Critical Cases - Hypertensive Encephalopathy!


  • 73 yo M PMH HTN, prior posterior CVA with residual peripheral vision deficit, DM, hyperlipidemia, p/w change in mental status
  • Wife heard pt fall, found him down
  • Immediately after the fall, patient was speaking but confused.
  • Per EMS, he has had declining mental status while en route to the hospital.
  • Stroke alert was called in the field by EMS


Physical Exam

T 98.4, HR 117, BP 270/143, Pulse ox 92% RA, RR 16

  • Laying on stretcher with eyes closed
  • Pupils equal, round, reactive, no gaze deviation
  • No verbal response, not following commands
  • Localizes to pain with deep sternal rub 
  • Cardiopulmonary exam wnl
  • Abdomen soft, non-tender


Differential Diagnosis

  • Stroke  vs intracranial hemorrhage vs seizure
  • Hypertensive encephalopathy vs PRES given marked elevation in BP


  • Stroke alert activated
  • Pt brought to CT scanner from ambulance triage for CT head non contrast and CTA head and neck

Diagnostics and Case Progression

  • CT head showed no ICH, CTA showed no LVO N
  • On return from CT scan, repeat blood pressure again 270s/140s
  • Symptoms suspected due to hypertension vs PRES, so nicardipine infusion was started
  • As patient’s BP came down, his exam improved
  • Over the next 2 hours, his systolic BP was lowered to about 200 systolic
  • Repeat physical exam at this time showed patient tracking examiner with eyes and following commands in all four extremities


  • Hypertensive encephalopthy is thought to be due to failure of cerebral autoregulation, leading to vasogenic edema especially of the posterior circulation (i.e. PRES syndrome - Posterior Reversible Encephalopathy Syndrome)
  • Diagnosis suspected with acute onset encephalopathy, markedly elevated blood pressure usually >200 systolic/120 diastolic, and lack of other diagnosis to explain symptoms
  • An MRI of the brain may reveal the classic changes of PRES in the posterior circulation as seen below

  • Treatment is directed at reversal of underlying cause, if any, as well as reduction of systemic blood pressure with medications such as nicardepene, a peripherally acting calcium channel blocker



Feske, Steven. Posterior Reversible Encephalopathy Syndrome: A ReviewSemin Neurol 2011; 31(2): 202-215.