Hypertensive Emergency With End-Organ Damage and Multifocal Intracranial Lesions Mimicking Disseminated Metastatic Disease: A Case Report

Hypertensive emergency is a life-threatening condition characterized by severe elevation in blood pressure with evidence of acute end-organ damage. Neurological involvement may present with imaging findings that mimic intracranial malignancy, posing a significant diagnostic challenge. A 41-year-old man with presumed IgA nephropathy and poor adherence to antihypertensive therapy presented with a 10-day history of headache, vomiting, and progressive visual disturbance. On admission, he was found to have severe hypertension (systolic blood pressure >200 mmHg) with evidence of end-organ damage, including bilateral retinal hemorrhages, exudates, macular edema, and acute-on-chronic renal failure with markedly elevated creatinine levels. Initial CT of the head demonstrated a right cerebellar hypodensity. Subsequent MRI of the head revealed multifocal intracranial lesions involving the cerebellum, temporal cortex, caudate nucleus, and medulla, raising concern for disseminated metastatic disease. However, contrast-enhanced CT of the chest, abdomen, and pelvis did not identify a primary malignancy. Follow-up contrast-enhanced MRI head performed on day 12 demonstrated marked interval resolution of the lesions, with only minimal residual abnormalities, findings not in keeping with metastatic disease and interpreted as a resolving inflammatory or infectious process. Hypertensive emergency may be associated with reversible intracranial abnormalities that closely mimic metastatic disease. Careful clinicoradiological correlation, along with lesion improvement following blood pressure control, may support diagnostic clarification and help avoid unnecessary investigations.