worsen the condition.

When to see a doctor?

It is advisable to see a doctor immediately if experiencing symptoms of decreased consciousness accompanied by nausea, vomiting, blurred vision, seizures, severe headaches, and confusion. If you have hypertension (high blood pressure), it is important to undergo regular blood pressure checks at the nearest healthcare facility. Additionally, patients with a history of heart disease, stroke, or kidney failure are advised to regularly monitor their condition with a doctor to keep their diseases under control.

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