Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Hypertensive Intracranial Hemorrhage


KEY FACTS

Terminology

  • Hypertensive intracranial hemorrhage (hICH)

  • Acute nontraumatic intracerebral hemorrhage (ICH) secondary to systemic hypertension

  • 2nd most common cause of stroke

Imaging

  • Initial screen = NECT in patients with HTN

  • CT: Acute round or oval hyperdense mass

    • Striatocapsular: Putamen/external capsule (60-65%)

    • Thalamus (15-25%)

    • Pons, cerebellum (10%)

  • Multifocal “microbleeds” (1-5%)

  • Heterogeneous density (coagulopathy, active bleed)

  • Other findings: Intraventricular extension, mass effect, hydrocephalus, herniation

  • MR signal intensity (varies with age of clot)

    • Hyperacute (< 24 hours): T1WI iso-hypo/T2WI hyper

    • Acute (~ 1-3 days): T1WI iso-hypo/T2WI hypo

    • Subacute (days): T1WI hyper/T2WI hypo-hyper

    • Chronic (weeks-months): T1WI hyper/T2WI hypo

Top Differential Diagnoses

  • Cerebral amyloid angiopathy

  • Hemorrhagic neoplasm

  • Coagulopathy

  • Deep cerebral venous thrombosis

  • Drug abuse (especially in young patient)

  • Vascular malformation (rare in elderly)

Clinical Issues

  • HTN single most important risk factor for all types of stroke

  • 10-15% of stroke patients have hICH

  • 40-50% of nontraumatic ICHs caused by hICH

  • HTN most common cause of spontaneous ICH in patients 45-70 years old

  • 10-15% of hypertensive patients with spontaneous ICH have underlying aneurysm or arteriovenous malformation

Axial CT in a 61-year-old hypertensive woman shows the classic appearance of a left basal ganglia hemorrhage
involving the putamen and external capsule (striatocapsular). Note areas of periventricular hypodensity
likely related to chronic small vessel ischemia.

Axial SWI shows a large hypertensive basal ganglia hemorrhage
, as well as multiple foci of susceptibility artifact
from hemosiderin deposition related to microhemorrhages from chronic hypertension.

Axial graphic shows a classic acute hypertensive basal ganglia/external capsule hemorrhage
with dissection into the lateral ventricle. Hemorrhage extends through the foramen of Monro
into the 3rd ventricle
.

A coronal CTA in a young patient with a right basal ganglia hemorrhage
shows displacement of the lenticulostriate arteries
medially, compared with the normal left side
by the hematoma. There is no spot sign that would indicate active bleeding. No underlying vascular lesion is present.

TERMINOLOGY

Abbreviations

  • Hypertensive intracranial hemorrhage (hICH)

Synonyms

  • Stroke, hypertensive hemorrhage

Definitions

  • Acute nontraumatic intracerebral hemorrhage (ICH) secondary to systemic hypertension (HTN)

IMAGING

General Features

  • Best diagnostic clue

    • Round or oval hyperdense mass in basal ganglia (BG) or thalamus in patients with hypertension

  • Location

    • Striatocapsular: Putamen/external capsule (60-65%)

    • Thalamus (15-25%)

    • Pons, cerebellum (10%)

    • Lobar (5-10%)

  • Size

    • Subcentimeter (“microbleeds”) to several centimeters

  • Morphology

    • Typically rounded or oval

    • 2 distinct patterns seen with hICH

      • –

        Acute focal hematoma

      • –

        Multiple subacute/chronic “microbleeds” (1-5%)

CT Findings

  • NECT

    • Round or oval hyperdense parenchymal mass

    • Heterogeneous density if coagulopathy or active bleeding

    • Intraventricular extension of hemorrhage common

    • Mass effect, hydrocephalus, herniation common

  • CECT

    • No enhancement in acute hICH

  • CTA

    • Avascular mass effect in acute hICH

    • No underlying vascular lesion

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here

Related Posts