Malignant hypertension, the most severe form of hypertension, is characterized by acute and diffuse microvascular damage. The ophthalmological, renal and cardiological consequences are well described. Brain damage is considered rare and poorly known, although it is one of the main causes of death.

We performed a systematic cerebral MRI on patients of the Bordeaux cohort with malignant hypertension between 2008 and 2018, regardless of their neurological symptoms. A subgroup of patients benefited from a second cerebral MRI. All MRI were analysed by the same trained operator.

92 patients were included, 67.5% male, mean age 47.8±12 years. On admission, 41.5% of the patients were totally asymptomatic from a neurological aspect. Cerebral MRI was normal in 18.5% of patients. A posterior reversible encephalopathy syndrom was found in 16.5% of patients, 33.5% had an ischemic or hemorrhagic stroke. Patients had marked microvascular impairment (SVD score 2 or higher) in 59% of cases. In asymptomatic patients or patients with headaches only, MRI found PRES in 15.5% of cases, recent ischemic or hemorrhagic stroke in 29% of cases, and SVD score 2 or higher in 51.5% of cases.

Most patients with malignant hypertension have brain injuries, regardless of their symptoms. This warrants systematic cerebral MRI, as the results may impact on their management. The consequences of these severe lesions, which are disproportionately severe for young patients, raise questions about the need for cognitive assessment and management.