Brain revascularisation in hypertension.

Abstract

SUMMARY Neurological symptoms in hypertensive subjects may be a reflection of intracranial vascular disease and not just a consequence of hypertension. Two hypertensive children with renovascular disease, neurological symptoms, and severe cerebral arterial disease were treated by extracranial-intracranial arterial bypass surgery with improvement of symptoms and easier control of blood pressure. Where revascularisation surgery is appropriate, this should be undertaken before neurological complications arise.Renal arterial disease may reflect more widespread arterial disease including that in intracranial vessels.' This association is not widely recognised, but is important as neurological symptoms may otherwise be attributed erroneously to the effect of the hypertension alone.Identification of cerebral abnormalities in these patients has implications, not only because of the possibility of specific treatment for stenosed areas, as in the two children we report, but also because lowering their blood pressure may lead to cerebral ischaemia, and hence permanent neurological damage. We report two children with severe hypertension secondary to renal arterial disease, both of whom had symptoms or signs suggestive of intracranial involvement. The difficulties experienced in management and the importance of timing of surgical intervention in the treatment of the cerebral arterial abnormalities is stressed. After three years both grafts are pulsatile, he has had no further neurological problems, and his rate of growth has been normal. His blood pressure is maintained at a level appropriate to his age (110/70 1177

Angioplasty for Renovascular Hypertension in Children: 20-Year Experience

“…Although the association between renovascular disease and widespread arterial involvement has been reported, 2,4,8,9,16 it seemed to be more extensive in our cohort than in other series, 7,14,[17][18][19][20][21][22][23] in which extensive investigations for widespread vascular stenoses were not performed. In our series, bilateral RAS was seen in 48% of patients and intrarenal disease in 45% of patients.…”

“…In addition, there was a high incidence of involvement of other vascular beds, particularly the brain (n ϭ 7; 21%) and aorta (n ϭ 8; 24%), in this study. Reportedly, the carotid and vertebral arteries are involved in 25% to 30% of patients with FMD, 5,9 and a non-Takayasu midaortic syndrome is well recognized in children. 24 Seven of our patients had severe cerebrovascular involvement.…”

“…13 It is not always possible to determine which children have cerebral arterial involvement on the basis of the nature or extent of their renal vascular disease. 4,9 Therefore, cerebral perfusion was assessed for all children with singlephoton emission tomography with hexamethylpropyleneamineoxime labeled with technetium-99m; in our experience, this method helpfully identified significant decreases in perfusion associated with major arterial stenosis. Cerebral angiography was performed in selected cases, when clinical signs (such as a cranial bruit) or perfusion study data suggested functionally important arterial pathologic conditions.…”

“…4 Unlike adults, among whom the disease is almost invariably atherosclerotic in nature, 5 children with RVH are more likely to have fibromuscular dysplasia (FMD), 6 with bilateral and segmental disease and involvement of the small intrarenal arteries 4,6-8 and other vascular beds. 8,9 Adequate control of blood pressure (BP) is often impossible despite the use of several antihypertensive agents. Adverse effects of the drugs and problems with compliance are common.…”

Moyamoya: to cut or not to cut is not the only question. A paediatric neurologist’s perspective

“…If renovascular intervention is considered electively, there may be a role for undertaking cerebral revascularization first. Interestingly, it has been observed that blood pressure tends to drop in children without renovascular disease who have undergone surgical revascularization, 18 presumably as the cerebral circulation is no longer so reliant on systemic blood pressure. The importance of maintaining circulating volume during periods of vomiting or diarrhoea and in the postoperative period cannot be overemphasized.…”