Hypertensive brainstem encephalopathy (HBE) is a hypertensive encephalopathy that is limited to the brainstem. It is thought to occur when blood pressures exceed the limits for autoregulation with segmental vasodilatation and vascular permeability.


Clinical features:

(1) severe hypertension

(2) visual disturbances associated with hypertensive retinopathy

(3) variable headache

(4) variable impairment in the level of consciousness, including confusion

(5) variable paresthesias and/or weakness and/or gait abnormalities


Imaging studies:

(1) swelling and diffuse hyperintense lesions in the brainstem and cerebellum on T2-weighted and/or FLAIR (fluid-attenuated inversion recovery) MRI

(2) absence of lesions in the parieto-occipital lobes

(3) variable involvement of the basal ganglia


Sometimes patients may have marked changes on the MRI yet few clinical symptoms (clinico-radiologic dissociation).


Many of the changes are reversible once the hypertension is brought under control, but residual damage may be present.


Differential diagnosis:

(1) tumor in the brainstem

(2) infarction of the brainstem and/or basal ganglia

(3) infection

(4) brainstem encephalopathy without hypertension.


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