This case report is designed to be interactive. It includes questions on diagnosis and management, allowing the reader the opportunity to consider their own answer to a question before going on to read the recommended answer

We present the case of a middle-aged lady with recent onset severe hypertension who presented with hypertensive encephalopathic changes (posterior leuko-encephalopathy). We describe this relatively rare entity, and then discuss the management of a complex case. We do not pretend what we did was ‘right’—it was what we did, and it seemed to work. But maybe other approaches would have been better? In particular, the risks and benefits of using ACE inhibitors and ARBs (angiotensin II receptor blockers) after successful renal arterial intervention need to be studied more closely.