This 43 year-old Afro-American man has poorly controlled hypertension despite compliance with diuretic, beta-blocker, ACE inhibitor, and calcium channel blocker. For six months, he awakens every day with dull occipital aching pain and dizziness. This headache resolves after he eats breakfast.

Today he awakens with left orbital throbbing pain and vomits twice. He notes difficulty using his right arm and trips going to the bathroom. His speech is slurred. His wife calls an ambulance and he is brought to the hospital.

Exam findings

BP 230/130,     P-80,     R-12
NE - awake naming, repeating, comprehension; dysarthria
Right hemiparesis
Normal sensation
Left gaze preference; nl visual fields
Hypertensive retinopathy
Neck supple

Images

1. What is the mechanism and location of the neurological disturbance?
   
   
2. What is the most appropriate initial diagnostic study?
   
   
3. After reviewing the CT scan, what is the diagnosis?
   
   
4. How should treatment be initiated?
   
   
5. List the most common location for hypertensive parenchymal hemorrhages and the associated clinical findings.
   
   
6. List the most common lacunar syndromes and their locations.
   
   
7. Based upon clinical and CT findings could this be "hypertensive crisis with encephalopathy"?

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rev. 3/16/04