The perils of a “hypertensive” diagnosis

The current framework for approaching patients with severe hypertension assigns every patient with arterial pressure above an arbitrary threshold to a state of either “hypertensive emergency” or “hypertensive urgency.” By labeling every condition in these patients a “hypertensive” condition, this framework implies that elevated blood pressure is responsible for every vascular event. An extension of this idea holds that hypertension is even capable of causing symptoms directly, without any intervening pathology. A man in his early 60s presented to the Emergency Department with new hypertension, headache, vomiting and diplopia. His doctors confidently diagnosed his presentation as “symptomatic hypertensive urgency” — a direct hypertensive effect. However, when he reported back pain and leg weakness two days later, investigation resumed. Spinal MRI showed subacute hemorrhage extending along the spinal cord from T9-T12. Catheter angiography revealed a small fusiform aneurysm of the posterior spinal artery at T11. The aneurysm was surgically clipped. The patient made a complete recovery and his hypertension resolved. Subarachnoid hemorrhage from a spinal aneurysm is a rare entity. Typical presenting symptoms of back pain and leg weakness help localize the lesion, but when intracranial symptoms such as headache or confusion predominate the diagnosis can be challenging. In this case, misconceptions about hypertension led clinicians to anchor on a diagnosis of “symptomatic hypertensive urgency.” When clinicians attribute signs and symptoms directly to elevated blood pressure they may fail to search for real disease processes.