Hypertensive intracerebral hemorrhage
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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 depending on the region and size of the hemorrhage:
basal ganglia hemorrhage usually presents with an ipsilateral deviation of the eyes due to descending capsular pathways from the frontal eye field
thalamic hemorrhage often presents with a downward deviation of the eyes and a lack of pupillary response to light
pontine hemorrhage usually causes coma due to disruption of the reticular activating system (unless small) and quadriparesis due to disruption of the corticospinal tract 4
cerebellar hemorrhage usually presents with typical "posterior circulation symptoms" of vertigo, ataxia, nausea, vomiting and headache 6
Long-standing poorly-controlled hypertension leads to a variety of pathological changes in the vessels:
microaneurysms of perforating arteries (Charcot-Bouchard aneurysms)
accelerated atherosclerosis: affects larger vessels
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.
Treatment and prognosis
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
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