Hypertensive Encephalopathy Case File

https://medical-phd.blogspot.com/2021/05/hypertensive-encephalopathy-case-file.html

Eugene C. Toy, MD, Barry C. Simon, MD, Terrence H. Liu, MD, MHP, Katrin Y. Takenaka, MD,
Adam J. Rosh, MD, MS

Case 17
A 55-year-old man is brought in to the emergency department (ED) by his wife for altered mental
status (AMS). She states that for the past day, he has been confused and unsteady when he walks.
The patient has a history of hypertension (HTN) and hyperlipidemia. He complains of headache
and blurry vision. On examination, he is alert and oriented to person only. On fundoscopy, the optic
discs appear hyperemic and swollen, with a loss of sharp margins. His neurologic examination is
nonfocal and otherwise has a normal physical examination. The patient’s vital signs are a blood
pressure of 245/140 mm Hg, heart rate of 95 beats per minute, respiratory rate of 18 breaths per
minute, oxygen saturation of 98% on room air and he is afebrile.

⯈ What is the most likely diagnosis?

⯈ What is the best management?

ANSWER TO CASE 17:

Hypertensive Encephalopathy

Summary: 55-year-old man with a history of hypertension that presents with AMS, headache, and
blurry vision with a blood pressure of 245/140 mm Hg. His physical examination is significant for
bilateral papilledema and AMS.

 Most likely diagnosis: Hypertensive encephalopathy.

 Best management: Confirm the diagnosis by ruling out ischemic or hemorrhagic stroke,
infection, and mass lesion. Lower blood pressure with intravenous (IV) medications and
check for evidence of other end-organ damage.

ANALYSIS
Objectives

1. Identify the presentation of various hypertensive emergencies.

2. Recognize the difference between a hypertensive urgency and emergency.
3. Understand how to manage blood pressure in hypertensive emergencies.

This is a 55-year-old man with AMS, papilledema, and severe hypertension. This presentation is
most likely hypertensive encephalopathy, which is defined as the presence of neurologic
abnormalities secondary to acute elevation in blood pressure. In the past, hypertensive
encephalopathy and malignant hypertension have been used interchangeably. The latter term,
however, was removed from the national blood pressure guidelines. Hypertensive encephalopathy
is one of many forms of hypertensive emergency. It is critical for the physician to manage the
patient’s blood pressure if there is evidence of end-organ dysfunction. This is in contrast to blood
pressure management in hypertensive urgency.

Once the patient’s airway, breathing, and circulation (ABCs) are addressed, the first step in
management is to obtain a noncontrast head computed tomography (NCHCT) to rule out the
presence of mass lesion and hemorrhagic or ischemic stroke. Once these diagnoses are eliminated
and the diagnosis of hypertensive encephalopathy is established, the focus should turn to lowering
the blood pressure. Intravenous antihypertensives should be administered to lower
the patient’s blood pressure. The goal is not to normalize the blood pressure because this can
lead to cerebral ischemia secondary to hypoperfusion. Instead, the goal is to reduce the MAP by
20% to 25% over the first hour. Various antihypertensive agents are available to manage this
disorder. This is in contrast to typical blood pressure management in patients with long-standing
hypertension who do not have acute end-organ damage. Sodium nitroprusside, labetalol, and
nicardipine are the first-line agents for lowering blood pressure in the setting of hypertensive
encephalopathy. Sodium nitroprusside is administered as an IV infusion starting at a rate of 0.25
μg/kg/min and can be increased to a maximum of 10 μg/ kg/min. Labetalol is administered as an IV
bolus of 20 mg, which can be repeated. It can also be administered as an IV infusion at a rate of 0.5
to 2.0 mg/min. Nicardipine is administered at 5 mg/h, and can be increased by 2.5 mg/h every 5
minutes to a maximum of 30 mg/h.

Approach To:
Hypertensive Emergencies

DEFINITIONS
HYPERTENSION: Defined as blood pressure greater than or equal to 140/90 mm Hg.

HYPERTENSIVE EMERGENCY: The presence of acute end-organ damage in the setting of

elevated blood pressure.

HYPERTENSIVE URGENCY: The presence of elevated blood pressure, without evidence of

acute, ongoing end-organ damage. It requires urgent, but not emergent, blood pressure reduction.

HYPERTENSIVE ENCEPHALOPATHY: Transient neurologic symptoms associated with

elevated blood pressure.

PREECLAMPSIA: Elevated blood pressure (140 mm Hg systolic or 90 mm Hg diastolic) in a

pregnant patient accompanied by proteinuria, edema, or both occurring after 20 weeks of gestation.
Preeclampsia in a patient with preexisting essential hypertension is diagnosed if systolic BP has
increased by 30 mm Hg or if diastolic BP has increased by 15 mm Hg.

SEVERE PREECLAMPSIA: Severe hypertension, excess proteinuria, oliguria, cerebral or visual

disturbances, pulmonary edema, impaired liver function, epigastric or right upper quadrant pain,
thrombocytopenia or fetal growth restriction.
ECLAMPSIA: Seizure activity or coma unrelated to other cerebral conditions in a pregnant patient
with preeclampsia.