Hypertensive intracerebral hemorrhage
Updates to Article Attributes
Hypertensive intracerebral haemorrhages due to chronic hypertension are the most common cause of intracerebral haemorrhage.
They can be divided according to their typical locations, which include, in order of frequency:
- basal ganglia haemorrhage (especially the putamen)
- thalamic haemorrhage
- pontine haemorrhage
- cerebellar haemorrhage
Clinical presentation
Patients will present depending on the region and size of the haemorrhage:
- basal ganglia haemorrhage usually presents with an ipsilateral deviation of the eyes due to descending capsular pathways from the frontal eye field
- thalamic haemorrhage often presents with a downward deviation of the eyes and a lack of pupillary response to light
- pontine haemorrhage usually causes coma due to disruption of the reticular activating system (unless small) and quadriparesis due to disruption of the corticospinal tract 4
Pathology
Long-standing poorly-controlled hypertension leads to a variety of pathological changes in the vessels.
- microaneurysms of perforating arteries (Charcot-Bouchard aneurysms)
- small (0.3-0.9 mm) diameter
- occur on small (0.1-0.3 mm) diameter arteries
- distribution which matches the incidence of hypertensive haemorrhages
- 80% lenticulostriate
- 10% pons
- 10% cerebellum
- found in hypertensive patients
- may thrombose, leak (see cerebral microhaemorrhages) or rupture 2
- accelerated atherosclerosis: affects larger vessels
- hyaline arteriosclerosis
- hyperplastic arteriosclerosis: seen in very elevated and protracted cases
Radiographic features
CT
Hypertensive haemorrhages demonstrate typical CT characteristics of intracerebral haemorrhage, and are typically located in the basal ganglia (see basal ganglia haemorrhage), thalamus (see thalamic haemorrhage), pons (see pontine haemorrhage), or cerebellum (see cerebellar haemorrhage).
There are many predictors of haematoma expansion potentially evident on CT, which are discussed in depth in the main intracerebral haemorrhage article.
MRI
MRI is usually obtained when concern exists that the bleed is from an underlying lesion. Findings depend on the size and age of the bleed (see ageing blood on MRI).
In cases of chronic hypertension leading to hypertensive intracerebral haemorrhage, multiple small areas of susceptibility-induced signal drop-out may be evident on GRE or SWI in the basal ganglia, thalamus, pons, or cerebellum, in-keeping keeping with previous cerebral microhaemorrhages.
Treatment and prognosis
Haemorrhage causes displacement of brain tissue, but once resorbed, the patient recovers with fewer deficits compared to similar-sized infarcts.
Characteristics of hypertensive haemorrhages that lead to poorer prognosis include 3:
- bleed in the posterior fossa
- large amount of mass effect
- extension into the ventricular system
Video
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-<li><a href="/articles/thalamic-haemorrhagic-stroke">thalamic haemorrhage</a></li>- +<li><a href="/articles/thalamic-haemorrhage-1">thalamic haemorrhage</a></li>
-<a href="/articles/basal-ganglia-haemorrhage-2">basal ganglia haemorrhage</a> usually presents with ipsilateral deviation of the eyes due to descending capsular pathways from the frontal eye field</li>- +<a href="/articles/basal-ganglia-haemorrhage-2">basal ganglia haemorrhage</a> usually presents with an ipsilateral deviation of the eyes due to descending capsular pathways from the frontal eye field</li>
-<a href="/articles/thalamic-haemorrhagic-stroke">thalamic haemorrhage</a> often presents with downward deviation of eyes and lack of pupillary response to light</li>- +<a href="/articles/thalamic-haemorrhagic-stroke">thalamic haemorrhage</a> often presents with a downward deviation of the eyes and a lack of pupillary response to light</li>
-</ul><h4>Radiographic features</h4><h5>CT</h5><p>Hypertensive haemorrhages demonstrate typical CT characteristics of <a href="/articles/intracerebral-haemorrhage">intracerebral haemorrhage</a>, and are typically located in the <a href="/articles/basal-ganglia">basal ganglia</a> (see <a href="/articles/basal-ganglia-haemorrhage-2">basal ganglia haemorrhage</a>), <a title="Thalamus" href="/articles/thalamus">thalamus</a> (see <a href="/articles/thalamic-haemorrhagic-stroke">thalamic haemorrhage</a>), <a href="/articles/pons">pons</a> (see <a href="/articles/pontine-haemorrhage">pontine haemorrhage</a>), or <a href="/articles/cerebellum">cerebellum</a> (see <a href="/articles/cerebellar-haemorrhage">cerebellar haemorrhage</a>).</p><p>There are many predictors of haematoma expansion potentially evident on CT, which are discussed in depth in the main <a href="/articles/intracerebral-haemorrhage">intracerebral haemorrhage</a> article.</p><h5>MRI</h5><p>MRI is usually obtained when concern exists that the bleed is from an underlying lesion. Findings depend on the size and age of the bleed (see <a href="/articles/haemorrhage-on-mri">ageing blood on MRI</a>). </p><p>In cases of chronic hypertension leading to hypertensive intracerebral haemorrhage, multiple small areas of susceptibility-induced signal drop-out may be evident on GRE or SWI in the <a href="/articles/basal-ganglia">basal ganglia</a>, <a href="/articles/thalamus">thalamus</a>, <a href="/articles/pons">pons</a>, or <a href="/articles/cerebellum">cerebellum</a>, in-keeping with previous <a href="/articles/cerebral-microhaemorrhage">cerebral microhaemorrhages</a>.</p><h4>Treatment and prognosis </h4><p>Haemorrhage causes displacement of brain tissue, but once resorbed, the patient recovers with fewer deficits compared to similar-sized infarcts.</p><p>Characteristics of hypertensive haemorrhages that lead to poorer prognosis include <sup>3</sup>: </p><ul>- +</ul><h4>Radiographic features</h4><h5>CT</h5><p>Hypertensive haemorrhages demonstrate typical CT characteristics of <a href="/articles/intracerebral-haemorrhage">intracerebral haemorrhage</a>, and are typically located in the <a href="/articles/basal-ganglia">basal ganglia</a> (see <a href="/articles/basal-ganglia-haemorrhage-2">basal ganglia haemorrhage</a>), <a href="/articles/thalamus">thalamus</a> (see <a href="/articles/thalamic-haemorrhagic-stroke">thalamic haemorrhage</a>), <a href="/articles/pons">pons</a> (see <a href="/articles/pontine-haemorrhage">pontine haemorrhage</a>), or <a href="/articles/cerebellum">cerebellum</a> (see <a href="/articles/cerebellar-haemorrhage">cerebellar haemorrhage</a>).</p><p>There are many predictors of haematoma expansion potentially evident on CT, which are discussed in depth in the main <a href="/articles/intracerebral-haemorrhage">intracerebral haemorrhage</a> article.</p><h5>MRI</h5><p>MRI is usually obtained when concern exists that the bleed is from an underlying lesion. Findings depend on the size and age of the bleed (see <a href="/articles/haemorrhage-on-mri">ageing blood on MRI</a>). </p><p>In cases of chronic hypertension leading to hypertensive intracerebral haemorrhage, multiple small areas of susceptibility-induced signal drop-out may be evident on GRE or SWI in the <a href="/articles/basal-ganglia">basal ganglia</a>, <a href="/articles/thalamus">thalamus</a>, <a href="/articles/pons">pons</a>, or <a href="/articles/cerebellum">cerebellum</a>, in keeping with previous <a href="/articles/cerebral-microhaemorrhage">cerebral microhaemorrhages</a>.</p><h4>Treatment and prognosis </h4><p>Haemorrhage causes displacement of brain tissue, but once resorbed, the patient recovers with fewer deficits compared to similar-sized infarcts.</p><p>Characteristics of hypertensive haemorrhages that lead to poorer prognosis include <sup>3</sup>: </p><ul>
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