What is the management approach for a patient with a hypertensive crisis, profound hyperglycemia, and Wall-Eyed Bilateral Internuclear Ophthalmoplegia (WEBINO) syndrome, suspected of having a Posterior Circulation Infarction (POCI)?

Management of Hypertensive Crisis with Profound Hyperglycemia and WEBINO Syndrome/Posterior Circulation Infarction

Immediate Blood Pressure Management

In this patient with acute posterior circulation stroke (WEBINO/POCI) and hypertensive crisis (BP 256/121 mmHg), blood pressure should NOT be aggressively reduced unless it exceeds 220/120 mmHg, and even then, reduction should be limited to 15% over the first 24 hours to avoid extending the ischemic penumbra. 1

Blood Pressure Targets in Acute Ischemic Stroke

• For acute ischemic stroke with BP >220/120 mmHg: Reduce mean arterial pressure by only 15% within the first hour, then cautiously over 24 hours 2, 3
• For BP <220/120 mmHg in acute stroke: Withhold antihypertensive medications entirely during the acute phase (first 5-7 days) unless there are other compelling indications 1, 2
• Critical pitfall: This patient's BP of 256/121 mmHg exceeds the 220/120 threshold, but aggressive reduction risks catastrophic extension of the brainstem infarct 1

Medication Selection for Blood Pressure Control

Labetalol is the preferred first-line agent for hypertensive emergencies with neurological involvement, as it reduces blood pressure while maintaining cerebral blood flow and does not increase intracranial pressure 2, 3, 4

• Labetalol dosing: Start at 5 mg/hr IV infusion, increase by 2.5 mg/hr every 5-15 minutes to maximum 15 mg/hr 2, 3
• Alternative agent: Nicardipine 5 mg/hr IV, titrate by 2.5 mg/hr every 15 minutes to maximum 15 mg/hr 2, 5
• Avoid: Sodium nitroprusside (increases intracranial pressure), short-acting nifedipine (unpredictable drops), hydralazine (excessive variability) 6, 7, 8

Monitoring Requirements

• ICU admission mandatory for continuous arterial line blood pressure monitoring 1, 2, 3
• Monitor neurological status every 15-30 minutes during titration—any deterioration mandates immediate cessation of BP reduction 1, 2
• Cardiac monitoring for arrhythmias, particularly atrial fibrillation which may be the embolic source 1

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Hyperglycemia Management

Target blood glucose reduction to 140-180 mg/dL (7.8-10 mmol/L) using intravenous insulin, avoiding aggressive normalization which can worsen neurological outcomes. 1

Glycemic Targets and Approach

• Current glucose: 20.4 mmol/L (367 mg/dL) requires treatment but not aggressive normalization 1
• Target range: 140-180 mg/dL (7.8-10 mmol/L) based on stroke-specific evidence 1
• Avoid: Rapid normalization or glucose <140 mg/dL, which increases risk of hypoglycemia and neurological deterioration 1
• Method: IV insulin infusion with hourly glucose monitoring initially, then every 2-4 hours once stable 1

Fluid Management

• Avoid glucose-containing IV solutions during acute stroke phase 1
• Use normal saline for volume resuscitation if needed, as many hypertensive emergencies have underlying volume depletion 2, 9
• Monitor for hypovolemia which can worsen cerebral perfusion 1

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Acute Stroke-Specific Management

Thrombolysis Considerations

This patient is NOT a candidate for IV thrombolysis (rtPA) due to multiple exclusion criteria 1:

• Blood pressure 256/121 mmHg exceeds the 185/110 mmHg threshold for rtPA eligibility 1
• Presentation beyond 3-hour window (symptoms for 2+ days) 1
• Imaging shows old infarcts and small vessel disease, not acute changes 1

Neuroimaging Requirements

• Initial CT/CTA completed appropriately ruled out hemorrhage and acute large vessel occlusion 1
• MRI with diffusion-weighted imaging should be obtained when stable to confirm acute brainstem infarction and assess extent 1
• Repeat imaging if neurological deterioration occurs 1

Antiplatelet Therapy

Aspirin 150-300 mg should be administered within 48 hours of stroke onset once hemorrhage is excluded by imaging 1

• Delay aspirin until BP is controlled below 220/120 mmHg to minimize hemorrhagic transformation risk 1
• Do NOT use anticoagulation (heparin, LMWH) routinely in acute ischemic stroke 1

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Comprehensive Diagnostic Workup

Essential Laboratory Tests

Obtain comprehensive laboratory panel immediately to assess target organ damage and guide management 2:

• Complete blood count: Hemoglobin, platelets (assess for thrombotic microangiopathy) 2
• Metabolic panel: Creatinine, BUN, sodium, potassium (evaluate acute kidney injury) 2
• Hemolysis markers: LDH, haptoglobin (screen for malignant hypertension with microangiopathy) 2
• Urinalysis: Protein, sediment (identify hypertensive nephropathy) 2
• Troponin: Rule out acute coronary syndrome 2
• HbA1c: Confirm chronic hyperglycemia and establish diabetes diagnosis 1

Cardiac Evaluation

• 12-lead ECG: Assess for left ventricular hypertrophy, ischemia, atrial fibrillation 1, 2
• Continuous telemetry: Monitor for paroxysmal atrial fibrillation (potential embolic source) 1
• Echocardiogram: Evaluate for cardioembolic sources, left ventricular function, and hypertensive heart disease 2, 3

Temperature and Fever Management

• Treat fever aggressively with antipyretics (acetaminophen) as hyperthermia worsens stroke outcomes 1, 2
• Monitor temperature every 4 hours 1

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Secondary Prevention and Risk Factor Management

Screening for Secondary Hypertension

20-40% of patients with malignant hypertension have secondary causes requiring specific workup after stabilization 2, 3:

• Renal artery stenosis (renal artery duplex ultrasound or CTA) 2
• Primary aldosteronism (aldosterone-renin ratio) 2
• Pheochromocytoma (plasma metanephrines) 2
• Obstructive sleep apnea (clinical screening) 2

Transition to Oral Antihypertensives

• Begin oral therapy after 24-48 hours of stability 1, 2
• Restart home antihypertensives (if previously prescribed) after first 24 hours if neurologically stable 1
• Target long-term BP: 120-129/<80 mmHg after acute phase resolves 2
• Use combination therapy with RAS blocker, calcium channel blocker, and diuretic 2

Diabetes Management

• Confirm diabetes diagnosis with HbA1c (likely markedly elevated given osmotic symptoms) 1
• Transition to subcutaneous insulin regimen once stable 1
• Diabetes education and outpatient endocrinology follow-up 1

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Critical Pitfalls to Avoid

Blood Pressure Management Errors

• Never normalize BP acutely in stroke patients—chronic hypertension shifts cerebral autoregulation curve rightward, making "normal" BP relatively hypotensive for the brain 2, 3, 9
• Avoid sublingual nifedipine—causes precipitous, uncontrolled BP drops with risk of stroke extension 1
• Do not use sodium nitroprusside in acute stroke—increases intracranial pressure and has cyanide toxicity risk 6, 7, 8

Glucose Management Errors

• Avoid aggressive insulin protocols targeting normoglycemia—increases hypoglycemia risk without benefit 1
• Never allow hypoglycemia (<60 mg/dL)—immediately detrimental to ischemic brain 1
• Do not use glucose-containing IV fluids in acute stroke 1

Monitoring Failures

• Failure to recognize neurological deterioration during BP lowering—requires immediate cessation of antihypertensives 1, 2
• Inadequate glucose monitoring—check hourly initially, then every 2-4 hours 1
• Missing atrial fibrillation—requires extended cardiac monitoring as paroxysmal AF may be embolic source 1

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Prognosis and Long-Term Considerations

Bilateral MLF lesions (WEBINO syndrome) typically have poor functional recovery, with persistent diplopia and gait ataxia being common 2

• 1-year mortality for untreated hypertensive emergencies exceeds 79% 2, 3
• Stroke recurrence risk is highest in first 90 days, requiring aggressive secondary prevention 1
• Vascular risk factor control is paramount—this case demonstrates catastrophic consequences of untreated hypertension and diabetes 2
• Monthly follow-up required until BP controlled and organ damage stabilizes 4