Chronic hypertensive encephalopathy

Case contributed by Frank Gaillard
Diagnosis almost certain


A 55 year old woman with obesity, type II diabetes mellitus and poorly controlled hypertension presents with symptoms of depression and psychosis contextualised by a gradual decline in cognitive and occupational function. She does not have a significant past psychiatric history.

Patient Data

Age: 55
Gender: Female

There is diffuse extensive periventricular deep white matter T2 hyperintensity changes, with associated ex vacuo ventriculomegaly and global, symmetrical, supra and infratentorial involutional changes. 

Multiple punctate focus of susceptibility signal loss within the cerebellar hemispheres, pons, thalami and basal ganglia. No regions of restricted diffusion. 
No intra or extra-axial collections. 


Extensive diffuse periventricular white matter change can be attributed to background small vessel ischemic disease, the extent of the changes are disproportionate to the patient's age. Numerous microhemorrhages are in a distribution suggestive of chronic hypertensive encephalopathy (hypertensive microangiopathy) .

Case Discussion

This distribution of microhemorrhages is typical of hypertensive encephalopathy and the location mirrors that of larger hypertensive hemorrhages which are most common in the basal ganglia, pons and cerebellar hemispheres. 

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