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Kidney Week

Abstract: PO2100

Rostral Ventrolateral Medullary Compression: A Rare but a Cardinal Cause of Refractory Hypertension (RfHTN)

Session Information

Category: Trainee Case Report

  • 1402 Hypertension and CVD: Clinical, Outcomes, and Trials


  • Sarkar, Mrinalini, University of California Los Angeles, Los Angeles, California, United States
  • Nicholas, Susanne B., University of California Los Angeles, Los Angeles, California, United States

RfHTN is defined as uncontrolled HTN with BP >140/90 mmHg despite ≥5 different classes of maximally tolerated antihypertensive agents, including a diuretic and a mineralocorticoid receptor antagonist. RfHTN may be underdiagnosed.

Case Description

A 43-year-old female with a history of mitral valve prolapse, iron deficiency anemia, mild asthma and migraines presented for management of uncontrolled severe HTN. Her HTN became increasingly resistant following use of pheniramine and fenfluramine for two years and a recent hysterectomy, with persistently elevated blood pressure (BP) up to 250/100 mmHg. Her medications included: hydralazine, lopressor, procardia, demadex, accupril, diovan, catapres and aldactone.
On physical exam, her BP was 230/136 mmHg with regular pulse of 96 beats/min and no papilledema or bruits. Renal function and aldosterone levels were normal. Renal ultrasound/doppler, captopril scan, and angiograms showed no renal artery stenosis or coactation of the aorta, and 24-hour urine metanephrines were normal. Her echocardiogram showed concentric left ventricular hypertrophy with ejection fraction of 60%. Minoxidil was initiated and procardia and lopressor were maintained, with no effect on BP.
A high-resolution brain MRI with spectroscopy showed a venous angioma in the right superior temporal lobe and CT angiogram showed irregularity of the basilar artery with outpouching at the left posterior communicating artery and right anterior choroidal artery. She was diagnosed with neurogenic arterial HTN from neurovascular compression (NVC) of the rostral ventrolateral (RVL) medulla. Left retro sigmoid craniotomy was performed for NVC decompression, but aborted eight hours later for fear of precipitating a massive stroke. The patient continues to have RfHTN despite maximal medical therapy and has now developed complications including a cervical ICA dissection, CKD stage 3, heart failure, and severe valvular disease.


NVC is related to neurogenic HTN when occurring in the RVL medulla. This case highlights that brain MRI be performed in patients with intractable resistant HTN when all other secondary causes are ruled out.