To highlight hypertensive crisis with autonomic dysfunction as an under-recognized cause of episodic confusion with transient neurological symptoms and abnormal motor movements that may mimic seizures—particularly when EEG lacks epileptiform abnormalities—in order to prevent misclassification as epileptic or psychogenic nonepileptic events.

Hypertension related neurological complications, including posterior reversible encephalopathy syndrome, are common hospital presentations. However, brainstem dysfunction secondary to acute blood-pressure dysregulation may be under-recognized and can present with altered mentation and abnormal motor movements. In addition, autonomic dysfunction may play a significant role requiring specialized therapy.

We describe two patients in their 70s with history of orthostatic hypotension who presented with recurrent episodes of confusion accompanied by diffuse tremors and polymyoclonus. Episodes lasted several minutes, followed by gradual full recovery. 

Neurological examination, laboratory testing, and brain MRI were unremarkable. Continuous video EEG monitoring captured events without electrographic seizures but coincided with marked blood pressure elevations. Both patients exhibited labile hypertension attributed to autonomic dysfunction, which was subsequently stabilized with medications including pyridostigmine, leading to near complete resolution of their episodes.

Careful monitoring and control of blood pressure fluctuations are essential when evaluating episodic confusion and seizure like movements, as recognition of autonomic dysfunction and treatment with agents such as pyridostigmine may prevent unnecessary diagnostic confusion and anti-seizure therapy.