What is the best course of management for a 47-year-old male with worsening headaches, double vision, neck tightness, and facial tingling, who has a history of hypertension, smokes, and consumes alcohol, and presents with hypertension and tachycardia?

Management of Suspected Intracranial Hypertension with Vascular Abnormality

This patient requires urgent neuroimaging with MRI/MRA or CTA to evaluate the 5mm vascular abnormality at the Circle of Willis, immediate blood pressure control with a target below 140/90 mmHg, and ophthalmologic evaluation for papilledema given the constellation of progressive headaches, diplopia, and facial symptoms. 1

Immediate Diagnostic Priorities

Neuroimaging

• MRI with MRA or CTA is essential to fully characterize the 5mm vascular abnormality at the proximal Circle of Willis, which could represent an aneurysm, vascular malformation, or stenosis 1
• The imaging should specifically evaluate for:
  • Intracranial aneurysm (given the location and patient's risk factors) 1
  • Signs of elevated intracranial pressure including empty sella, optic nerve sheath enlargement, flattened posterior globe, and venous sinus stenosis 1
  • Evidence of posterior reversible encephalopathy syndrome (PRES) or hypertensive encephalopathy, particularly in posterior brain regions 1, 2
  • Exclusion of intracranial hemorrhage 1

Ophthalmologic Examination

• Urgent fundoscopic examination is mandatory to assess for papilledema, which would indicate elevated intracranial pressure 1
• Look specifically for flame-shaped hemorrhages, cotton wool spots, or papilledema that would define malignant hypertension 1
• The diplopia (double vision) requires evaluation for sixth nerve palsy, which can occur with elevated intracranial pressure or cavernous sinus pathology 1

Additional Cranial Nerve Assessment

• The facial tingling involving one side suggests trigeminal nerve (V1) involvement, which can occur with cavernous sinus lesions, vascular compression, or elevated intracranial pressure 1
• Examine for other cranial neuropathies, particularly III, IV, and VI nerve palsies 1

Blood Pressure Management

Acute Control

• Antihypertensive treatment should target blood pressure below 140/90 mmHg 1
• The rate of BP reduction matters more than the absolute value—avoid precipitous drops that could worsen cerebral ischemia 1
• Given the patient's medication non-adherence with losartan, restart this medication immediately while evaluating for secondary causes 1

Caution with Hypertensive Encephalopathy

• If neuroimaging confirms hypertensive encephalopathy or PRES, BP should be lowered gradually (not more than 25% in the first hour) to prevent cerebral hypoperfusion 1, 2
• The posterior brain regions, including areas near the Circle of Willis, are particularly vulnerable to hypertensive damage due to less effective sympathetic innervation 1, 2

Evaluation for Elevated Intracranial Pressure

Clinical Indicators Present

This patient has multiple features suggesting possible idiopathic intracranial hypertension (IIH) or secondary intracranial hypertension:

• Progressive headaches worse with noise (pressure-type) 1
• Diplopia (suggesting sixth nerve palsy from elevated ICP) 1
• Neck tightness 1
• Facial paresthesias 1

Diagnostic Testing

• If papilledema is present on fundoscopy, lumbar puncture with opening pressure measurement is indicated after neuroimaging excludes mass lesion 1
• Laboratory evaluation should include:
  • Complete blood count (to assess for thrombocytopenia in thrombotic microangiopathy) 1
  • Creatinine and electrolytes (hypertensive nephropathy) 1
  • Urinalysis for protein and sediment 1

Management of the Vascular Abnormality

If Aneurysm is Confirmed

• Neurosurgical consultation is urgent for a 5mm aneurysm at the Circle of Willis, particularly given the patient's uncontrolled hypertension and symptoms 1
• The combination of headache, cranial nerve symptoms, and neck pain with a vascular abnormality raises concern for aneurysmal expansion or sentinel leak 1

If Venous Sinus Stenosis is Found

• Venous sinus stenosis can cause elevated intracranial pressure and may be seen on vascular imaging 1
• Neurovascular stenting is not established for treatment but may be considered in specialized centers for refractory cases with visual loss 1

Risk Factor Modification

Essential Interventions

• Smoking cessation is critical—the patient's half-pack daily habit significantly increases stroke risk and atherosclerosis progression 1
• Alcohol reduction—three beers nightly exceeds recommended limits and can worsen hypertension 1
• Statin therapy should be initiated to reduce LDL cholesterol below 100 mg/dL given extracranial vascular disease risk 1
• Antiplatelet therapy with aspirin 75-325 mg daily should be considered given vascular risk factors 1

Common Pitfalls to Avoid

• Do not attribute all symptoms to "just hypertension" without excluding structural lesions—the vascular abnormality and progressive nature demand full evaluation 1
• Do not perform lumbar puncture before neuroimaging in a patient with focal neurological signs and possible mass effect 1
• Do not overlook sixth nerve palsy as a sign of elevated ICP—bilateral sixth nerve palsy is particularly concerning for raised intracranial pressure 1
• Do not aggressively lower BP if hypertensive encephalopathy is present without careful monitoring, as this can worsen cerebral perfusion 1

Follow-up Based on Findings

If Papilledema is Present

• Follow-up intervals depend on severity: severe papilledema with visual field defects requires evaluation within 1 week 1
• Moderate papilledema with stable vision requires follow-up within 1-3 months 1

If Vascular Intervention is Needed

• Neurosurgical or neurointerventional management takes precedence 1
• Long-term antithrombotic therapy may be required if stenting is performed 1