Review Question - QID 107387

A patient with malignant hypertension and increasingly severe headache in the setting of focal neurologic deficits is likely suffering from intraparenchymal hemorrhage due to his hypertension. The best test to diagnose this condition is a CT scan of the head without intravenous contrast.

The most common cause of hypertension is essential hypertension. Other causes of secondary hypertension include endocrine causes (Conn's syndrome, pheochromocytomas, hyperthyroidism), drug/medication abuse (cocaine, amphetamines), and cardiovascular causes (coarctation of the aorta, aortic dissection). Like in this patient, secondary hypertension may also be attributed to renovascular causes such as renal artery stenosis in fibromuscular dysplasia or people with atherosclerotic plaques. Severe uncontrolled hypertension can progress to intracranial (specifically intraparenchymal) bleeds with the most common sites involving the caudate and putamen, and they may manifest as focal neurological deficits, seizures, or loss of consciousness due to increased intracranial pressure.

Hainer et al. report on examining adult patients with acute headaches. They report that the presence of certain "red flag signs" warrant further examination via neuroimaging. These signs include focal neurologic signs, papilledema, neck stiffness, an immunocompromised state, sudden onset of the 'worst headache in the patient's life,' personality changes, headache after trauma, and headache that is worse with exercise. They also state that suspected intracranial bleeds should warrant CT imaging without contrast while most other causes (suspected malignancies, infectious causes, ischemic strokes) may require MRI imaging.

Tanaka et al. report on the effect of systolic blood pressure (SBP) variability (quantified as standard deviation in blood pressure variation) on acute intracerebral hemorrhage. They state that of all the patients in their study treated with antihypertensive medication, 16% showed hematoma expansion, 7% showed neurological deterioration, and 39% had unfavorable outcomes. They also state that SBP variability during the initial 24 hours of acute intracerebral hemorrhage was independently associated with neurological deterioration (OR 2.75, P<0.05) and unfavorable outcomes (1.42, P<0.05).

Incorrect Answers:
Answer 1: The patient should obtain a CT scan since it is much less time-consuming compared to a MRI. Contrast would hinder the examination of the scan for blood, so a noncontrast scan is necessary.
Answers 3 and 4: The patient should not obtain an MRI because it takes much longer than a CT scan. An MRI scan may be ordered later to examine for parenchymal damage.
Answer 5: A doppler ultrasound may be useful further on in the patient's stay if we are concerned for embolic phenomenon from the carotids, but the patient's current symptoms warrant an expedited investigation of a possible parenchymal intracranial hemorrhage, which is best achieved with a noncontrast CT scan.