Hypertensive Encephalopathy Clinical Presentation

  • Author: Ryan C Chang, MD; Chief Editor: Michael R Pinsky, MD, CM, FCCP, FCCM   more...
 
Updated: Apr 19, 2010
 

History

Most patients have a history of hypertension. Of those without a prior history of hypertension, place emphasis on past medical history, medication list, and medication compliance. Actively seek drug-induced causes.

  • Patients usually have vague neurologic symptoms and may present with symptoms of headache, confusion, visual disturbances, seizures, nausea, and vomiting. Headaches are usually anterior and constant in nature. The onset of symptoms usually occurs over 24-48 hours, with neurologic progression over 24-48 hours.
  • Patients also may present with symptoms resulting from other end organ damage. Examples of these symptoms include the following:
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Physical

A thorough and complete neurologic and funduscopic examination is essential in evaluation of patients.

  • Funduscopic examination: Grade IV retinal changes are associated with hypertensive encephalopathy,[2] including papilledema, hemorrhage, exudates, and cotton-wool spots.
  • Neurologic examination reveals transient and migratory neurological nonfocal deficits ranging from nystagmus to weakness and an altered mental status ranging from confusion to coma.
  • Include careful vascular examination to evaluate for vasculopathy because radiologic examinations might not acutely identify ischemic stroke.
  • Other target organ damage that may be found includes the following:
    • Cardiovascular - S3, elevated neck veins, peripheral edema, murmurs, abdominal pulsations, and diminished pulses
    • Renal - Acute renal failure, pulmonary edema, and peripheral edema
    • Pulmonary - Pulmonary edema, rales, and wheezes
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Causes

The most common cause of hypertensive encephalopathy is abrupt blood pressure elevation in the chronically hypertensive patient. Other conditions predisposing a patient to elevated blood pressure can cause the same clinical situation.

  • Chronic renal parenchymal disease
  • Acute glomerulonephritis
  • Renovascular hypertension
  • Withdrawal from hypertensive agents (eg, clonidine)
  • Encephalitis, meningitis
  • Pheochromocytoma
  • Sympathomimetic agents (eg, cocaine, amphetamines, phencyclidine [PCP], lysergic acid diethylamide [LSD])
  • Eclampsia and preeclampsia
  • Head trauma
  • Collagen vascular disease
  • Autonomic hyperactivity
  • Vasculitis
  • Ingestion of tyramine-containing foods or tricyclic antidepressants in combination with monoamine oxidase inhibitors (MAOIs)
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Contributor Information and Disclosures
Author

Ryan C Chang, MD  Consulting Staff, Department of Internal Medicine, Divisions of Pulmonary and Critical Care, Kaiser Permanente San Francisco

Ryan C Chang, MD is a member of the following medical societies: American College of Chest Physicians and American Thoracic Society

Disclosure: Nothing to disclose.

Coauthor(s)

Irawan Susanto, MD  Director of Pulmonary Consultation and Procedures, Associate Professor, Department of Internal Medicine, Divisions of Pulmonary and Critical Care, University of California at Los Angeles School of Medicine

Irawan Susanto, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Oleh Wasyl Hnatiuk, MD  Program Director, National Capital Consortium, Pulmonary and Critical Care, Walter Reed Army Medical Center; Associate Professor, Department of Medicine, Uniformed Services University of Health Sciences

Oleh Wasyl Hnatiuk, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Timothy D Rice, MD  Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, St Louis University School of Medicine

Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Michael R Pinsky, MD, CM, FCCP, FCCM  Professor of Critical Care Medicine, Bioengineering, Cardiovascular Disease and Anesthesiology, Vice-Chair, Academic Affairs, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center

Michael R Pinsky, MD, CM, FCCP, FCCM is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American Heart Association, American Thoracic Society, Association of University Anesthetists, European Society of Intensive Care Medicine, Shock Society, and Society of Critical Care Medicine

Disclosure: LiDCO Ltd Honoraria Consulting; iNTELOMED Intellectual property rights Board membership; Edwards Lifesciences Honoraria Consulting; Applied Physiology, Ltd Honoraria Consulting; Cheetah Medical Consulting fee Consulting

References

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  2. Amraoui F, van Montfrans GA, van den Born BJ. Value of retinal examination in hypertensive encephalopathy. J Hum Hypertens. Oct 29 2009;[Medline].

  3. Aggarwal M. Hypertensive crisis: hypertensive emergencies and urgencies. Cardiol Clin. 2006;24:135-46. [Medline].

  4. Biousse V, Newman NJ, Chang GY. Brainstem involvement in hypertensive encephalopathy: clinical and radiological findings. Neurology. Nov 9 2004;63(9):1759-60; author reply 1759-60. [Medline].

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  9. Immink RV, van den Born BJ, van Montfrans GA, Koopmans RP, Karemaker JM, van Lieshout JJ. Impaired cerebral autoregulation in patients with malignant hypertension. Circulation. Oct 12 2004;110(15):2241-5. [Medline].

  10. Lip GY, Beevers M, Beevers DG. Complications and survival of 315 patients with malignant-phase hypertension. J Hypertens. Aug 1995;13(8):915-24. [Medline].

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  13. Schilling S, Hartel C, Gehl HB, Sperner J. MRI findings in acute hypertensive encephalopathy. Eur J Neurol. May 2003;10(3):329-30. [Medline].

  14. Smith TM, Nokes SR. Posterior reversible encephalopathy syndrome: an overview. J Ark Med Soc. Dec 2003;100(6):200-2. [Medline].

  15. Strandgaard S, Olesen J, Skinhoj E, Lassen NA. Autoregulation of brain circulation in severe arterial hypertension. Br Med J. Mar 3 1973;1(5852):507-10. [Medline].

  16. Tsou TP, Yen ZS, Fang CC, et al. Hypertensive encephalopathy. J Emerg Med. Jul 2004;27(1):85-6. [Medline].

  17. Tzourio C, Dufouil C, Ducimetiere P, Alperovitch A. Cognitive decline in individuals with high blood pressure: a longitudinal study in the elderly. EVA Study Group. Epidemiology of Vascular Aging. Neurology. Dec 10 1999;53(9):1948-52. [Medline].

  18. Webster J, Petrie JC, Jeffers TA, Lovell HG. Accelerated hypertension--patterns of mortality and clinical factors affecting outcome in treated patients. Q J Med. Aug 1993;86(8):485-93. [Medline].

 
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