- Brain damage from high blood pressure starts early
- Hypertension's effects go beyond stroke
- Related Articles
- Effects seen on axons, myelin
- Probing the mechanism behind the damage
- Men in study are part of larger Vietnam registry
- Many risk factors for high blood pressure are reversible
- What’s Considered Normal?
- What Causes High Blood Pressure?
- What Are the Risk Factors?
- How is it Treated?
- NEXT STEPS AND HELPFUL RESOURCES
- How Are Reversible Strokes Associated With High Blood Pressure?
- Blood pressure and your brain
- What is blood pressure?
- High pressure, high risk
- Losing it
- High pressure, short memory
- Never too late
- Getting control
- Hypertension and Stroke: Update on Treatment
- Intracerebral hemorrhage (ICH), hemorrhagic stroke, stroke | Cincinnati, OH Mayfield Brain & Spine
- What is an intracerebral hemorrhage (ICH)?
- What are the symptoms?
- What are the causes?
- Who is affected?
- How is a diagnosis made?
- What treatments are available?
- Recovery & prevention
- Clinical trials
- Sources & links
Brain damage from high blood pressure starts early
July 23, 2015
Diffusion MRI images such as these can reveal subtle white-matter damage in the brain. (Courtesy of L. McEvoy)
Diffusion MRI images such as these can reveal subtle white-matter damage in the brain. (Courtesy of L. McEvoy)
If you want to keep your brain healthy as you age—and who doesn't?—nip hypertension in the bud.
That's the message of a new report from the Vietnam Era Twin Study of Aging, now appearing in the journal Hypertension, published by the American Heart Association.
VA and university researchers, based mainly in San Diego, imaged the brains of more than 300 Vietnam-era Veterans. They found similar white-matter damage in those with high blood pressure whether the condition was relatively new or long-standing. The effects were also similar regardless of whether the high blood pressure was controlled through medication.
“The results suggest that prevention—rather than management of hypertension—may be vital to preserving brain health in aging,” wrote the researchers.
In other words, once blood pressure rises above normal, subtle but harmful brain changes can occur rather quickly—perhaps within a year or two. And those changes may be hard to reverse, even if blood pressure is nudged back into the normal range with treatment.
Dr. William Kremen is with the Center of Excellence for Stress and Mental Health at the VA San Diego Healthcare System and the Center for Behavioral Genomics at UCSD. (Photo by Kevin Walsh)
Dr. William Kremen is with the Center of Excellence for Stress and Mental Health at the VA San Diego Healthcare System and the Center for Behavioral Genomics at UCSD. (Photo by Kevin Walsh)
“The findings suggest that doctors should be aggressive in preventing hypertension—for example, educating patients who are only pre-hypertensive about the importance of lifestyle changes,” says senior author Dr. William Kremen. “Patients may be more willing to make those changes if they realize that their brains may be affected by hypertension, even if medications can be used to adequately control blood pressure.”
Kremen, a psychologist, is with the Center of Excellence for Stress and Mental Health at the VA San Diego Healthcare System and the Center for Behavioral Genomics at the University of California, San Diego.
Hypertension's effects go beyond stroke
Lead author Dr. Linda McEvoy adds that most people associate high blood pressure only with strokes, but the potential effects on the brain are much wider—including the insidious microscopic damage to white matter seen in her team's study. White matter acts a highway in the brain, allowing for the relay of electrical signals between brain cells.
“People may be aware that high blood pressure increases the risk of stroke, which can lead to cognitive impairment and dementia, but many may not be aware that even in the absence of stroke, high blood pressure may be causing subtle cognitive decline,” says McEvoy, an associate adjunct professor in the department of radiology at UCSD. “It can be contributing to some of the changes in our ability to think that we attribute to growing older. And hypertension-related brain damage can also make the symptoms of Alzheimer's disease worse, or make them appear earlier in the course of the disease than they would otherwise.”
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To date, most studies linking high blood pressure to poor brain health have focused on older people. Researchers are only now coming to understand how the condition can affect brain health in those who are middle-aged or even younger—and how fast those changes set in.
The 316 men in the study had an initial assessment and returned to the clinic nearly six years later for brain imaging and further exams. Some of the men had normal blood pressure on both occasions.
Others had high blood pressure at both visits and were classified as longer-duration cases.
Others had developed hypertension only in the interim—between visits—and were thus classified as shorter-duration cases.
Given the time frame of the study, the difference in duration between the short- and long-standing diagnoses was not great—only around five years or less. The researchers say more years of follow-up might in fact reveal increasing damage with longer-standing hypertension.
In any case, they say the results “suggest that hypertension has widespread effects on brain white matter” that begin early in the course of the disease and “may not be easily reversible.”
Effects seen on axons, myelin
The researchers used diffusion MRI, which tracks water molecules as they move through brain tissue. The method detects subtle microscopic damage to the brain's white matter.
One example is decreasing diameter of the nerve fibers, or axons—the thread projections that relay messages from one brain cell to another.
Another is a loss of myelin, the insulation around nerve fibers that enables them to function.
Emerging research suggests such subtle damage, measured at the micrometer scale, is not benign; it can translate into clinical symptoms.
For example, a 2013 study that involved Boston VA researchers linked “white matter microstructure” changes to poorer executive function and processing speed.
The results from the new research also complement those from a 2012 study by a team at the University of California, Davis, which found that even adults in early middle age could show white-matter damage related to high blood pressure.
The study involved third-generation Framingham Heart Study participants, who were only about 40 years old, on average, and healthy overall. The study, published in 2012 in The Lancet Neurology, concluded that “subtle vascular brain injury develops insidiously during life, with discernible effects even in young adults.
These findings emphasize the need for early and optimum control of blood pressure.”
The Vietnam-era Veterans in the San Diego study were about 62 years old, on average, when they were scanned. So the findings may not be as stunning as those from the younger Framingham adults. Still, they underscore the importance of preventing high blood pressure in the first place, rather than trying to control it and stem its harmful effects on the brain and the rest of the body.
Probing the mechanism behind the damage
The latest report focuses only on microscopic white-matter damage. The San Diego team has also documented macroscopicwhite-matter damage, visible to the eye, that is also attributable to high blood pressure. Those results, the same Veterans, will be published in the future.
Researchers don't yet fully understand how hypertension damages the brain's white matter. But they do know that the condition affects the flow of blood—and thus oxygen—into these tissues.
“Other studies have shown that hypertension causes a number of changes to blood vessels, including the blood vessels supplying white matter,” explains McEvoy.
“These changes result in periods of hypoperfusion, or reduced blood flow, which results in reduced oxygen supply to the local tissue.
Myelinated axons in the white matter appear to be highly susceptible to this disruption in oxygen supply.”
Men in study are part of larger Vietnam registry
The 316 men taking part in the Vietnam Era Twin Study of Aging are part of a larger group of volunteers who make up the Vietnam Twin Registry. The total registry contains data on some 7,000 middle-aged male twin pairs, all of whom served in the U.S. military during the Vietnam War. All the men served between 1964 and 1975.
Managed by VA's Seattle-based Epidemiologic Research and Information Center, the registry is among the largest twin registries in the nation, with members in all 50 states. It was initially formed to help answer questions about the long-term health effects of service in Vietnam, but today it serves as a resource for studies on a wide range of mental and physical health conditions.
McEvoy and Kremen's team received support from the National Institutes of Health and VA. Besides VA, participating institutions were the UCSD, Boston University, and the University of Southern California.
Many risk factors for high blood pressure are reversible
Blood pressure is one of the most commonly checked measures of a person’s health, a routine test given by virtually every kind of doctor. That’s because having high blood pressure puts you at risk for a variety of serious diseases, including heart attack, heart failure and stroke.
“One of the things it can do is it makes the heart work harder,” says Steven Almany, M.D., director of the catheterization lab at Beaumont.
Blood pressure is defined as the force of your blood pushing against your blood vessels. The more blood your heart pumps and the narrower your arteries, the higher your blood pressure.
A little over a quarter of adults in the U.S. suffer from high blood pressure, Dr. Almany says. But while severe cases may cause headaches, nosebleeds or shortness of breath, most people with high blood pressure typically exhibit no symptoms. So the average person may go years with high blood pressure and not even know it.
What’s Considered Normal?
Blood pressure is expressed in a way that looks a fraction, with the systolic number over the diastolic number. The American Heart Association considers normal blood pressure to be readings below 120/80, while systolic readings above 120 become more problematic.
“The numbers have come down pretty consistently over time” as the medical science evolves, Dr. Almany says.
What Causes High Blood Pressure?
Roughly 95 percent of the time, it’s not possible to find the direct cause of high blood pressure – what doctors label “essential hypertension,” Dr. Almany explains. This type tends to run in families, is more common among African Americans, and affects men more often than women. It also typically develops gradually over time.
When a cause is identified, called “secondary hypertension,” the condition tends to appear more suddenly and lead to higher blood pressure. Causes include kidney disease, sleep apnea, thyroid problems and other abnormalities.
What Are the Risk Factors?
There are many risk factors that contribute to high blood pressure:
- being overweight or obese
- lack of exercise
- too much salt in your diet
- too little potassium in your diet
- drinking too much alcohol
- old age
- family history
- certain chronic conditions
How is it Treated?
When there’s no obvious cause, doctors typically treat high blood pressure with medication. But certain risk factors are reversible, quitting smoking, managing stress, following a healthier diet with less salt, getting regular exercise and losing weight.
If you have high blood pressure, it’s a good idea to get serious about bringing it down. Dr. Almany says studies have found that bringing your systolic blood pressure down by 10 points brings a 20-percent reduction in the risk of cardiovascular disease and mortality.
NEXT STEPS AND HELPFUL RESOURCES
How Are Reversible Strokes Associated With High Blood Pressure?
Jim Craigmyle / Getty Images
A syndrome that is known as reversible posterior leukoencephalopathy syndrome, or RPLS, is a rare, stroke- condition caused by swelling in the brain. Reversible posterior leukoencephalopathy is usually associated with an episode of extremely high blood pressure or with the use of some drugs.
However, the syndrome may develop in an unpredictable way before it resolves. And, because it is never guaranteed that a stroke or a stroke- episode will eventually resolve, it is important to get medical attention for neurological symptoms.
If you have been told that you or a loved one has had RPLS, you probably have a few questions about it.
This condition is considered a syndrome, or a constellation of symptoms that typically occur together and are caused by one or more etiologies (origins of illness or disease). The regions of the brain affected by this syndrome are located mostly in the back of the brain.
In the case of RPLS, it is the white matter of the brain that is most predominantly affected. One of the characteristics of RPLS is that it is reversible in the majority of cases, which means that this condition is temporary and that its symptoms and MRI findings are transient.
Leukoencephalopathy is defined as a clouding of consciousness, confusion, or an altered mental state due to a condition that affects a large region of the brain.
Variability of RPLS
As it turns out, the symptoms observed with this condition are not as clearly defined as its acronym implies, as RPLS has been shown to cause a variety of symptoms, all of which have a wide spectrum of severity, and duration.
The most common of these, as reported by one study, include encephalopathy (92%) seizures (87%), headaches (54%) and visual problems (39%). But not all cases of RPLS are reversible, posterior, or related to swelling in the white matter.
So almost any area of the brain can be affected by RPLS, and other stroke symptoms might also be present.
The diagnosis of RPLS is made through a careful medical workup which includes a careful history of the symptoms experienced by the patient, a neurological physical examination, an MRI of the brain, and the presence of high blood pressure around the time of the event.
One research study, however, shows that some people might suffer from RPLS in the presence of normal blood pressure. This may occur in a condition called eclampsia, which most often is associated with late pregnancy or labor and delivery.
Encephalopathy and leukoencephalopathy can also occur in people who use certain medications.
Typically, the MRI of the brain of patients with RPLS shows an appearance of swelling in the white matter of the posterior region of the brain on both the left and right sides.
However, in some cases, RPLS can involve areas in the front of the brain or other regions of the brain, and it may even involve the gray matter.
Furthermore, many cases of RPLS have left survivors with permanent brain damage, although in most cases a resolution of the swelling does occur. Improvement can typically be confirmed by a follow-up MRI of the brain.
The treatment for RPLS is focused on closely controlling blood pressure and fluid levels in the body. For cases associated with certain medications, discontinuation of the offending drug is required.
Additionally, preventing and treating seizures is an important component of the acute management of this condition.
Closely watching symptoms such as headaches is an important component of determining urgent changes in the condition.
Typically, symptoms resolve within a few days to weeks after the initial onset of RPLS. However, as with all episodes of stroke or mini-stroke, there might be residual symptoms from brain damage.
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- Lee VH, Wijdicks EF, Manno EM, Rabinstein AA. Clinical spectrum of reversible posterior leukoencephalopathy syndrome. Archives of Neurology. 2008 Feb 1;65(2):205-10. doi:10.1001/archneurol.2007.46
- Mohr JP, Choi DW, Grotta JC, Weir B, Wolf PA. Stroke: Pathophysiology, Diagnosis, and Management. Churchill Livingstone; 4th edition (2004).
Blood pressure and your brain
Hypertension is a circulatory disease. All parts of the body depend on the circulation, and many organs suffer from the impact of untreated hypertension. One of the organs at greatest risk is the brain.
What is blood pressure?
Blood pressure is the vital force that propels oxygen-rich blood to all parts of your body. Your heart is the pump that generates the force, and your arteries are the channels that transport and distribute the blood.
The height of your blood pressure is determined by how forcefully your heart's main pumping chamber, the left ventricle, contracts, and by the diameter and stiffness of your arteries.
In turn, your heart and arteries are influenced by a large number of genetic, hormonal, metabolic, neurological, psychological, and lifestyle factors that determine your blood pressure.
Because these influences are so numerous and complex, your blood pressure can vary from minute to minute and hour to hour during the course of the day, to say nothing of the slower shifts that occur over the course of a lifetime.
Blood pressure has two components. Your systolic blood pressure is the higher number, recorded while your heart is pumping blood into your arteries; your diastolic blood pressure is the lower number, recorded when your heart is relaxing and refilling with blood between beats.
Both numbers are calibrated in millimeters of mercury (mm Hg), a vestige of the mercury column used in the first pressure manometers more than 100 years ago.
By convention, the higher number is recorded first; a systolic pressure of 110 mm Hg and diastolic pressure of 70 mm Hg would be written as 110/70 and pronounced “110 over 70.”
In adults, normal blood pressure means you have readings below 120/80. According to the newest guidelines, a systolic blood pressure between 120 and 129 is known as elevated blood pressure.
Stage 1 high blood pressure (a diagnosis of hypertension) is now between 130 and 139 systolic or between 80 and 89 diastolic (the bottom number). Stage 2 high blood pressure is now equal to or higher than 140 systolic or 90 diastolic.
Hypertension is also enormously consequential; in fact, it contributes to one of every six deaths in American adults. Because it involves the heart and blood vessels, hypertension is classified as a cardiovascular disease.
But since arteries are vital to the health of all our organs, hypertension is actually a multisystem disease.
In many cases, hypertension's most damaging impact does not fall on the heart but on the eyes, the kidneys, and especially the brain.
There are two major types of strokes, ischemic and hemorrhagic (see illustration). Hemorrhagic strokes are less common but often cause the most dramatic symptoms. They occur when a blood vessel in the brain bursts, spilling blood into the brain or the fluid that surrounds it.
Ischemic strokes, which account for about 87% of all strokes, result when an artery that supplies blood to the brain becomes blocked by a clot. This can happen in either of two ways. In a thrombotic stroke, the clot forms in a diseased artery within the brain itself.
In an embolic stroke, the clot forms outside the brain, then breaks away and is carried by the blood to the brain, where it lodges in a previously normal artery. Most emboli originate on atherosclerotic plaques in the carotid artery or aorta, or in the heart itself.
Each of these major types of strokes has a milder counterpart. Although major hemorrhagic strokes are impossible to overlook, MRI studies show that small microbleeds are much more common. Similarly, many people have tiny ischemic strokes, which are classified as lacunar strokes because of their small size.
Although a simple microbleed or lacunar stroke is not ly to produce symptoms, a series of these events can produce major problems, including memory loss, or cognitive dysfunction (see below).
According to American Heart Association estimates, more than 13 million Americans have had one or more of these “silent” strokes, which are particularly common in people over 60, especially if they have hypertension.
High pressure, high risk
High blood pressure is the leading cause of strokes, both symptomatic and silent. Both systolic and diastolic hypertension contribute to risk; the higher your pressure, the higher your risk.
According to one Harvard study, hypertension increases a man's risk of stroke by 220%; according to another, each 10 mm Hg rise in systolic pressure boosts the risk of ischemic stroke by 28% and of hemorrhagic stroke by 38%.
That's the bad news. The good news is that treating hypertension is extremely protective; in round figures, if you reduce your systolic blood pressure by 10 mm Hg, you should cut your risk of stroke by a whopping 44%.
Mental decline is one of the most feared consequences of aging.
But although many senior citizens experience some changes in memory as they grow older, most men who remain healthy continue to function at high levels.
They learn to compensate for minor changes in the speed of recall and to use the wisdom that has accumulated over the years to maintain the ability to reason and think creatively.
Unfortunately, many men don't stay healthy, and many develop cognitive dysfunction. A variety of illnesses and medications can contribute to cognitive dysfunction — and as research continues to come in, it's increasingly clear that hypertension takes a toll on the aging brain.
Mild cognitive impairment can be a problem, but it's usually quite manageable.
But severe memory loss is a disaster; you may think of it by its old name, senility, but doctors now use the term dementia to characterize these severe disturbances of memory, reasoning, and judgment.
Although dozens of neurological diseases can cause dementia, just two account for the lion's share, multi-infarct or vascular dementia and Alzheimer's disease.
Multi-infarct dementia occurs when small vessels in the brain become diseased or blocked, depriving brain cells of the oxygen and glucose they need. If enough nerve cells are damaged or killed by the process, memory can't be restored.
Alzheimer's disease is different.
The problem begins with the accumulation of beta-amyloid, a small sticky protein that interferes with the function of nerve cells and eventually kills off cells, leaving neuritic plaques in its wake.
In advanced disease, brain cells become clogged with neurofibrillary tangles composed of a protein called tau. In most cases, the part of the brain that is responsible for memory (the hippocampus) is hit the hardest.
|Patients with hypertension often have additional medical problems that influence the choice of a blood pressure medication. Here are some conditions that may benefit from a specific class of medication; in every case, a physician should choose the medication that's best for that particular patient.|
|Compelling indicators for blood pressure drugs|
|Previous heart attack||BB, ACEI, ARB|
|Previous stroke||Diuretic, ACEI, ARB|
|Kidney disease||ACEI, ARB|
|High risk of coronary artery disease||Diuretic, BB, CCB, ACEI, ARB|
|ACEI = angiotensin-converting–enzyme inhibitorBB = beta blockerARB = angiotensin-receptor blockerCCB = calcium-channel blocker|
High pressure, short memory
Since hypertension damages blood vessels, it's easy to see how it contributes to vascular dementia. Although the link to Alzheimer's disease is less obvious, research suggests that vascular damage and tissue inflammation accelerate injury.
The details vary from study to study, but the weight of evidence now suggests that high blood pressure increases the risk of mild cognitive impairment, vascular dementia, and even Alzheimer's disease. Both systolic and diastolic hypertension take a toll; in general, the higher the pressure and the longer it persists without treatment, the greater the risk.
Most investigations focus on older adults. For example, a study of 2,505 men between the ages of 71 and 93 found that men with systolic pressures of 140 mm Hg or higher were 77% more ly to develop dementia than men with systolic pressures below 120 mm Hg.
Doctors may be able to help ease the burden of dementia, but the damage and disability cannot be reversed. That makes prevention doubly important. Can treating hypertension help prevent dementia?
Yes. European scientists reported that long-term antihypertensive therapy reduced the risk of dementia by 55%. Several American studies are only slightly less optimistic. One linked therapy to a 38% lower risk.
Another reported that each year of therapy was associated with a 6% decline in the risk of dementia; in particular, men treated for 12 years or more enjoyed a 65% lower risk of Alzheimer's disease than men with untreated hypertension.
Never too late
It's good to know that blood pressure control can reduce the risk of cognitive dysfunction. But what about men who already have mild memory loss? Can treating hypertension help stave off further damage?
Perhaps. Italian scientists studied 80 patients with mild cognitive dysfunction. Over a two-year period, patients who were given antihypertensive medications were 80% less ly to progress to full-blown Alzheimer's than untreated patients. It's only one study, and a small one at that.
For your head as well as your heart, get your blood pressure down. And even if you forget that hypertension is bad for your brain, remember that men with normal blood pressures live about five years longer than hypertensive men.
The first step is to know your blood pressure. The next step is to know your goal. Third, live right. Lifestyle modification can lower your blood pressure. It's an essential part of prevention and treatment of high blood pressure. Here are five steps that can help:
Reduce your sodium intake to less than 2,300 mg a day; 1,500 mg is the new, though stringent, goal for people with hypertension and for totally healthy folks who are middle-aged and older.
Reduce your intake of animal fat and processed foods, but chow down lots of fruits, vegetables, whole grains, and fish. A good diet can lower systolic blood pressure by 10 to 22 mm Hg.
2. Exercise. Moderate exercise is excellent, even outperforming intense exercise in some studies. Walking for 30 minutes a day is one way to lower your systolic pressure by 4 to 9 mm Hg or more.
3. Weight control. Diet and exercise will get you there. An obese person who sheds 20 pounds can expect a drop of 5 to 20 points in blood pressure over and above the benefits of diet and exercise.
4. Moderate alcohol use. Light to moderate drinking to the tune of one to two drinks a day won't raise your blood pressure, but heavy drinking will.
5. Use nonsteroidal anti-inflammatory drugs (NSAIDs) judiciously. Long-term use of NSAIDs (ibuprofen, naproxen, others) can raise blood pressure, particularly in older people.
6. Stress control. It's easier said than done in today's hectic world, but winding down can help you keep your pressure down.
Finally, use medications if you need more help. It's another point that should be obvious, but a shocking 55% of hypertensive patients are above their targets.
The authoritative JNC7 report recommends thiazide diuretics, ACE inhibitors, angiotensin-receptor blockers, calcium-channel blockers, and beta blockers as first-line medications, but research suggests beta blockers may be less desirable than the others, particularly to prevent strokes.
Many experts start with a thiazide diuretic, but if you have particular needs, another drug may be best (see box above). And a combination of two or more drugs is often needed.
Cooperate with your family to improve your lifestyle, and work with your doctor to find the medication that will bring you to your target blood pressure safely. It will take patience and persistence, but it's the brainy thing to do.
As a service to our readers, Harvard Health Publishing provides access to our library of archived content. Please note the date of last review or update on all articles. No content on this site, regardless of date, should ever be used as a substitute for direct medical advice from your doctor or other qualified clinician.
Pregnancy and the postpartum period are associated with an increased risk of ischemic and hemorrhagic stroke.1–3 the estimate from 11 studies published between 1990 and January 2017, stroke is most common in the peripartum and postpartum periods.4 Stroke is estimated to affect 30 per 100 000 pregnancies.
Some of the mechanisms underlying this increased risk include venous or arterial thrombosis because of estrogen-related hypercoagulability; cerebral hypoperfusion related to acute blood loss; cardioembolism because of peripartum cardiomyopathy; and endotheliopathy, vasospasm, and hypertensive intracerebral hemorrhage (ICH) related to hypertensive disorders of pregnancy.2,5–7
Hypertensive disorders of pregnancy include chronic hypertension, gestational hypertension, and preeclampsia/eclampsia. Gestational hypertension is defined as a systolic blood pressure ≥140 mm Hg or a diastolic blood pressure ≥90 mm Hg in a previously normotensive woman at ≥20 weeks of gestation.
8 Preeclampsia is distinct from gestational hypertension in that it additionally involves at least one of the following criteria: proteinuria, thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, or cerebral or visual symptoms (Table). Preeclampsia can progress to eclampsia, which is characterized by seizure activity in a preeclamptic woman.
Preeclampsia most commonly occurs during pregnancy and the peripartum period although postpartum preeclampsia can occur.9,10
|Hypertension after 20 wk of gestation in a previously normotensive woman||SBP ≥140 mm Hg, or||Blood pressure must be elevated on 2 measurements taken at least 4 h apart|
|DBP ≥90 mm Hg|
|Hypertension after 20 wk of gestation in a previously normotensive woman||SBP ≥160 mm Hg, or||Blood pressure must be elevated on 2 measurements which can be taken minutes apart|
|DBP ≥110 mm Hg|
|and 1 of the following:|
|Proteinuria||≥300 mg/protein per 24-h urine collection, or||Dipstick method permissible if quantitative methods are not available|
|Protein/creatinine ratio ≥0.3, or|
|Urine dipstick reading of 1+|
|Thrombocytopenia||Platelets 1.1 mg/dL or doubling of serum creatinine||Not permissible if presence of other renal disease|
|Impaired liver function||Doubling of serum transaminases|
|Cerebral or visual symptoms|
Preeclampsia is a systemic, multiorgan endotheliopathy, affecting the kidneys, heart, liver, and brain. Preeclampsia can be associated with premature birth, placental abruption, and stillbirth.11,12 Potential cerebral complications of preeclampsia include ischemic stroke, hemorrhagic stroke, cerebral edema, and seizure.
13 Preeclampsia has been associated with posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS).
The differential diagnosis of preeclampsia with cerebral complications may commonly include metabolic derangement, toxic ingestion, central nervous system infection, and cerebral venous sinus thrombosis.
The pathophysiology underlying preeclampsia remains incompletely characterized. Preeclampsia has been associated with aberrant trophoblast (blastocyst cell) invasion into the uterus and uterine spiral arteries14; reduced placental perfusion15; imbalance of pro- and antiangiogenic factors16; and an excessive intravascular inflammatory response to placental tissue.17
Preeclampsia is generally reported to complicate
Hypertension and Stroke: Update on Treatment
Stroke is the second most common cause of mortality worldwide and the third most common cause of disability.
1 Although there has been a global trend towards a reduction in stroke incidence, prevalence and mortality since the 1990s, the overall stroke burden in terms of absolute number of people affected continues to increase.
2 More than 1 million people have a stroke every year in Europe and that figure is estimated to rise to 1.5 million by 2025, due to the ageing population.3
There are three main types of stroke: ischaemic, intracebral and subarachnoid haemorrhage. In the US, the proportion of ischaemic strokes, intracerebral haemorrhage and subarachnoid haemorrhage is 87%, 10% and 3%, respectively.
4 These percentages seem to be similar globally, with a trend of a higher increase in the frequency of haemorrhage in developed countries in relation to developing countries, while death rate is significantly higher in developing countries compared with developed countries.5–7
Men have a higher incidence of stroke than women at younger ages, with the incidence reversed by the age of 75 years, although recent data suggests this may not be the case for black people as the stroke risk for black women aged 65 to 74 years was similar when compared with black men.4,8 The finding could be driven by race and sex group differences for stroke risk factors, mainly hypertension.8
Hypertension is the most prevalent risk factor for stroke, data from 30 studies, and has been reported in about 64% of patients with stroke.
2,9 In low-income countries, the reported prevalence of risk factors among patients with stroke is lower, however patients have the highest in-hospital mortality, probably due to delays in presentation for seeking acute stroke care, differences in health system response and acute stroke management.10
The cause of stroke and haemodynamic consequences are heterogeneous across stroke subtypes and timing of disease presentation. Thus, the management of blood pressure (BP) in stroke patients is complex and requires an accurate diagnosis and precise definition of therapeutic goals.
The present review will address the management of BP in patients with stroke, mostly recent published guidelines. In general, guideline recommendations from different countries are similar, including the gaps in evidence and suggestions for the need for further studies (Figure 1).
Blood Pressure and Primary Prevention of Cardiovascular Disease and Stroke
There is robust evidence that screening and treatment of hypertension prevents cardiovascular disease (CVD) and reduces mortality in the middle-aged population (50–65 years).
Even in older adults, lowering BP is ly to be beneficial provided that treatment is well tolerated, despite a lack of studies to support this.
However, there is a lack of high-quality evidence for a favourable harm–benefit balance of antihypertensive treatment among older adults, especially among the oldest age groups (>80 years).16
There has been a debate about how far BP should be lowered.
The American Guidelines for Management of Hypertension, influenced by the results of the Systolic Blood Pressure Intervention Trial (SPRINT) recommends a reduction of the treatment target from 140/90 mmHg to 130/80 mmHg, including for the very old.17-19 However, some authors emphasised that there is a greater potential for harm to exceed benefit when BP targets are lowered.20
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The European Guidelines for the Management of Arterial Hypertension recommend lowering systolic BP to
Intracerebral hemorrhage (ICH), hemorrhagic stroke, stroke | Cincinnati, OH Mayfield Brain & Spine
Intracerebral hemorrhage (ICH) is caused by bleeding within the brain tissue itself — a life-threatening type of stroke. A stroke occurs when the brain is deprived of oxygen and blood supply.
ICH is most commonly caused by hypertension, arteriovenous malformations, or head trauma.
Treatment focuses on stopping the bleeding, removing the blood clot (hematoma), and relieving the pressure on the brain.
What is an intracerebral hemorrhage (ICH)?
Tiny arteries bring blood to areas deep inside the brain (see Anatomy of the Brain). High blood pressure (hypertension) can cause these thin-walled arteries to rupture, releasing blood into the brain tissue.
Enclosed within the rigid skull, clotted blood and fluid buildup increases pressure that can crush the brain against the bone or cause it to shift and herniate (Fig. 1). As blood spills into the brain, the area that artery supplied is now deprived of oxygen-rich blood – called a stroke.
As blood cells within the clot die, toxins are released that further damage brain cells in the area surrounding the hematoma.
Figure 1. An intracerebral hemorrhage (ICH) is usually caused by rupture of tiny arteries within the brain tissue (left). As blood collects, a hematoma or blood clot forms causing increased pressure on the brain.
An ICH can occur close to the surface or in deep areas of the brain. Sometimes deep hemorrhages can expand into the ventricles – the fluid filled spaces in the center of the brain. Blockage of the normal cerebrospinal (CSF) circulation can enlarge the ventricles (hydrocephalus) causing confusion, lethargy, and loss of consciousness.
What are the symptoms?
If you experience the symptoms of an ICH, call 911 immediately! Symptoms usually come on suddenly and can vary depending on the location of the bleed. Common symptoms include:
- headache, nausea, and vomiting
- lethargy or confusion
- sudden weakness or numbness of the face, arm or leg, usually on one side
- loss of consciousness
- temporary loss of vision
What are the causes?
- Hypertension: elevated blood pressure may cause tiny arteries to burst inside the brain. Normal pressure is 120/80 mm Hg.
- Blood thinners: drugs such as coumadin, heparin, and warfarin used to prevent clots in heart and stroke conditions may cause ICH.
- AVM: a tangle of abnormal arteries and veins with no capillaries in between.
- Aneurysm: a bulge or weakening of an artery wall.
- Head trauma: fractures to the skull and penetrating wounds (gunshot) can damage an artery and cause bleeding.
- Bleeding disorders: hemophilia, sickle cell anemia, DIC, thrombocytopenia.
- Tumors: highly vascular tumors such as angiomas and metastatic tumors can bleed into the brain tissue.
- Amyloid angiopathy: a buildup of protein within the walls of arteries.
- Drug usage: alcohol, cocaine and other illicit drugs can cause ICH.
- Spontaneous: ICH by unknown causes.
Who is affected?
Ten percent of strokes are caused by ICH. ICH is twice as common as subarachnoid hemorrhage (SAH) and has a 40% risk of death.
ICH occurs slightly more frequently among men than women and is more common among young and middle-aged African Americans and Japanese. Advancing age and hypertension are the most important risk factors for ICH.
Approximately 70% of patients experience long-term deficits after an ICH.
How is a diagnosis made?
When a person is brought to the emergency room with a suspected brain hemorrhage, doctors will learn as much about his or her symptoms, current and previous medical problems, medications, and family history. The person's condition is assessed quickly. Diagnostic tests will help determine the source of the bleeding.
Computed Tomography (CT) scan is a noninvasive X-ray to review the anatomical structures within the brain and to detect any bleeding. CT angiography involves the injection of contrast into the blood stream to view arteries of the brain.
Angiogram is an invasive procedure, where a catheter is inserted into an artery and passed through the blood vessels to the brain. Once the catheter is in place, contrast dye is injected into the bloodstream and X-rays are taken.
Magnetic resonance imaging (MRI) scan is a noninvasive test, which uses a magnetic field and radio-frequency waves to give a detailed view of the soft tissues of your brain. An MRA (Magnetic Resonance Angiogram) involves the injection of contrast into the bloodstream to examine the blood vessels as well as the structures of the brain.
What treatments are available?
Treatment may include lifesaving measures, symptom relief, and complication prevention.
Once the cause and location of the bleeding is identified, medical or surgical treatment is performed to stop the bleeding, remove the clot, and relieve the pressure on the brain.
If left alone the brain will eventually absorb the clot within a couple of weeks – however the damage to the brain caused by ICP and blood toxins may be irreversible.
Generally, patients with small hemorrhages (3 cm3) who are deteriorating or who have brainstem compression and hydrocephalus are treated surgically to remove the hematoma as soon as possible. Patients with large lobar hemorrhages (50 cm3) who are deteriorating usually undergo surgical removal of the hematoma.
The patient will stay in the stroke unit or intensive care unit (ICU) for close monitoring and care.
- If the patient was on blood thinners, reversal drugs will be given to restore clotting factors.
- Blood pressure is managed to decrease the risk of more bleeding yet provide enough blood flow (perfusion) to the brain.
- Controlling intracranial pressure is a factor in large bleeds. A device called an ICP monitor may be placed directly into the ventricles or within the brain to measure pressure. Normal ICP is 20mm HG.
- Removing cerebrospinal fluid (CSF) from the ventricles helps control pressure. A ventricular catheter (VP shunt) may be placed to drain CSF fluid and allow room for the hematoma to expand without damaging the brain.
- Hyperventilation also helps control ICP. In some cases, coma may be induced with drugs to bring down ICP.
The goal of surgery is to remove as much of the blood clot as possible and stop the source of bleeding if it is from an identifiable cause such as an AVM or tumor. Depending on the location of the clot either a craniotomy or a stereotactic aspiration may be performed.
- Craniotomy involves cutting a hole in the skull with a drill to expose the brain and remove the clot. Because of the increased risk to the brain, this technique is usually used only when the hematoma is close to the surface of the brain or if it is associated with an AVM or tumor that must also be removed.
- Stereotactic clot aspiration is a minimally invasive surgery for large hematomas located deep inside the brain. The procedure uses a stereotactic frame to guide a needle or endoscope directly into the clot. Stereotactic guidance is the GPS system in your car. It is a navigation your presurgical imaging scans. The CT scan helps pinpoint the best trajectory into the hematoma. In the OR, the surgeon drills a small burr hole about the size of quarter in the skull. With the aid of the stereotactic frame, a hollow cannula is passed through the hole, through the brain tissue, directly into the clot. The hollow cannula is attached to a large syringe to withdraw the liquid portion of the blood clot (Fig. 2). A smaller catheter is then inserted to continue draining over the next days to weeks (Fig. 3).
Figure 2. Clot aspiration through a catheter to reduce the mass effect and pressure in the brain. Figure 3. CT scan of a large ICH before and after clot removal. A catheter remains in the space to continue draining for several days.
Recovery & prevention
Immediately after an ICH, the patient will stay in the intensive care unit (ICU) for several weeks where doctors and nurses watch them closely for signs of rebleeding, hydrocephalus, and other complications. Once their condition is stable, the patient is transferred to a regular room.
ICH patients may suffer short-term and/or long-term deficits as a result of the bleed or the treatment. Some of these deficits may disappear over time with healing and therapy. The recovery process may take weeks, months, or years to understand the level of deficits incurred and regain function.
Clinical trials are research studies in which new treatments—drugs, diagnostics, procedures, and other therapies—are tested in people to see if they are safe and effective. Research is always being conducted to improve the standard of medical care.
Information about current clinical trials, including eligibility, protocol, and locations, are found on the Web. Studies can be sponsored by the National Institutes of Health (see clinicaltrials.gov) as well as private industry and pharmaceutical companies (see www.
Sources & links
If you have more questions, please contact Mayfield Brain & Spine at 800-325-7787 or 513-221-1100.
- Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. Stroke 46:2032-60, 2015.
- Fewel ME, Thompson BG, Hoff JT: Spontaneous Intracerebral Hemorrhage:a review. Neurosurg Focus 15: 2003.
National Stroke Association
American Stroke Association
craniotomy: surgical opening of a portion of the skull to gain access to intracranial structures and replacement of the bone flap.
hematoma: a blood clot.
hydrocephalus: swelling in the brain due to a blockage of cerebrospinal fluid.
intracranial pressure (ICP): pressure within the skull.
ICP monitor: a device used to measure intracranial pressure inside the brain.
stereotactic: a precise method for locating deep brain structures by the use of 3-dimensional coordinates.
ventricles: hollow areas in the center of the brain containing cerebrospinal fluid.
ventriculoperitoneal (VP) shunt: a catheter placed in the ventricle of the brain to drain excess cerebrospinal fluid.
updated > 4.2018
reviewed by > Andrew Ringer, MD, Mayfield Clinic, Cincinnati, Ohio
Mayfield Certified Health Info materials are written and developed by the Mayfield Clinic. We comply with the HONcode standard for trustworthy health information. This information is not intended to replace the medical advice of your health care provider.