Death from cerebral hypoperfusion during nitroprusside treatment of acute angiotensin-dependent hypertension.

A 37-year-old woman, while being treated with nitroprusside for acute hypertension due to an intramural renal artery hemorrhage, became blind on the fourth hospital day, comatose on the fifth, and brain dead on the seventh. Postmortem examination of her brain revealed border-zone infarcts in the parietal-occipital regions and cerebrellum of the sort associated with cerebral hypoperfusion due to hypotension. Yet her blood pressure had been lowered judiciously to a mean pressure in the vicinity of 110 to 120 mm Hg, and episodes of hypotension had been avoided. As possible explanations for this unusual complication, the roles of acute hyperangiotensinemia and nitroprusside administration are discussed.