PSAT026 A Treatable but Commonly Missed Etiology of Cerebrovascular Disease in Younger Adults: A Case of Primary Hyperaldosteronism Presented with Hemorrhagic Stroke
Authors: Faya Marines , Tuna Kubra , Ngo Thu , Abdelmasih Randa , Torres Humberto , Reed Justin 
Published: November 2022

Abstract

Introduction
Primary hyperaldosteronism is the leading cause of secondary hypertension. Although PH is an independent risk factor for acute stroke, it seems to be underdiagnosed as a cause of hypertensive emergencies. Here we discuss a case of a patient who presented with hypertensive emergency and stroke-like symptoms, eventually found to have hyperaldosteronism.

Case Presentation
A case of a 46-year-old male with a past medical history of uncontrolled hypertension and hypokalemia was admitted for acute onset of left-sided numbness and weakness associated with slurred speech. On admission, blood pressure was 292/156mmHg; physical exam revealed flaccid paralysis on the left upper and lower extremities, decreased sensation to light touch, and pinprick in the left side of the body. Initial potassium was 2.2mmol/L. CT scan of the brain revealed intracranial hematoma in the right basal ganglia, which brain MRI confirmed. The patient was first started on strict blood pressure control with IV medications and transitioned to oral antihypertensive and potassium supplementation. Given resistant hypokalemia, plasma renin activity and serum aldosterone levels were ordered and revealed to be 0.771ng/mL/hr. and 24.4ng/dL with a ratio &gt;20 (31.26). The patient was started on spironolactone, and CT abdomen and pelvis with contrast revealed a 1.8cm nodule of the left adrenal. The patient's blood pressure and electrolyte abnormalities improved. Further evaluation with adrenal vein sampling to localize the functional adrenal tumor and possible surgery deferred until his neurological deficits improve.

Discussion
This case report emphasizes the consequences of primary hyperaldosteronism given that the aldosterone excess has detrimental cardiovascular and cerebrovascular effects that are in part independent of high blood pressure. Early detection of a disease that was previously believed to be rare has an essential impact on clinical outcomes and survival, especially in the younger population. Studies have shown that the overall risk of stroke was almost three times higher than that of patients with essential hypertension. Despite this elevated risk, the most significant problem in underdiagnosis is that the screening test is often not even performed. Screening guidelines for primary hyperaldosteronism consist of serum aldosterone/renin ratio; only done when there is suspicion of a secondary hypertension causes. The diagnosis of PH should not only rest on endocrinologists but also on primary care providers, who are initially the point of contact when hypertension is first detected.

Conclusion
PH is an identified risk factor for CVA; however, its diagnosis can be challenging if the CVA is the initial feature. This case sheds light on considering PH among the differential diagnosis when facing younger patients presenting with CVA in the setting of persistent hypertension and hypokalemia. Once diagnosed and adequately treated, it decreases the risk of CVA and avoids further complications.
Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.