What is the assessment and plan for a patient with severe hypertension, pleuritic chest pain, severe left-sided headache with blurry vision, and progressive right-sided neurological symptoms, including a history of coronary artery disease, deep vein thromboses, and anaphylaxis to iodinated contrast?

Management of Severe Hypertension with Neurological Symptoms, Pleuritic Chest Pain, and Contrast Allergy

Acute Neurological Symptoms with Right-Sided Weakness

This patient requires immediate ICU admission for hypertensive emergency management with a target blood pressure reduction of no more than 25% in the first hour, followed by cautious reduction to 160/100 mmHg over 2-6 hours, using IV labetalol as first-line therapy. 1

Blood Pressure Management in Acute Stroke Setting

• Target BP <185/110 mmHg per stroke protocol given the NIHSS score of 4 and potential stroke presentation, as this threshold is critical if thrombolytic therapy becomes indicated 2
• The 2-day symptom timeline makes the patient outside the standard 3-hour window for rtPA, but blood pressure control remains essential for preventing hemorrhagic transformation 2
• Avoid excessive BP reduction beyond 25% in the first hour, as patients with chronic hypertension have altered cerebral autoregulation and acute normalization can precipitate cerebral, renal, or coronary ischemia 2, 1
• For acute ischemic stroke with BP >220/120 mmHg, reduce mean arterial pressure by 15% within 1 hour 2

Diagnostic Imaging Strategy

• MRI brain without contrast is the priority imaging modality to evaluate for acute infarction, given the contrast allergy and superior sensitivity for early ischemic changes 2
• MRA head and neck can be performed without gadolinium contrast using time-of-flight sequences to assess for vascular occlusion or stenosis 2
• MRV is essential given the severe headache and history of deep vein thromboses, as cerebral venous thrombosis can present with this constellation of symptoms 2
• Transthoracic echocardiogram should be performed to evaluate for cardioembolic source, particularly given the coronary artery disease history 2

Medication Selection for Hypertensive Emergency with Neurological Symptoms

• IV labetalol is the first-line agent for hypertensive emergency with neurological involvement, dosed at 0.25-0.5 mg/kg IV bolus or 2-4 mg/min continuous infusion until goal BP is reached, then 5-20 mg/hr maintenance 1
• Nicardipine is an excellent alternative (5 mg/hr IV, titrating by 2.5 mg/hr every 15 minutes, maximum 15 mg/hr) as it preserves cerebral blood flow and does not increase intracranial pressure 1
• Avoid immediate-release nifedipine, hydralazine, and sodium nitroprusside due to unpredictable effects and potential for precipitous BP drops 1

Monitoring Requirements

• Continuous arterial line monitoring in ICU setting for precise BP control 1
• Neurological assessments every 15 minutes during initial treatment, then every 30 minutes for 6 hours, then hourly until 24 hours 2
• Blood pressure measurements every 15 minutes for the first 2 hours, then every 30 minutes for 6 hours, then hourly 2

Pleuritic Chest Pain with DVT History

Diagnostic Approach for Pulmonary Embolism

• Ventilation-perfusion (V/Q) scan is the preferred imaging modality for evaluating pulmonary embolism given the anaphylactic contrast allergy 2
• D-dimer level should be obtained, though it has limited utility in the acute setting with multiple potential causes of elevation 1
• Compression ultrasonography of bilateral lower extremities to evaluate for acute DVT, which would support anticoagulation even without definitive PE imaging 1
• Confirm presence and location of inferior vena cava filter if history is uncertain, as this affects anticoagulation decisions 1

Anticoagulation Decision-Making

• Defer anticoagulation until neurological imaging excludes hemorrhagic stroke, as the risk of intracranial hemorrhage outweighs PE treatment benefits until this is clarified 2
• If imaging confirms ischemic stroke without hemorrhage and PE is suspected, delay anticoagulation for 24 hours minimum after any potential thrombolytic therapy 2
• If PE is confirmed and stroke is excluded, initiate therapeutic anticoagulation with unfractionated heparin for easier reversibility in this high-risk patient 1

Severe Headache with Visual Disturbances

Cerebral Venous Thrombosis Evaluation

• MRV is the critical diagnostic test given the combination of severe headache, visual symptoms, and history of thrombotic disease 2
• The presence of right-sided neurological deficits with headache significantly increases the probability of cerebral venous thrombosis versus simple hypertensive encephalopathy 2
• Fundoscopic examination should be performed immediately to assess for papilledema, retinal hemorrhages, or cotton wool spots indicating malignant hypertension 2, 1

Hypertensive Encephalopathy Considerations

• The combination of severe headache, visual disturbances, and altered mental status (disorientation noted on exam) suggests possible hypertensive encephalopathy 2
• MRI with FLAIR imaging will demonstrate characteristic posterior reversible encephalopathy syndrome (PRES) if present, showing increased signal intensity in posterior brain regions 2
• CT brain is useful primarily to exclude intracranial hemorrhage but has limited sensitivity for early ischemic changes or PRES 2

Management of Iodinated Contrast Allergy

Alternative Imaging Strategies

• MRI/MRA without gadolinium contrast should be the primary vascular imaging modality, using non-contrast techniques like time-of-flight angiography 2
• V/Q scan for pulmonary embolism evaluation instead of CT pulmonary angiography 2
• Ultrasound-based assessments (echocardiography, lower extremity venous duplex, carotid duplex) should be maximized 2

Premedication Protocol if Contrast Becomes Unavoidable

• If iodinated contrast becomes absolutely necessary for life-saving intervention (e.g., urgent cardiac catheterization), use a different ICM than the one that caused the previous anaphylaxis 3
• Premedication regimen: methylprednisolone 32-40 mg IV 12 hours and 2 hours before procedure, plus diphenhydramine 50 mg IV 1 hour before, plus famotidine 20 mg IV 1 hour before 1, 3
• Rapid desensitization protocol may be considered with progressively incremental doses of the contrast media if time permits 4
• Emergency resuscitation equipment and medications (epinephrine, additional antihistamines, corticosteroids, airway management supplies) must be immediately available 1

Risk Stratification

• History of anaphylaxis to ICM is the strongest risk factor for repeat severe reactions, with breakthrough reactions possible even with premedication 5
• Skin testing to alternative contrast agents may help identify a safer alternative if the procedure can be delayed 6, 5
• Patients with previous severe ICM hypersensitivity show 81.8% skin test positivity, supporting the value of testing when feasible 6

Hyperglycemia Management in Acute Stroke

• Target glucose 140-180 mg/dL using insulin sliding scale, as both hypoglycemia and severe hyperglycemia worsen stroke outcomes 1
• Avoid hypoglycemia, particularly given labetalol use, as beta-blockade may mask hypoglycemic symptoms (tachycardia) 7
• Fingerstick glucose monitoring every 4-6 hours initially, then adjust frequency based on stability 1

Chronic Medication Management

Antiplatelet Therapy

• Hold aspirin and clopidogrel for 24 hours pending neurological imaging results to minimize hemorrhagic transformation risk if stroke is confirmed 2
• If imaging shows ischemic stroke without hemorrhage and patient is not receiving thrombolytics, resume antiplatelet therapy after 24 hours 2
• If hemorrhagic stroke is identified, antiplatelet therapy should be held indefinitely pending neurology consultation 1

Antihypertensive Medications

• Do not resume home antihypertensive medications during acute phase of hypertensive emergency management 1
• After stabilization and transition from IV to oral therapy, initiate combination therapy with RAS blocker, calcium channel blocker, and diuretic targeting long-term BP <130/80 mmHg 1
• Oral labetalol can be initiated at 100 mg twice daily and titrated by 100 mg increments every 2-3 days as needed, with usual maintenance dose 200-400 mg twice daily 7

Critical Pitfalls to Avoid

• Do not treat the blood pressure number alone—the presence or absence of acute target organ damage determines whether this is a true emergency requiring IV therapy versus urgency manageable with oral agents 1
• Do not reduce BP to "normal" acutely—patients with chronic hypertension cannot tolerate rapid normalization due to altered autoregulation 2, 1
• Do not use immediate-release nifedipine—it causes unpredictable precipitous BP drops and reflex tachycardia that can worsen myocardial ischemia 2, 1
• Do not delay neurological imaging to obtain contrast studies—MRI without contrast provides superior information for stroke evaluation 2
• Do not assume transient BP elevation from pain/distress is a hypertensive emergency—many patients normalize when the underlying condition is treated 1
• Do not start anticoagulation before excluding intracranial hemorrhage, even with high PE suspicion 2