Hypertensive brainstem encephalopathy: Three cases presenting with severe brainstem edema

Hypertensive encephalopathy (HTE) is manifested by headache, confusion, seizures, and visual disturbance and may progress to coma and death.1 CT or MRI scans usually show transient, predominantly posterior white matter involvement that rapidly improves with control of hypertension. The following three patients were unusual in having severe brainstem involvement without accompanying occipital lobe changes. Patient 1. A 54-year-old woman with a history of poorly controlled hypertension presented with 3 days of walking difficulty, right leg weakness, and mild headache with nausea. She denied any visual problems. Examination showed blood pressure (BP) of 210/144 mm Hg. She was confused with mild right hemiparesis. Funduscopic examination showed scattered posterior pole exudates and hemorrhages without disc edema. The T2-weighted and fluid-attenuated inversion-recovery (FLAIR) images showed hyperintense signals in the brainstem, with scattered mild signal changes in the cerebellum and periventricular white matter (figure, A and B). Diffusion-weighted MRI showed only a small left subcortical infarct. Figure. (A and B) Patient 1. MRI–fluid-attenuated …