Hypertensive intracerebral hemorrhage

Last revised by Rohit Sharma on 12 Feb 2024

Hypertensive intracerebral hemorrhages are the most common type of intracerebral hemorrhage (ICH) by cause, commonly affecting the basal ganglia, thalamus, pons or cerebellum.

Hypertension is the single most important risk factor for ICH, with hypertensive patients 3.5x more likely to have ICH than non-hypertensive patients 5. Globally, uncontrolled hypertension accounts for ~75% of the risk for ICH 7.

Patients will present variably depending on the region and size of the hemorrhage:

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 matches the incidence of hypertensive hemorrhages

    • found in patients with hypertension

    • may thrombose, leak (see cerebral microhemorrhages) or rupture 2

  • accelerated atherosclerosis: affects larger vessels

  • hyaline arteriosclerosis

  • hyperplastic arteriosclerosis: seen in very elevated and protracted cases

Imaging findings will depend on the location and time since bleeding, which are covered in the intracerebral hemorrhage article.

When hypertensive microangiopathy is present, multiple small areas of blooming artifact representing cerebral microhemorrhages may be evident on GRE or SWI sequences in addition to the ICH.

Hemorrhage causes displacement of brain tissue, but once resorbed, the patient recovers with fewer deficits compared to similar-sized infarcts. Treatment of uncontrolled hypertension is very important to prevent recurrent ICH 7.

Characteristics of hypertensive hemorrhages that lead to poorer prognosis include 3

  • bleed in the posterior fossa 

  • large amount of mass effect 

  • extension into the ventricular system 

ADVERTISEMENT: Supporters see fewer/no ads