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Hypertensive Encephalopathy Clinical Presentation

  • Author: Irawan Susanto, MD, FACP; Chief Editor: Michael R Pinsky, MD, CM, Dr(HC), FCCP, MCCM  more...
 
Updated: Aug 16, 2016
 

History

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.[5]

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.[6] Examples of these symptoms include the following:

  • Cardiovascular symptoms of aortic dissection, congestive heart failure, angina, palpitations, irregular heartbeat, or dyspnea
  • Renal hematuria and acute renal failure
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Physical Examination

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,[7] 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.[8]

Papilledema. Note the swelling of the optic disc, Papilledema. Note the swelling of the optic disc, with blurred margins.
Hypertensive retinopathy. Note the flame-shaped heHypertensive retinopathy. Note the flame-shaped hemorrhages, soft exudates, and early disc blurring.

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
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Complications

Complications of hypertensive encephalopathy result in neurologic deficits from hemorrhage and strokes, which can progress to death. Complications of hypertension include the following:

  • Coma
  • Death
  • Stroke
  • Nephropathy
  • Myocardial ischemia or infarction
  • Nephropathy
  • Retinopathy
  • Peripheral vascular disease
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Contributor Information and Disclosures
Author

Irawan Susanto, MD, FACP Clinical Professor of Medicine, Director of Pulmonary Consultation and Procedures, Divisions of Interventional Pulmonology and Critical Care, University of California, Los Angeles, David Geffen School of Medicine

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

Disclosure: Nothing to disclose.

Chief Editor

Michael R Pinsky, MD, CM, Dr(HC), FCCP, MCCM Professor of Critical Care Medicine, Bioengineering, Cardiovascular Disease, Clinical and Translational Science and Anesthesiology, Vice-Chair of Academic Affairs, Department of Critical Care Medicine, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine

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

Disclosure: Received income in an amount equal to or greater than $250 from: Masimo<br/>Received honoraria from LiDCO Ltd for consulting; Received intellectual property rights from iNTELOMED for board membership; Received honoraria from Edwards Lifesciences for consulting; Received honoraria from Masimo, Inc for board membership.

Additional Contributors

Najia Huda, MD Assistant Professor, Wayne State University School of Medicine; Director of MICU, Division of Pulmonary and Critical Care, Detroit Receiving Hospital

Najia Huda, MD is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Acknowledgements

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.

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 Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

References
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  2. Bales A. Hypertensive crisis. How to tell if it's an emergency or an urgency. Postgrad Med. 1999 May 1. 105(5):119-26, 130. [Medline].

  3. 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. 2004 Oct 12. 110(15):2241-5. [Medline].

  4. Schwartz RB, Jones KM, Kalina P, et al. Hypertensive encephalopathy: findings on CT, MR imaging, and SPECT imaging in 14 cases. AJR Am J Roentgenol. 1992 Aug. 159(2):379-83. [Medline].

  5. Grossman E, Messerli FH. High blood pressure. A side effect of drugs, poisons, and food. Arch Intern Med. 1995 Mar 13. 155(5):450-60. [Medline].

  6. Frohlich E.D. Target organ involvement in hypertension: a realistic promise of prevention and reversal. Med Clin North Am. 2004. 88:1-9. [Medline].

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

  8. Ahmed ME, Walker JM, Beevers DG, Beevers M. Lack of difference between malignant and accelerated hypertension. Br Med J (Clin Res Ed). 1986 Jan 25. 292(6515):235-7. [Medline]. [Full Text].

  9. Lambert CR, Hill JA, Nichols WW, Feldman RL, Pepine CJ. Coronary and systemic hemodynamic effects of nicardipine. Am J Cardiol. 1985 Mar 1. 55(6):652-6. [Medline].

  10. Gavras H, Brunner HB, Vaughan ED, Laragh JH. Angiotensin-sodium interaction in blood pressure maintenance of renal hypertensive and normotensive rats. Science. 1973 Jun 29. 180(4093):1369-71. [Medline].

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Papilledema. Note the swelling of the optic disc, with blurred margins.
Hypertensive retinopathy. Note the flame-shaped hemorrhages, soft exudates, and early disc blurring.
 
 
 
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