What is the best course of management for a hypertensive patient with decreased sensorium, initial weakness, and subsequent improvement, with a negative computed tomography (CT) scan?

Management of Hypertensive Patient with Transient Neurological Symptoms and Negative CT

This patient requires urgent MRI brain with and without contrast to exclude acute ischemic stroke, hypertensive encephalopathy, or other occult pathology, as CT misses the majority of small vessel disease and early posterior circulation events that present with transient weakness and altered sensorium. 1

Immediate Diagnostic Priorities

Why CT is Insufficient in This Clinical Scenario

• CT has severe limitations in detecting subtle pathology causing neurological symptoms in hypertensive patients, missing 70% of ischemic strokes that present with altered mental status 1
• Small vessel disease, microinfarcts, and early hypertensive encephalopathy are frequently invisible on CT but readily apparent on MRI with diffusion-weighted imaging (DWI) and FLAIR sequences 1, 2
• MRI changed clinical management in 76% of patients with altered mental status, including revised diagnoses and levels of care 1

Specific MRI Protocol Required

• Order MRI brain without and with IV contrast to definitively characterize focal lesions and evaluate for tumor, infection, inflammatory conditions, or vascular abnormalities 1
• The contrast component is essential because transient symptoms with improvement could represent an underlying mass lesion, metastases, or inflammatory pathology requiring contrast enhancement for detection 1
• DWI/FLAIR sequences detect acute ischemia with 95% sensitivity and identify posterior reversible encephalopathy syndrome (PRES), which commonly affects hypertensive patients 2

Critical Differential Diagnoses to Exclude

Acute Ischemic Stroke

• Transient improvement does not exclude stroke, as fluctuating symptoms occur with evolving infarction or transient ischemic attack 2
• Posterior circulation strokes frequently present with altered sensorium and weakness, are often missed on CT, and require MRI for detection 1, 2

Hypertensive Encephalopathy/PRES

• When blood pressure is markedly elevated and cerebral autoregulation fails, cerebral edema develops especially in posterior brain regions where sympathetic innervation is less pronounced 3, 4
• Clinical features include altered sensorium, headache, visual disturbances, and focal neurological deficits that may fluctuate 3
• MRI with FLAIR imaging shows characteristic increased signal intensity in posterior regions, which is fully reversible with timely recognition and blood pressure management 3, 4

Subcortical Small Vessel Disease

• Hypertension causes narrowing and sclerosis of small penetrating arteries leading to subcortical white matter demyelination and microinfarction 1, 4
• These lesions directly correlate with cognitive impairment and neurological symptoms but are invisible on CT 1

Blood Pressure Management Strategy

Do NOT Lower Blood Pressure Acutely Until Stroke is Excluded

• Blood pressure should not be lowered unless >220/120 mmHg in the setting of potential acute ischemic stroke, as cerebral perfusion depends on systemic pressure when autoregulation is impaired 2
• Hold all antihypertensive medications until MRI excludes stroke 2
• If stroke is confirmed and BP remains <220/120 mmHg, continue withholding BP medications for 5-7 days 2

If Hypertensive Emergency is Confirmed (After Imaging)

• Hypertensive emergency requires BP ≥180/110 mmHg with acute target organ damage and warrants immediate, controlled reduction using IV titratable agents in an intensive care setting 3, 5
• Preferred IV agents include labetalol, nicardipine, or clevidipine; avoid hydralazine, immediate-release nifedipine, and use sodium nitroprusside with extreme caution due to toxicity 5

Essential Diagnostic Workup

Laboratory Evaluation

• Complete blood count, comprehensive metabolic panel to assess renal function and electrolytes 3, 2
• Troponin and BNP/NT-proBNP to evaluate cardiac involvement 2
• LDH, haptoglobin, and peripheral blood smear to assess for thrombotic microangiopathy if platelet count is low 3
• Urinalysis with microscopy for proteinuria, hematuria, and casts indicating hypertensive nephropathy 3

Additional Imaging and Testing

• 12-lead ECG to assess for left ventricular hypertrophy, ischemia, or arrhythmia 2
• Chest X-ray if respiratory symptoms are present 2
• Fundoscopic examination for grade III/IV retinopathy (hemorrhages, exudates, papilledema), which indicates severe hypertensive emergency with high mortality risk 3

Common Pitfalls to Avoid

Do Not Dismiss Negative CT as Ruling Out Pathology

• A negative CT does NOT exclude significant pathology in a hypertensive patient with neurological symptoms, as CT misses the majority of small vessel disease and early hypertensive encephalopathy 1

Do Not Assume Improvement Means Resolution

• Transient improvement followed by deterioration is characteristic of evolving stroke, fluctuating hypertensive encephalopathy, or progressive small vessel disease 1, 2
• Progressive symptoms in a hypertensive patient suggest evolving vascular cognitive impairment requiring MRI characterization 1

Do Not Delay MRI for Metabolic Workup

• Structural lesions requiring urgent intervention must be excluded first before attributing symptoms to metabolic causes 1

Long-Term Management After Acute Phase

Once Acute Pathology is Excluded or Treated

• Initiate or optimize antihypertensive therapy with first-line agents: ACE inhibitor or ARB combined with calcium channel blocker or thiazide diuretic, preferably as fixed-dose combination 3, 6
• Target blood pressure <130/80 mmHg in most adults <65 years, and systolic <130 mmHg in adults ≥65 years 3, 6
• Lifestyle modifications including sodium restriction, weight loss, physical activity, and alcohol moderation enhance pharmacologic efficacy 3, 6

Follow-Up Imaging

• Repeat MRI in 3-6 months if initial MRI shows white matter changes or microinfarcts to assess progression and guide intensification of vascular risk factor management 3, 1