Encefalopatia ipertensiva
Table of Contents
Definizione
L’encefalopatia ipertensivaè una sindrome caratterizzata da un’ ipertensione arteriosa transitoria accompagnata da disturbi neurologici la cui durata varia da qualche minuto a qualche giorno e che non lascia sequele. Di solito l’encefalopatia è secondaria al repentino aumento dei valori di pressione arteriosa ed è più frequente nei soggetti giovani, precedentemente normotesi, in cui vi è un improvviso aumento dei valori pressori. L’encefalopatia ipertensiva è la manifestazione clinica dell’edema cerebraleche si forma per aumento di flusso ematico cerebrale. Tale condizione si verifica quando la pressione arteriosa mediasupera i valori 150 mmHg.In questa situazione, il meccanismo di autoregolazione del flusso cerebrale non riesce a mantenere costante il flusso ematico cerebrale; ne consegue un aumento del flusso con passaggio di liquido dal compartimento vascolare a quello interstiziale. Gli elevati valori di pressione arteriosa, per la compromissione del meccanismo di autoregolazione del flusso cerebrale, possono determinare la comparsa di edema cerebrale che, se non trattato tempestivamente, può indurre ischemia cerebrale ed erniazione cerebrale acuta con fenomeni compressivi sulle delicate strutture del tronco encefalico. I sintomi più comuni sonocefalea, alterazioni dello stato di coscienza, irritabilità, alterazioni del visus, deficit focali, crisi concussive, vomito.
Eziologia
L’encefalopatia ipertensiva si osserva sia in soggetti abitualmente ipertesi (qualunque sia la causa dell’ipertensione) in cui la pressione aumenta temporaneamente, sia in soggetti che non sono normalmente ipertesi, ma presentano episodi ipertensivi (nefrite acuta, preclampsia ecc..). Nel primo gruppo, si tratta di fenomeni spastici delle arterie cerebrali, mentre nel secondo gruppo si tratta probabilmente di episodi di edema celebrale.
Sintomi e manifestazioni cliniche
Disturbi neurologici generalizzati:
Si osservano soprattutto nei soggetti che non sono abitualmente ipertesi e non hanno lesioni vascolari cerebrali, ma la cui pressione arteriosa aumenta velocemente ( per es. in caso di nefrite acuta e di eclampsia).
Si osservano segni di edema cerebrale in particolare:
- Cefalea, vomito, edema papillare con disturbi visivi.
- Stato delirante o stuporoso, crisi convulsive, talvolta coma.
Disturbi neurologici di localizzazione: si osservano soprattutto negli ipertesi di lunga data e nei quali le lesioni vascolari cerebrali preesistono alla crisi scatenata dal parossismo ipertensivo. Si osserva serve un quadro analogo a quello dell’ictus cerebrale, ma transitorio e senza sequele:
- Perdita di conoscenzao più o meno brusca.
- Crisi convulsive generalizzate o localizzate.
- Disturbi della parola, della visione e del’udito.
- Emiplagia o emiparesi.
- Disturbi della sensibilità e della coordinazione.
- All’esame del fondo dell’occhio, si possono osservare alterazioni delle arterie,emorragie retiniche ed edema papillare.
- Il liquido cefalo-rachidiano è spesso iperteso e le proteine aumentate.
Diagnosi differenziale
La diagnosi differenziale va posta con le altre forme di encefalopatia (metaboliche, infettive) che normalmente non si accompagnano a elevati valori di pressione arteriosa.
Terapia
La terapia dell’encefalopatia ipertensiva mira alla repentinariduzione dei valori di pressione arteriosafacendo attenzione , comunque, a evitare una brusca riduzione dei valori pressori. La terapia deve essere praticata tenendo monitorata la pressione arteriosa. Le classi di farmaci più utilizzati sono i diuretici dell’ansa come lafurosemide, i vasodilatatori come ilnitroprussiatodi sodioe gliantagonisti adrenergici. Bisogna notare che la somministrazione di nitroprussiato, provocando vasodilatazione dei vasi cerebrali, può risultare pericoloso nell’encefalopatia ipertensiva.
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