Hypertensive Brainstem Encephalopathy

A 34-year-old man, previously in good health with no past history of hypertension, presented with a 2-day history of bitemporal headaches and a sudden onset of left-sided weakness 4 days after ingesting traditional Chinese medications for nonspecific abdominal pain. He was afebrile, drowsy, disoriented, and dysarthric, with a blood pressure of 270/170 mm Hg. Clinical examination revealed mild left facial weakness and strength of Medical Research Council grade 4/5 in the left upper and lower limbs. Deep tendon reflexes were brisk, and he demonstrated bilateral extensor plantar responses. Fundoscopy revealed grade 4 hypertensive retinopathy changes (Figure 1). ECG was consistent with left ventricular hypertrophy. Treatment with intravenous glyceryl trinitrate was commenced to achieve normotension. …