Differential Diagnosis for Malignant Hypertensive Urgency with Neurological Symptoms

The patient's presentation of malignant hypertensive urgency, blurred vision, tingling in both upper extremities, headache, and slight left side weakness, along with negative CT Head and CT Angiogram Head/Neck for stroke, suggests a complex clinical picture. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • Hypertensive Encephalopathy: This condition is characterized by elevated blood pressure leading to cerebral edema, which can cause symptoms such as headache, vision changes, and even focal neurological deficits like weakness. The absence of stroke on imaging supports this diagnosis, as it is a direct consequence of severely elevated blood pressure.

• Other Likely Diagnoses

  • Posterior Reversible Encephalopathy Syndrome (PRES): Although the CT scans were negative, PRES, which is associated with hypertension, can sometimes be missed on initial CT scans. It typically presents with headache, vision changes, and can have focal neurological signs.
  • Reversible Cerebral Vasoconstriction Syndrome (RCVS): This condition involves constriction of cerebral arteries and can present with thunderclap headache and sometimes focal neurological deficits. It's often associated with hypertension and can be a consideration given the patient's symptoms.

• Do Not Miss Diagnoses

  • Subarachnoid Hemorrhage (SAH): Although the CT Head was negative, it's crucial to consider SAH, especially if the patient's symptoms suggest a sudden, severe headache. A lumbar puncture might be necessary to rule out SAH, as it can be life-threatening if missed.
  • Aortic Dissection: Given the patient's malignant hypertension, an aortic dissection could present with a variety of symptoms, including neurological deficits if the dissection involves the carotid arteries. This is a medical emergency that requires immediate attention.
  • Cervical Artery Dissection: Similar to aortic dissection, dissection of the cervical arteries can lead to stroke or transient ischemic attack (TIA) symptoms and is a critical diagnosis not to miss.

• Rare Diagnoses

  • Eclampsia: If the patient is pregnant, eclampsia could be a consideration, characterized by new-onset seizures in a pregnant woman with pre-eclampsia. However, the absence of mention of pregnancy makes this less likely.
  • Cerebral Vasculitis: This is an inflammation of the blood vessels in the brain and can present with a wide range of neurological symptoms. It's rare and would typically require further diagnostic testing, such as MRI and angiography, to consider.
  • Mitochondrial Encephalopathy, Lactic Acidosis, and Stroke-like episodes (MELAS): A rare mitochondrial disorder that can cause stroke-like episodes, especially in younger patients. The presentation can be varied and includes headaches, seizures, and focal neurological deficits.