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

(Left) 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

ſt likely related to chronic

small vessel ischemia. (Right)

Axial SWI shows a large

hypertensive basal ganglia

hemorrhage ﬇, as well as

multiple foci of susceptibility

artifact ſt from hemosiderin

deposition related to

microhemorrhages from

chronic hypertension.

(Left) 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 ﬈.

(Right) A coronal CTA in a

young patient with a right

basal ganglia hemorrhage ſt

shows displacement of the

lenticulostriate arteries ﬇

medially, compared with the

normal left side st by the

hematoma. There is no spot

sign that would indicate active

bleeding. No underlying

vascular lesion is present.

Trauma, and Stroke

Brain: Pathology-Based Diagnoses: Malformations,

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