Hypertensive encephalopathy, brain bleeding, and its impact in driving

Hypertensive encephalopathy

Acute or subacute disorder caused by serious hypertension (HT), characterized by headache, dulling, confusion, or stupor and seizures.

Neurological disorders are commonly seen with cortical blindness, hemiparesis, and hemisensory deficit, usually with advanced retinopathy.

The treatment consists of a slow but progressive blood pressure reduction, until reaching values closer to the normal ones.

Advice on hypertensive encephalopathy

• With untreated serious refractory or malignant HT, the patient cannot drive.
• The specific treatment with a favorable outcome of the clinical condition will enable the physician to assess the ability of the patient to drive.
• The urgent hypertensive crisis and the hypertensive emergency prevent from driving in the acute episode and also subsequently, until the patient it is properly diagnosed, managed, and stabilized without involvement of visceral injuries reducing his ability to drive.
• While the patient has symptoms and his blood pressure levels are high, he cannot drive.
• If the HT is secondary and symptomatic, until the complete diagnosis is obtained, the risks of the causal disease have been established, and the applied treatment is satisfactory, the patient cannot drive.
• Therefore, symptomatic and/or refractory hypertensive patients will be advised against driving, as these situations hinder driving and increase the risks when driving.
• If the visceral injuries are significant or there is hypertensive encephalopathy data, the patient cannot drive.
• The patient who knows that he is hypertensive and starts to notice symptoms while driving, must par the car in a safe area as soon as possible, turn off the car, get calmed and wait for the symptoms to subside.
• If he does not improve, he will ask for assistance to be transferred to the closest health center and that the physician measures blood pressure, confirms the diagnosis and establishes the adequate treatment.
• The hypertensive patient with symptoms must not drive to the medical center.

Cerebral bleeding

Intracranial bleeding syndromes are vascular disorders caused by bleeding in the brain tissue or in the meningeal, epidural, subdural, or subarachnoid spaces, or in a combination of sites.

Epidural or subdural bleeding are often the result of cranial injuries.

Brain bleeding accounts for 50% of intracranial bleeding and is usually due to the secondary breakage of a vessel by HT, or to ischemia from local thrombus formation.

Hypertensive brain bleeding is usually extensive, single and with a poor outcome.

• Symptoms: Brain bleeding typically starts suddenly with headache, followed by neurological disorders that worsen progressively.
  Significant bleeding causes hemiparesis when located in the hemispheres, and symptoms of cerebellar dysfunction or of the encephalic trunk as conjugated gaze deviation or ophthalmoplegia, when located in the posterior fossa.
  Loss of consciousness is frequent. Nausea, vomiting, delirium, and focal or generalized seizures also often become evident, and they have a high mortality rate.
  In surviving patients, consciousness is recovered, and gradually neurological disorders.
  The smaller bleeding cause focal defects similar to those seen in ischemic stroke, that reflect the localization of the injury.
• Treatment: The treatment is based on the correction of the coagulation disorder, possible urgent neurosurgical evacuation of the hematoma, preventive anticonvulsant treatment, and adequate treatment of hypertension.
  Some degree of impairment usually persists, with mild dysphasia if the affected hemisphere is the dominant, but in many patients there is an advanced recovery, mainly if the affected area is silent.

Advice on brain bleeding

• These are serious clinical conditions, that except for the cases of minor bleeding in brain areas with scant symptomatic impact, usually are disabling for driving.
• The degree of neurological recovery will enable to assess the ability of the patient to drive.
• HT refractory to treatment prevents from driving, as it is the leading cause of brain bleeding.
• Many patients with an advanced recovery can drive again if the cause resulting in brain bleeding is controlled.
• Mild sequels can permit driving, but car adaptations are required to ensure the adequate control of the commands, and for this purpose a medical report with the description of the sequels and their prognosis is essential.
• The increased risk of new bleeding prevents from driving, even if the patient has recovered without symptoms.