Neurological Review of Systems for Hypertensive Patients
For a patient with hypertension, your neurological ROS should specifically screen for symptoms of hypertensive encephalopathy, stroke, and cognitive impairment, as these represent the most critical hypertension-mediated organ damage affecting the brain.
Essential Neurological Symptoms to Screen
Acute Hypertensive Emergency Symptoms
- Headache - particularly severe, bifrontal, or occipital headaches that may indicate hypertensive encephalopathy or intracranial pathology 1, 2
- Visual disturbances - including diplopia, blurred vision, cortical blindness, or transient vision loss, which are recognized neurological symptoms of hypertensive encephalopathy and intracranial hypertension 1, 2, 3
- Altered mental status - confusion, lethargy, somnolence, or decreased verbal output, as these represent early neurological features that can progress to seizures and coma if untreated 1, 2, 4
- Seizures - tonic-clonic seizures may occur in hypertensive encephalopathy 1, 3
- Focal neurological deficits - weakness, numbness, speech difficulties (expressive or receptive aphasia), or motor dysfunction, which should raise immediate suspicion for stroke rather than uncomplicated hypertensive encephalopathy 1, 4
Chronic Hypertensive Brain Damage Symptoms
- Memory impairment - difficulty with short-term memory recall or word-finding, as hypertension significantly increases risk of both vascular cognitive impairment and Alzheimer's disease 5, 6, 7
- Cognitive decline - problems with concentration, executive function, or processing speed, which may indicate cerebral small vessel disease 6, 8, 7
- Gait disturbances - unsteadiness or balance problems that may reflect white matter disease or prior lacunar infarcts 6
- Dizziness - episodic or persistent, particularly if associated with BP lability 1
Symptoms Suggesting Secondary Hypertension
- Episodic symptoms - pallor, palpitations, and dizziness occurring together suggest pheochromocytoma 1
- Snoring and hypersomnolence - indicating obstructive sleep apnea as a secondary cause 1
Critical Clinical Context
The presence of ANY neurological symptom—not the absolute BP value—defines a hypertensive emergency requiring immediate intervention 1, 2, 5. Hypertensive encephalopathy occurs in 10-15% of patients with malignant hypertension, and focal neurological lesions are rare in pure hypertensive encephalopathy; their presence should immediately raise suspicion for intracranial hemorrhage or ischemic stroke 1, 2, 4.
Common Pitfalls to Avoid
- Do not dismiss subtle symptoms like transient memory issues or diplopia as "benign" in the setting of elevated BP, as these represent neurological symptoms significantly increasing likelihood of intracranial pathology 2, 5
- Do not rely solely on absence of focal deficits to exclude hypertensive encephalopathy, PRES, or early stroke 2, 4
- Do not assume all neurological symptoms are from hypertensive encephalopathy - focal findings warrant immediate neuroimaging to exclude hemorrhage or ischemic stroke, which require different BP management strategies 1, 4
Physical Examination Components
Beyond the ROS, your neurological examination should include 1:
- Fundoscopy - to identify papilledema, flame hemorrhages, cotton wool spots, or Grade III/IV hypertensive retinopathy, though advanced retinopathy may be absent in up to one-third of hypertensive encephalopathy cases 1, 2, 5
- Focused neurological exam - assessing mental status, cranial nerves, motor strength, sensory function, coordination, and gait 1
- Cognitive screening - particularly in elderly hypertensives to detect initial brain deterioration 1
Prognostic Significance
Chronic hypertension increases stroke risk three- to fivefold and is a major risk factor for cognitive impairment and dementia through cerebral small vessel disease, white matter disease, cerebral microbleeds, and cerebral atrophy 6, 8, 7. Without treatment, hypertensive emergencies have a 1-year mortality rate >79% with median survival of only 10.4 months 2, 5.