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Chronic Hypertensive Encephalopathy


KEY FACTS

Terminology

  • Subcortical arteriosclerotic encephalopathy

Imaging

  • General features

    • Lacunae (lenticular nuclei, pons, thalamus, internal capsule, caudate)

    • Cerebral hemorrhage (basal ganglia/external capsule, thalamus)

    • Confluent white matter (WM) disease (centrum semiovale, corona radiata)

  • CT

    • Diffuse WM hypodensity on CT

    • Lacunar infarcts [basal ganglia (BG), thalamus/brainstem]

  • MR

    • Hyperintense lesions within corona radiata, centrum semiovale, BG

    • Multiple microhemorrhages (GRE, SWI)

      • –

        Predilection for BG/thalami, brainstem, cerebellum

    • Acute WM lesions may restrict

Top Differential Diagnoses

  • Amyloid angiopathy

  • CADASIL

  • Dementing disorders

    • Alzheimer dementia

    • Multiinfarct dementia

  • Antiphospholipid antibody syndrome

  • Neuropsychiatric systemic lupus erythematosus

  • Vasculitis

Pathology

  • Chronic HTN is associated with hyaline deposition within small arteries (so-called lipohyalinosis)

Clinical Issues

  • Stepwise/gradual mental deterioration

  • Acute strokes, lacunar syndrome

Axial NECT shows the typical appearance of chronic hypertensive encephalopathy, seen here as diffuse confluent periventricular white matter hypodensity
.

Axial FLAIR in a 72-year-old woman with longstanding systemic HTN demonstrates multifocal discrete and confluent hyperintensities scattered throughout the deep periventricular white matter, especially near the atria and occipital horns
. Note the old, hypertensive, basal ganglionic hemorrhage
.

Axial SWI in a patient with long-standing poorly controlled HTN shows numerous microhemorrhages in the basal ganglia
and thalami
. A few microhemorrhages are also seen in the subcortical white matter
.

Axial SWI in the same patient shows more microhemorrhages in the brainstem
and both cerebellar hemispheres
. The distribution of these microhemorrhages is typical for chronic hypertensive encephalopathy.

TERMINOLOGY

Abbreviations

  • Chronic hypertensive encephalopathy (CHE)

Synonyms

  • Subcortical arteriosclerotic encephalopathy

    • a.k.a. Binswanger disease

  • Hypertension-related microvascular disease

Definitions

  • Brain parenchymal changes due to longstanding effects of untreated or poorly treated systemic hypertension (HTN)

    • CHE is most common cause of leukoaraiosis (diffuse rarefaction of white matter)

      • –

        Others include diabetes

  • CHE: Important cause of cognitive deficits caused by vascular disease (i.e., vascular dementia)

IMAGING

General Features

  • Best diagnostic clue

    • 2 major features

      • –

        Diffuse white matter (WM) lesions (hypodense on CT, hyperintense on T2WI)

      • –

        Microhemorrhages (“bloom” on T2*)

  • Location

    • WM lesions

      • –

        Centrum semiovale, corona radiata

      • –

        Brainstem, cerebellum

    • Gray matter lesions

      • –

        Basal ganglia (BG), thalami, brainstem

    • Microhemorrhages

      • –

        Basal ganglia/thalami, brainstem, cerebellum, subcortical WM

  • Size

    • WM lesions initially small; may become confluent over time

  • Morphology

    • Rounded or patchy, discrete or confluent

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