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For further information, see CMDT Part 24-09: Stroke

Key Features

Essentials of Diagnosis

  • Hypertension is the usual cause

  • Hypertensive intracerebral hemorrhage occurs most frequently in the basal ganglia, pons, thalamus, cerebellum and less commonly in the cerebral white matter

  • Hemorrhage may extend into the ventricular system or subarachnoid space, and signs of meningeal irritation are then found

General Considerations

Hypertensive intracerebral hemorrhage

  • Spontaneous, nontraumatic intracerebral hemorrhage in patients with no angiographic evidence of an associated vascular anomaly (eg, aneurysm or angioma) is usually due to hypertension

  • Likely pathologic basis is microaneurysms that develop on perforating vessels 100–300 mcm in diameter in hypertensive patients

  • Occurs most frequently in the basal ganglia and less commonly in the pons, thalamus, cerebellum, and cerebral white matter

  • Extension into the ventricular system or subarachnoid space may cause signs of meningeal irritation

  • In the elderly, cerebral amyloid angiopathy is another important and frequent cause of hemorrhage

    • It is usually lobar in distribution and sometimes recurrent

    • It is associated with a better prognosis than hypertensive hemorrhage

Other causes

  • May occur with

    • Hematologic and bleeding disorders (eg, leukemia, thrombocytopenia, hemophilia, or disseminated intravascular coagulation)

    • Anticoagulant therapy

    • Liver disease

    • High alcohol intake

    • Cocaine and methamphetamine abuse

    • Herpes simplex encephalitis

    • Vasculitis

    • Moyamoya disease

    • Reversible cerebral vasoconstriction syndrome

    • Primary or secondary brain tumors

  • There is also an association with advancing age, male sex, and high alcohol intake

  • Bleeding from an intracranial aneurysm or arteriovenous malformation is primarily into the subarachnoid space, but it may also be partly intraparenchymal

  • Hemorrhage can also occur into arterial and venous cerebral infarcts

Clinical Findings

Symptoms and Signs

Hemorrhage into the cerebral hemisphere

  • Consciousness is initially lost or impaired in about 50% of patients

  • Vomiting is frequent at the onset, and headache is sometimes present

  • Focal symptoms and signs follow, depending on the site of the bleed

  • With hypertensive hemorrhage, there is generally a rapidly evolving neurologic deficit with hemiplegia or hemiparesis

  • A hemisensory disturbance occurs with more deeply placed lesions

  • With lesions of the putamen, loss of conjugate lateral gaze may be present

  • With thalamic hemorrhage, there may be a loss of upward gaze, downward or skew deviation of the eyes, lateral gaze palsies, and pupillary inequalities

Cerebellar hemorrhage

  • Sudden onset of nausea and vomiting; dysequilibrium; ataxia of gait, limbs, or trunk; headache; and loss of consciousness that may be fatal within 48 hours

  • Less commonly, the onset is gradual and episodic or slowly progressive, suggesting an expanding cerebellar lesion

  • Onset and course can be intermediate

    • Lateral conjugate gaze palsies to the side of the lesion

    • Small reactive pupils

    • Contralateral hemiplegia; peripheral facial weakness

    • Ataxia of gait, limbs, or trunk

    • Periodic respiration


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