A 65-year-old man is brought to the emergency department due to acute-onset, right-sided weakness and slurred speech. He also has a severe headache and nausea. Medical history is significant for poorly controlled hypertension and chronic tobacco use. Blood pressure is 240/120 mm Hg and pulse is 104/min. On physical examination, the patient is lethargic with right hemiparesis and lower facial weakness, right hemisensory loss, and dysarthria. Noncontrast CT scan of the head is shown in the image below. Which of the following cerebral blood vessels is most likely affected in this patient?

Question

A 65-year-old man is brought to the emergency department due to acute-onset, right-sided weakness and slurred speech.  He also has a severe headache and nausea.  Medical history is significant for poorly controlled hypertension and chronic tobacco use.  Blood pressure is 240/120 mm Hg and pulse is 104/min.  On physical examination, the patient is lethargic with right hemiparesis and lower facial weakness, right hemisensory loss, and dysarthria.  Noncontrast CT scan of the head is shown in the image below.  Which of the following cerebral blood vessels is most likely affected in this patient?

Quizplus · Accepted Answer

11ec160b_35b0_4b15_9249_ad8c71e428e6_MD0001_00 This patient's CT findings (eg, hyperdense mass) are consistent with an acute putaminal hemorrhage (ie, affecting the basal ganglia). Because of their location, putaminal hemorrhages almost always affect the adjacent internal capsule, leading to dysarthria, contralateral hemiparesis, and contralateral hemisensory loss due to disruption of the corticobulbar, corticospinal, and somatosensory fibers. As the hemorrhage expands, it leads to increase intracranial pressure (headache, nausea/vomiting, and altered mental status), midline shift from mass effect, and possible cerebral herniation. Hypertensive vasculopathy involving the small, penetrating branches of the major cerebral arteries is the most common cause of spontaneous deep intracerebral hemorrhage. Chronic hypertension leads to the formation of Charcot-Bouchard aneurysms, which may ultimately rupture and bleed within the deep brain structures. The most frequently affected locations include the basal ganglia (putamen), cerebellar nuclei, and pons. The basal ganglia are supplied by the lenticulostriate arteries, which are deep, small vessel branches off the middle cerebral arteries. (Choice A) Cortical branches of the major cerebral arteries are affected in lobar hemorrhages (eg, occipital), as opposed to deep hypertensive hemorrhages. Spontaneous lobar hemorrhages tend to occur in the elderly due to amyloid angiopathy. (Choices B, E, and F) The middle (inferior and superior divisions) and posterior cerebral arteries are large, proximal vessels arising from the circle of Willis. These arteries are typically associated with ischemic stroke due to thrombotic/embolic vessel occlusion or subarachnoid hemorrhage after saccular aneurysm rupture; intracerebral hemorrhage involving the basal ganglia is more likely due to rupture of deep penetrating arteries. (Choice D) The pontine arteries are small branches of the basilar artery that can rupture in the setting of poorly controlled chronic hypertension. Pontine hemorrhages usually occur close to the midline and affect both sides of the pons. They typically present with coma (disruption of the reticular activating system), locked-in syndrome (corticospinal and corticobulbar tracts), and pinpoint pupils (descending sympathetic tract). Educational objective: Spontaneous deep intracerebral hemorrhage is typically caused by hypertensive vasculopathy involving the small, penetrating branches of the major cerebral arteries. The most frequently affected locations include the basal ganglia (putamen), cerebellar nuclei, thalamus, and pons. The putamen is supplied by the lenticulostriate arteries, which are deep, small vessel branches off the middle cerebral arteries. __________ References: Update in intracerebral hemorrhage. (http://www.ncbi.nlm.nih.gov/pubmed/23983850)

A 65-Year-Old Man Is Brought to the Emergency Department Due