Hypertensive Encephalopathy Clinical Presentation
- Author: Irawan Susanto, MD, FACP; Chief Editor: Michael R Pinsky, MD, CM, Dr(HC), FCCP, MCCM more...
Most patients with hypertensive encephalopathy have a history of hypertension. In patients who do not have a prior history of hypertension, place emphasis on the past medical history, the medication list, and medication compliance. Actively seek drug-induced causes, for example, sympathomimetic agents and illicit drugs such as cocaine.
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:
- Renal hematuria and acute renal failure
A thorough and complete neurologic and ophthalmoscopic (funduscopic) examination is essential in the evaluation of patients. On ophthalmoscopy, grade IV retinal changes are associated with hypertensive encephalopathy, including papilledema, hemorrhage, exudates, and cotton-wool spots (see the images below). Although papilledema is usually considered a more severe finding, it actually does not confer worse survival than hemorrhages and exudates alone.
Neurologic examination reveals transient and migratory neurologic nonfocal deficits ranging from nystagmus to weakness and an altered mental status ranging from confusion to coma.
In addition, include a careful vascular examination to evaluate for vasculopathy; 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
Complications of hypertensive encephalopathy result in neurologic deficits from hemorrhage and strokes, which can progress to death. Complications of hypertension include the following:
- Myocardial ischemia or infarction
- Peripheral vascular disease
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