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

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, with blurred margins.

View Media Gallery

Hypertensive retinopathy. Note the flame-shaped hemorrhages, soft exudates, and early disc blurring.

View Media Gallery

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

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

Differential Diagnoses

Media Gallery

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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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

Helmi L Lutsep, MD Professor and Vice Chair, Department of Neurology, Oregon Health and Science University School of Medicine; Associate Director, OHSU Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology, American Stroke Association

Disclosure: Medscape Neurology Editorial Advisory Board for: Stroke Adjudication Committee, CREST2; Physician Advisory Board for Coherex Medical; National Leader and Steering Committee Clinical Trial, Bristol Myers Squibb; Abbott Laboratories, advisory group.

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