What are the neurological symptoms of a hypertensive emergency?

From the Guidelines

Neurological symptoms of hypertensive emergency include headache, visual disturbances, dizziness, and other neurological deficits, which can progress to somnolence, lethargy, tonic–clonic seizures, and cortical blindness if left untreated. These symptoms occur due to severely elevated blood pressure causing cerebral edema, hypertensive encephalopathy, or cerebral hemorrhage [ 1 ]. According to the 2024 ESC guidelines for the management of elevated blood pressure and hypertension, hypertensive emergency is defined as BP of ≥180/110 mmHg associated with acute organ damage, often in the presence of symptoms [ 1 ].

Key Neurological Symptoms

• Headache
• Visual disturbances
• Dizziness
• Somnolence
• Lethargy
• Tonic–clonic seizures
• Cortical blindness
• Focal neurological deficits are rare and should raise the suspicion of stroke [ 1 ]

The management of hypertensive emergencies requires immediate and careful intervention to reduce BP, often with i.v. therapy [ 1 ]. Treatment should aim to reduce blood pressure in a controlled manner, typically by 25% within the first hour, using intravenous medications like labetalol, nicardipine, or clevidipine in an intensive care setting. Overly rapid reduction must be avoided as it can lead to cerebral hypoperfusion and ischemia. The neurological symptoms occur because extreme hypertension overwhelms the brain's autoregulatory mechanisms, causing increased cerebral blood flow, disruption of the blood-brain barrier, and vasogenic edema.

Management Principles

• Immediate and careful intervention to reduce BP
• Use of i.v. therapy
• Reduction of blood pressure by 25% within the first hour
• Use of intravenous medications like labetalol, nicardipine, or clevidipine
• Avoidance of overly rapid reduction to prevent cerebral hypoperfusion and ischemia [ 1 ]

From the FDA Drug Label

Advise patients to contact a healthcare professional immediately for any of the following signs of a new hypertensive emergency: neurological symptoms, visual changes, or evidence of congestive heart failure. The neurological symptoms of a hypertensive emergency are not explicitly defined in the drug label, but it is mentioned that patients should seek immediate medical attention if they experience any neurological symptoms.

• The label does not provide a detailed list of neurological symptoms associated with hypertensive emergency.
• Patients are advised to contact a healthcare professional immediately if they experience any signs of a new hypertensive emergency, including neurological symptoms 2, 2.

From the Research

Neurological Symptoms of Hypertensive Emergency

The neurological symptoms of hypertensive emergency can be severe and potentially life-threatening. Some of the key symptoms and considerations include:

• Acute target-organ damage, including neurologic injury 3
• Cerebral hypoperfusion, which can cause vague and subtle early symptoms and signs 4
• Increased intracranial pressure (ICP), which requires careful monitoring and management 5, 4
• Risk of cerebral hypotensive episodes secondary to impaired cerebral circulation 5

Management of Neurological Symptoms

The management of neurological symptoms in hypertensive emergency requires careful consideration of the underlying pathophysiology and the potential risks and benefits of different treatments. Some key considerations include:

• The use of intravenous antihypertensive agents, such as sodium nitroprusside, nitroglycerin, and labetalol, which can help to rapidly lower blood pressure and reduce the risk of neurological damage 3, 6, 5, 4
• The importance of vigilant neurologic monitoring to detect early signs of cerebral hypoperfusion and other neurological complications 4
• The need to avoid acute reductions in mean arterial pressure (MAP) of more than 20% whenever possible, and to make subsequent reductions gradual 4
• The potential benefits of using specific agents, such as trimethaphan, in patients with elevated ICP or cerebral dysfunction 4

Treatment Options

Some of the treatment options for hypertensive emergency with neurological symptoms include:

• Sodium nitroprusside, which is a potent antihypertensive agent but requires careful monitoring due to its potential toxicity 3, 6, 5, 4
• Nitroglycerin, which is the agent of choice for acute ischemic heart disease complicated by severe hypertension 4
• Labetalol, which can be used in some cases but is not suitable for general use in hypertensive emergencies 4
• Nicardipine, which is a potent arteriolar vasodilator but should be used with caution in patients with severe aortic stenosis 5
• Esmolol, which is an alternative to IV propranolol for the treatment of aortic dissection, but should be used with caution due to its potential negative inotropic effect 5, 4