Hypertensive Encephalopathy

Key considerations: Ischemic stroke (do not lower BP aggressively), Hemorrhagic stroke, PRES (posterior reversible encephalopathy syndrome)

Cannot miss

history: Headache, visual changes, confusion, seizure history, pregnancy, medication non-compliance, stimulant use; exam: BP in both arms, fundoscopy (papilledema, flame hemorrhages), neurologic exam, mental status; labs: BMP, CBC, UA (proteinuria, hematuria), urine pregnancy test, LDH, haptoglobin (TTP workup if indicated); imaging: Head CT (hemorrhage, edema); MRI brain (PRES: occipital/parietal white matter changes); bedside: Continuous BP monitoring, ECG (LVH, strain), fundoscopy

immediate: IV antihypertensive: reduce MAP by no more than 25% in first hour, then gradual reduction over 24-48 hours; Nicardipine 5mg/hr IV titrate, or labetalol 10-20mg IV boluses, or clevidipine; general: Avoid nitroprusside (cyanide toxicity with prolonged use); Seizure management with benzodiazepines; Treat underlying cause; Avoid overly aggressive BP reduction (watershed ischemia risk)

admit: ICU admission, continuous BP monitoring, neurology consult; discharge: Never acutely; consults: Neurology, nephrology if renal involvement, OB if eclampsia

Do NOT aggressively lower BP in acute ischemic stroke — autoregulatory curve is shifted right in chronic hypertension
Exception: if giving tPA, target BP <185/110 before administration
PRES is reversible with BP control but can progress to infarction or hemorrhage if untreated