Medical Image of the Week: Hypertensive Emergencies

Figure 1. Head CT scan showing basal ganglia hemorrhage (red arrow) and posterior reversible encephalopathy syndrome (green arrows).

A 39-year-old man had sudden onset of left sided hemiparesis, headache and nausea. He had a history of untreated hypertension and diabetes mellitus. On initial evaluation by emergency medical services, his blood pressure was 270/170 mm Hg. Shortly after admission, he suffered a generalized seizure treated with levetiracetam. His labs were remarkable for a creatinine of 4.4 mg/dL and microscopic hematuria. His head CT findings are consistent with two simultaneous neurological hypertensive emergencies – intracranial hemorrhage of the basal ganglia and posterior reversible encephalopathy syndrome (PRES) (Figure 1) (1). PRES is areas of edema seen as multiple cortico-subcortical areas of hyperintense (white) signal involving the occipital and parietal lobes bilaterally and pons. His renal failure likely represents a third hypertensive emergency. His blood pressure was lowered into the 140/90 range within 2 hours by nicardipine infusion and intravenous labetalol boluses. He subsequently suffered worsening mental status and unilateral pupillary dilation and underwent emergent craniotomy. He survived but is currently past 50 days in the hospital.

Robert A. Raschke MD

Critical Care Medicine

Banner University Medical Center at Phoenix

Phoenix, AZ USA

Reference

1. Vaughan CJ, Delanty N. Hypertensive emergencies. Lancet. 2000 Jul 29;356(9227):411-7. [CrossRef] [PubMed]

Cite as: Raschke RA. Medical image of the week: hypertensive emergencies. Southwest J Pulm Crit Care. 2017;15(4):147. doi: https://doi.org/10.13175/swjpcc111-17 PDF

October 2017 Imaging Case of the Month

Paul J. Conomos, MD¹

Michael B. Gotway, MD²

¹Arizona Pulmonary Specialists

Phoenix, AZ USA

²Mayo Clinic Arizona

Scottsdale, AZ USA

Clinical History: An 18-year-old man with no known previous medical history presented with complaints of intermittent cough persisting several months. No hemoptysis was noted.

Physical examination was largely unremarkable and the patient’s oxygen saturation was 99% on room air. The patient’s vital signs were within normal limits.

Laboratory evaluation was unremarkable.  Quantiferon testing for Mycobacterium tuberculosis was negative, and testing for coccidioidomycosis was unrevealing. Frontal and lateral chest radiography (Figure 1) was performed.

Figure 1. Figure 1. Frontal (A) and lateral (B) chest radiography.

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to proceed to the second of eight pages)

1. The chest radiograph shows asymmetric reticulation and interlobular septal thickening
2. The chest radiograph shows bilateral reticulation associated with decreased lung volumes
3. The chest radiograph shows focal consolidation
4. The chest radiograph shows large lung volumes
5. The chest radiograph shows small cavitary pulmonary nodules

Cite as: Conomos PJ, Gotway MB. October 2017 imaging case of the month. Southwest J Pulm Crit Care. 2017;15(4):138-46. doi: https://doi.org/10.13175/swjpcc119-17 PDF